Every finding on record at Park Terrace Rehabilitation Center

Based on resident interview, staff interview, medical record review, review of resident admission agreements, review of facility job descriptions, review of facility self-reported incidents (SRIs), review of facility corrective action plan, and review of facility policy, the facility failed to provide care and services to residents in accordance with professional standards of practice, the comprehensive assessment of each resident, and physician orders. This failure resulted in multiple residents not receiving prescribed medications, treatments, or care interventions, thereby potentially placing all residents residing in the facility at risk. The facility census was 89.Findings include: Interview on 03/10/26 at 7:48 A.M. with Resident #40 revealed that on 02/22/26 she observed Licensed Practical Nurse (LPN) #100 working and appearing to be under the influence of an unknown substance. Resident #40 stated that LPN #100 administered her medications late.Interview on 03/10/26 at 8:03 A.M. with Resident #22 revealed that on 02/22/26 she observed LPN #100 working and appearing to be under the influence of an unknown substance. Resident #22 stated that LPN #100 told her she had been up for three days. Resident #22 further stated she observed LPN #100 administer medication to Resident #81 after dropping the medications on the floor. Resident #22 stated that LPN #223 and Certified Nursing Assistant (CNA) #101 telephoned the on-call manager, LPN #105, from the facility to notify her of LPN #100's erratic behaviors.Interview on 03/10/26 at 10:13 A.M. with the Director of Nursing (DON) revealed that neither she nor the Administrator were made aware of LPN #100's erratic behavior on 02/22/26. The DON stated that calls placed by CNA #101 and LPN #223 were directed to LPN #105 and not to herself or the Administrator. The DON stated that LPN #105 notified her that facility staff reported LPN #100 was acting strange but did not notify her of the extent of the erratic behavior. The DON stated that LPN #100 completed her scheduled shift on 02/22/26 and returned to work on 02/23/26, working part of her shift. The DON stated that LPN #105 told her LPN #100 reported being tired due to not sleeping well in the days immediately prior.Review of time punches for LPN #100 revealed she worked on 02/22/26 from 6:17 A.M. through 6:18 P.M., with a lunch break from 10:30 A.M. through 11:00 A.M. Further review of time punches revealed that on 02/23/26 LPN #100 worked from 6:20 A.M. through 12:38 P.M.Interview on 03/10/26 at 10:59 A.M. with LPN #105 verified she received calls from CNA #101 and LPN #223 on 02/22/26 regarding LPN #100's behavior. LPN #105 stated she notified the DON of the staff's concerns and was directed to call the facility and speak with LPN #100. LPN #105 stated that when she spoke with LPN #100 she appeared coherent and reported she was tired due to not sleeping well in the days immediately prior. LPN #105 stated she received no additional direction from the DON on 02/22/26. LPN #105 further stated that on 02/23/26 facility residents began complaining about LPN #100 and it was at that time the facility made the decision to drug test LPN #100. LPN #100 tested positive for cocaine.Interview on 03/10/26 at 11:35 A.M. with the DON revealed she asked LPN #223 why she did not contact herself or the Administrator regarding the concerns on 02/22/26. The DON stated that LPN #223 reported that LPN #105 told her she was going to contact the Administrator.Interview on 03/10/26 at 11:41 A.M. with Resident #81 revealed that on 02/22/26 LPN #100 appeared to be under the influence of an unknown substance. Resident #81 stated that LPN #100 administered his pain medication after dropping it on the floor. Resident #81 stated he reported his concerns to the DON and Administrator on 02/23/26 at approximately 10:00 A.M.Interview on 03/10/26 at 11:58 A.M. with Resident #9 revealed he did not receive his medications on 02/22/26.Interview on 03/10/26 at 12:27 P.M. with LPN #223 revealed that on 02/22/26 she observed LPN #100 appearing to be under the influence of an unknown substance. LPN #223 stated that Resident #81 informed her that LPN #100 dropped his medications and was slamming items. LPN #223 stated that LPN #100 appeared disheveled and very tired. LPN #223 stated she contacted LPN #105 to report her concerns and was told by LPN #105 she would investigate the situation and notify the Administrator.Interview on 03/11/26 at 9:52 A.M. with CNA #101 revealed she contacted LPN #105 three times on 02/22/26 at approximately 11:30 A.M., 12:41 P.M., and 2:52 P.M. CNA #101 stated she informed LPN #105 that LPN #100 was acting weird, appeared to be under the influence of an unknown substance, was falling asleep while standing up, and dozing off mid-conversation. CNA #101 further stated she informed LPN #105 that LPN #100 entered Resident #40's room and fell asleep on the resident's bed. CNA #101 stated that throughout her shift residents voiced concerns to her about not receiving medications, tube feedings, treatments, and other interventions. CNA #101 stated she observed LPN #100 drop Resident #81's medications on the floor prior to administering them.Review of the facility's substantiated Self-Reported Incident #271289 revealed residents reported to another nurse that LPN #100 was dropping pills and appeared to be under the influence of an unknown substance. The report indicated that LPN #223 contacted LPN #105; however, LPN #105 did not report the incident to the Administrator. When the Administrator was notified of the events of 02/22/26, LPN #100 was drug tested on [DATE] and tested positive for cocaine, (a highly addictive and powerful central nervous system stimulant derived from the leaves of the South American coca plant). Upon receiving the positive test result, LPN #100 was immediately suspended pending the facility investigation.Further review of this SRI revealed all facility residents were not assessed for possible negative effects related to this incident. Further review of this SRI revealed the facility did not obtain statements from all affected residents. Interview on 03/10/26 at 3:27 P.M. with Registered Nurse (RN) #281 verified the facility did not assess all facility residents nor did they obtain resident statements. Interview on 03/11/26 at 12:54 P.M. with the DON verified the investigation was not completed thoroughly. Review of SRI #271289 revealed the incident occurred on 02/22/26 and the investigation was concluded on 03/03/26. The facility could provide no documentation of obtaining resident statements, or of completing resident assessments demonstrating the incident was investigated thoroughly. There was no evidence of a Quality Assurance Performance Improvement (QAPI) meeting, or of the Medical Director being notified timely of the incident. Additionally, the facility staff education was not completed until 03/11/26. Interview on 03/10/25 at 3:27 P.M. with the DON verified the facility had not yet held a Quality Assurance Performance Improvement (QAPI) meeting to evaluate this incident. Follow up interview on 03/11/26 at 12:54 P.M. with the DON verified the facility had no additional documentation regarding this SRI, the corrective action for this SRI was not completed timely, the Medical Director was not notified of the incident until 02/25/26, and the facilities investigation was not completed thoroughly. Review of the facility Resident Agreement, dated 11/24/24, reveled the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that will compromise necessary and appropriate care consistent with the program for which the resident is contracted.Review of the Administrator Job Description revealed that major duties and responsibilities of this position include planning, developing, organizing, evaluating, and directing the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Managing and minimizing facility risk through a team approach to achieve desired outcomes in customer services, key performance indicators, employee retention, and other areas as identified, ensures resident incidents and concerns that arise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity with in the stated regulatory requirement, establish a culture of compliance by adhering to all facility policies and procedures, and complies with standards of business conduct, and state/federal regulations and guidelines.Review of the undated facility policy titled, Illegal Drug Use, revealed the facility is an illegal-drug free facility. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. Review of the undated facility policy titled, Abuse, Neglect and Exploitation, it is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies and procedures are implemented as written. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include:a. Identifying staff responsible for the investigation.b. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence.c. Investigating different types of alleged violations.d. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.e. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause.f. Providing complete and thorough documentation of the investigation.Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified time frames. Not later than 24 hours if the events that cause the allegation do not involve abuse and not result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number 2793023.

Based on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), Treatment Administration Record (TAR) review, staff interview, and review of facility documentation, the facility failed to provide routine and emergency medications and biologicals to meet the needs of each resident and failed to ensure medications were available and administered in accordance with physician orders and professional standards of practice. Specifically, the facility failed to ensure the availability and administration of physician-ordered medications for nine (#9, #12, #15, #24, #34, #43, #75, #77, and #89) of ten residents reviewed for medication administration. The facility census was 89. Findings include: 1. Review of the EMR for Resident #9 revealed an admission date of 02/13/26 with diagnoses including alcohol abuse, depression, anxiety, hypertension (HTN), insomnia, vitamin B12 deficiency, and vitamin D deficiency.Review of Resident #9's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed the resident required supervision or touching assistance with functional tasks including eating, hygiene, toileting, dressing, transferring, and walking.Review of the EMR revealed a physician orders dated 02/14/26 for cholecalciferol oral tablet 25 micrograms (mcg), administer two tablets by mouth every morning (total dose 50 mcg) for supplement, and cyanocobalamin oral tablet 500 mcg, administer one tablet by mouth once daily for supplement. Review of the MAR revealed the resident did not receive the physician-ordered doses of cholecalciferol and cyanocobalamin on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the Director of Nursing (DON) confirmed Resident #9 did not receive the physician-ordered doses of cholecalciferol and cyanocobalamin on 02/22/26.2. Review of the EMR for Resident #12 revealed an admission date of 09/17/23 with diagnoses including anoxic brain damage, personal history of sudden cardiac arrest, dissection of abdominal aorta, non-ST-elevation myocardial infarction (NSTEMI), depression, heart failure, anxiety, chronic respiratory failure with hypoxia, stage 3B chronic kidney disease (CKD3B), oropharyngeal dysphagia, seizures, pseudobulbar affect (PBA), urinary incontinence, incontinence of feces, sleep apnea, gastroesophageal reflux disease (GERD), insomnia, hyperlipidemia, dilated cardiomyopathy, major depressive disorder, and hypertension (HTN).Review of Resident #12's most recent quarterly MDS assessment revealed a BIMS score of 02, indicating severe cognitive impairment. Further review of the assessment revealed the resident required extensive assistance to total dependence for activities of daily living, including eating, hygiene, bathing, dressing, repositioning, and transferring.Review of the EMR revealed a physician order dated 08/13/25 for aspirin (ASA) 81 mg by mouth in the morning for antiplatelet therapy. Review of the MAR revealed the resident did not receive the physician-ordered dose of ASA on 02/22/26.Review of the EMR revealed a physician order dated 11/13/25 for lidocaine external patch 5% to be applied topically to the lower back in the morning for pain. Review of the MAR revealed the resident did not receive the physician-ordered lidocaine patch on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #12 did not receive the physician-ordered doses of aspirin and lidocaine patch on 02/22/26.3. Review of the EMR for Resident #15 revealed an admission date of 10/20/25 with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, personal history of sudden cardiac arrest, congestive heart failure (CHF), other specified diseases of the liver, and cerebral infarction.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating the cognitive assessment was unable to be completed. Further review of the assessment revealed Resident #15 required total assistance for functional areas including hygiene, dressing, repositioning, transferring, and locomotion via wheelchair.Review of the EMR revealed a physician order dated 02/22/26 for aspirin (ASA) 81 mg by mouth once daily for history of sudden cardiac arrest. Review of the Medication Administration Record (MAR) revealed the resident did not receive the physician-ordered dose of ASA on 02/22/26.Review of the EMR revealed a physician order dated 10/31/25 for MiraLAX 17 g by mouth every morning for constipation. Review of the MAR revealed the resident did not receive the physician-ordered dose of MiraLAX on 02/22/26.Review of the EMR revealed a physician order dated 10/20/25 for chlorhexidine gluconate mouth/throat solution 15 mg orally two times a day to prevent infection. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #15 did not receive the physician-ordered doses of MiraLAX, ASA and chlorhexidine gluconate on 02/22/26.4. Review of the EMR for Resident #24 revealed an admission date of 07/13/25 with diagnoses including malignant neoplasm of the prostate, severe protein-calorie malnutrition, chronic gastritis without bleeding, viral hepatitis C, supraventricular tachycardia (SVT), thrombocytosis, alcohol abuse, osteoarthritis, chronic pain, rash, altered mental status (AMS), hypertension (HTN), urinary retention, and allergic rhinitis.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating the resident had moderately impaired cognition. Further review of the assessment revealed the resident required assistance with activities of daily living including eating, showering/bathing, hygiene, and transfers.Review of the EMR revealed a physician order dated 07/14/25 for cetirizine 10 mg by mouth once daily for allergies. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 07/14/25 for magnesium 400 mg by mouth once daily for supplement. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 07/14/25 for a multivitamin by mouth once daily for supplement. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 07/14/25 for pantoprazole 40 mg by mouth every morning for gastroesophageal reflux disease (GERD). Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 08/24/25 for potassium chloride (KCl) 20 milliequivalents (mEq) by mouth once daily for hypokalemia. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 07/19/25 for Vitamin D3 50 micrograms (mcg) by mouth once daily for general health and osteoporosis prevention. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #24 did not receive the physician-ordered doses of pantoprazole, vitamin D3, potassium chloride, multivitamin, magnesium, or cetirizine on 02/22/26.5. Review of the EMR for Resident #34 revealed an admission date of 01/29/24 with diagnoses including central cord syndrome at the C5 level of the cervical spinal cord, severe protein-calorie malnutrition, transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), asthma, epilepsy, quadriplegia, acute renal failure (ARF), gangrene and necrosis of lung, acquired absence of kidney, pneumonia, dysphagia, sepsis, displaced intertrochanteric fracture of the right femur, generalized muscle weakness, cognitive communication deficit, anemia, sensorineural hearing loss, peripheral vascular disease, age-related nuclear cataract, left knee contracture, major depressive disorder, hyperlipidemia, nicotine dependence, hypertension (HTN), cervical spondylosis, right knee contracture, post-traumatic seizures, and hypotension.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed Resident #34 had bilateral impairment of the upper and lower extremities and required total assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transferring.Review of the EMR revealed a physician order dated 10/31/25 for aspirin (ASA) 81 milligrams (mg) by mouth once daily for anticoagulation. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 10/31/25 for lidocaine external patch 5% to be applied topically to the lower back in the morning for pain. Review of the MAR revealed the resident did not receive the physician-ordered lidocaine patch on 02/22/26.Review of the EMR revealed a physician order dated 10/30/25 for acetaminophen (APAP) 1000 mg by mouth three times a day for pain. Review of the MAR revealed the resident did not receive the physician-ordered doses in the morning and afternoon on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #34 did not receive the physician-ordered doses of acetaminophen, aspirin, or lidocaine patch 02/22/26.6. Review of the EMR for Resident #43 revealed an admission date of 11/28/25 with diagnoses including monoplegia of the upper limb, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), hypertension (HTN), functional quadriplegia, dementia, dry eye syndrome, long-term use of insulin, major depressive disorder, anxiety, generalized muscle weakness, and oropharyngeal dysphagia.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident was relatively cognitively intact. Further review of the assessment revealed the resident had impairment of the upper and lower extremities on one side and required substantial to maximal assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transfers.Review of the EMR revealed a physician order for aspirin (ASA) 81 milligrams (mg) by mouth every morning for cerebrovascular accident (CVA). Review of the Medication Administration Record (MAR) revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order for ergocalciferol 2000 units by mouth once daily for vitamin D deficiency. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order for vitamin B-12 500 micrograms (mcg) by mouth once daily for supplement. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 01/13/25 for magnesium 400 mg by mouth once daily for hypomagnesemia. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #43 did not receive the physician-ordered doses of aspirin, vitamin B12, ergocalciferol, and magnesium on 02/22/26.7. Review of the EMR for Resident #75 revealed an admission date of 07/24/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), moderate protein-calorie malnutrition, obstructive sleep apnea (OSA), acute renal failure (ARF), heart disease, anxiety, hypertension (HTN), hypothyroidism, transient ischemic attack (TIA), mild neurocognitive disorder, schizoaffective disorder, convulsions, and restless leg syndrome (RLS).Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident's cognition was intact. Further review of the assessment revealed Resident #75 required assistance with activities of daily living including toileting, bathing, dressing, hygiene, repositioning in bed, transferring, ambulation, and locomotion via wheelchair.Review of the EMR revealed multiple physician orders for medications including aspirin (ASA), potassium chloride, ProStat sugar free nutritional supplement, vitamin C, cyclosporine ophthalmic emulsion, and famotidine.Review of the MAR revealed the resident did not receive numerous physician-ordered medications on 02/22/26, including the morning doses of aspirin, potassium chloride, ProStat, vitamin C, cyclosporine ophthalmic drops, and famotidine.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #75 did not receive multiple physician-ordered medications on 02/22/26, including famotidine, potassium chloride, cyclosporine ophthalmic drops, aspirin, vitamin C, and ProStat.8. Review of the EMR for Resident #77 revealed an admission date of 07/27/19 with diagnoses including monoplegia of the upper limb following a cerebral infarction affecting the left non-dominant side, HTN, depression, GERD, hyperlipidemia, atherosclerotic heart disease, aphasia following cerebral infarction, DM2, drug-induced secondary parkinsonism, dysarthria and anarthria, and peripheral vascular disease.Review of Resident #77's most recent annual MDS assessment, dated 12/05/25, revealed a BIMS score of 11, indicating moderate cognitive impairment. Further review of this assessment revealed Resident #77 had impairment in one upper and one lower limb and required assistance with all functional abilities, including eating, hygiene, bathing, dressing, transferring, and toileting.Review of the EMR revealed a physician order dated 02/15/24 for ASA 81 mg every morning for DVT prevention. MAR review revealed the resident did not receive the physician-ordered dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #77 did not receive the physician-ordered dose of ASA on 02/22/26.9. Review of the EMR revealed Resident #89 had an admission date of 05/06/25 with diagnoses including chronic respiratory failure, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, benign prostatic hyperplasia (BPH), other idiopathic peripheral autonomic neuropathy, atrial fibrillation, HTN, obstructive sleep apnea (OSA), COPD, generalized anxiety disorder, fracture of unspecified part of the neck of the right femur, elevated white blood cells (WBC), chronic peripheral venous insufficiency, nasal congestion, urinary retention, and idiopathic progressive neuropathy.The most recent quarterly MDS assessment, dated 01/10/26, revealed a BIMS score of 11, indicating moderate cognitive impairment. Further review of this assessment revealed Resident #89 required maximal assistance or was dependent for functional abilities including, but not limited to, oral hygiene, toileting, bathing, dressing, hygiene, repositioning, transferring, and wheeling in a wheelchair.EMR review revealed a physician order dated 10/08/25 for a multivitamin once daily for supplement; 10/08/25 for polyethylene glycol powder 17 g once daily for constipation; and 10/08/25 for vitamin D 2000 units once daily for vitamin deficiency. MAR review revealed the resident did not receive these physician-ordered medications on 02/22/26.Additional EMR review revealed physician orders dated 10/07/25 for azelaic acid external gel 15% applied topically two times daily for rash; 10/07/25 for potassium chloride (KCl) 20 mEq two times daily for hypokalemia; and 10/07/25 for sennosides-docusate sodium 8.6-50 mg two times daily for constipation. MAR review revealed the resident did not receive the physician-ordered morning doses of these medications on 02/22/26.Further EMR review revealed physician orders dated 10/24/25 for Ensure 8 ounces two times daily for nutritional supplementation. MAR review revealed the resident did not receive the physician-ordered morning dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the Director of Nursing (DON) confirmed Resident #89 did not receive the physician-ordered doses of azelaic acid, vitamin D, apixaban, multivitamin, KCl, polyethylene glycol, sennosides-docusate, and Ensure on 02/22/26.Review of the facility Resident Agreement, dated 11/24/24, reveled the facility must protect and promote the rights of the residents. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that will compromise necessary and appropriate care consistent with the program for which the resident is contracted.Review of the undated facility policy titled, Medication Administration, revealed medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number 2793023.

Based on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), review of the Treatment Administration Record (TAR), staff interview, and review of facility documentation, the facility failed to ensure residents received necessary care and services in accordance with professional standards of nursing practice and physician orders. Specifically, the facility failed to ensure physician-ordered medications, treatments, assessments, monitoring, and interventions were implemented as ordered for 10 residents (#9, #12, #15, #24, #34, #43, #75, #77, #85, and #89).The facility's failure included, but was not limited to, failure to complete physician-ordered pain assessments; failure to administer ordered medications and tube feedings; failure to perform percutaneous endoscopic gastrostomy (PEG) tube monitoring and flushes; failure to perform blood glucose monitoring; failure to implement enhanced barrier precautions; failure to maintain head-of-bed elevation as ordered for respiratory conditions; failure to complete ordered behavior monitoring; failure to implement ordered safety supervision and interventions; and failure to document completion of ordered respiratory and therapy-related interventions.These failures occurred during the day shift on 02/22/26 and resulted in multiple residents not receiving ordered care and monitoring necessary to assess, maintain, and support their health and safety. This deficient practice reflects a breakdown in the facility's systems to ensure physician orders were implemented and monitored in accordance with professional standards of practice. The facility census was 89. Findings include: 1. Review of the EMR for Resident #9 revealed an admission date of 02/13/26 with diagnoses including alcohol abuse, depression, anxiety, hypertension (HTN), insomnia, vitamin B12 deficiency, and vitamin D deficiency.Review of Resident #9's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed the resident required supervision or touching assistance with functional tasks including eating, hygiene, toileting, dressing, transferring, and walking.Review of the EMR revealed a physician order dated 02/13/26 for a pain assessment using a 0-10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the Director of Nursing (DON) confirmed ordered day shift pain assessment was not completed on 02/22/26.2. Review of the EMR for Resident #12 revealed an admission date of 09/17/23 with diagnoses including anoxic brain damage, personal history of sudden cardiac arrest, dissection of abdominal aorta, non-ST-elevation myocardial infarction (NSTEMI), depression, heart failure, anxiety, chronic respiratory failure with hypoxia, stage 3B chronic kidney disease (CKD3B), oropharyngeal dysphagia, seizures, pseudobulbar affect (PBA), urinary incontinence, incontinence of feces, sleep apnea, gastroesophageal reflux disease (GERD), insomnia, hyperlipidemia, dilated cardiomyopathy, major depressive disorder, and hypertension (HTN).Review of Resident #12's most recent quarterly MDS assessment revealed a BIMS score of 02, indicating severe cognitive impairment. Further review of the assessment revealed the resident required extensive assistance to total dependence for activities of daily living, including eating, hygiene, bathing, dressing, repositioning, and transferring.Review of the EMR revealed a physician order dated 08/13/25 for the head of the bed (HOB) to be elevated every shift to alleviate shortness of breath related to chronic respiratory failure. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26.Review of the MAR revealed a physician order dated 09/17/25 for a diet communication order of regular diet, mechanical soft consistency, with thin liquids. Review of the TAR revealed the resident did not receive the physician-ordered diet communication on 02/22/26.Review of the EMR revealed a physician order dated 08/18/25 to monitor behaviors and document interventions every shift. Review of the TAR revealed physician-ordered behavior monitoring and interventions were not completed during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 08/13/25 for the resident to wear t-shirts instead of nightgowns as tolerated every shift. Review of the TAR revealed the resident did not receive the physician-ordered clothing on the day shift of 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #12 did not receive the physician-ordered behavior monitoring, diet communication, and ordered clothing were not completed on 02/22/26.3. Review of the EMR for Resident #15 revealed an admission date of 10/20/25 with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, personal history of sudden cardiac arrest, congestive heart failure (CHF), other specified diseases of the liver, and cerebral infarction.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating the cognitive assessment was unable to be completed. Further review of the assessment revealed Resident #15 required total assistance for functional areas including hygiene, dressing, repositioning, transferring, and locomotion via wheelchair.Review of the EMR revealed a physician order dated 10/21/25 for a pain assessment using a 0-10 pain scale every shift. Review of the Treatment Administration Record (TAR) revealed the ordered pain assessment was not completed during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 10/24/25 to flush the resident's PEG tube with 60 mL of water before and after each bolus feeding and every four hours. Review of the MAR revealed the resident did not receive the physician-ordered PEG tube flushes at 10:00 A.M. and 2:00 P.M. on 02/22/26.Review of the EMR revealed a physician order dated 10/22/25 to check PEG tube placement prior to medication administration and feedings every shift. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 10/22/25 to check gastric residuals and, if greater than 100 cubic centimeters (cc), hold the feeding for one hour, recheck after one hour, and notify the physician if still greater than 100 cc. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 10/21/25 to maintain the HOB in an elevated position as tolerated every shift to prevent or alleviate shortness of breath related to the resident's tracheostomy. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 12/09/25 to check the resident's peripheral oxygen saturation (SpO2) every shift and as needed. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #15 did not have the PEG tube placement, residual or flushes completed during the day shift on 02/22/26. The DON further confirmed the ordered day shift pain assessment, head-of-bed elevation, and a check of Resident #15's oxygen saturation was not completed on 02/22/26.4. Review of the EMR for Resident #24 revealed an admission date of 07/13/25 with diagnoses including malignant neoplasm of the prostate, severe protein-calorie malnutrition, chronic gastritis without bleeding, viral hepatitis C, supraventricular tachycardia (SVT), thrombocytosis, alcohol abuse, osteoarthritis, chronic pain, rash, altered mental status (AMS), hypertension (HTN), urinary retention, and allergic rhinitis.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating the resident had moderately impaired cognition. Further review of the assessment revealed the resident required assistance with activities of daily living including eating, showering/bathing, hygiene, and transfers.Review of the EMR revealed a physician order dated 07/14/25 for a pain assessment using a 0-10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON the physician-ordered pain assessment during the day shift was not completed on 02/22/26.5. Review of the EMR for Resident #34 revealed an admission date of 01/29/24 with diagnoses including central cord syndrome at the C5 level of the cervical spinal cord, severe protein-calorie malnutrition, transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), asthma, epilepsy, quadriplegia, acute renal failure (ARF), gangrene and necrosis of lung, acquired absence of kidney, pneumonia, dysphagia, sepsis, displaced intertrochanteric fracture of the right femur, generalized muscle weakness, cognitive communication deficit, anemia, sensorineural hearing loss, peripheral vascular disease, age-related nuclear cataract, left knee contracture, major depressive disorder, hyperlipidemia, nicotine dependence, hypertension (HTN), cervical spondylosis, right knee contracture, post-traumatic seizures, and hypotension.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed Resident #34 had bilateral impairment of the upper and lower extremities and required total assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transferring.Review of the EMR revealed a physician order dated 02/16/26 for enhanced barrier precautions (EBP) every shift. Enhanced barrier precautions require staff to wear gloves and gowns during high-contact resident care activities for residents at risk of or colonized with multidrug-resistant organisms (MDROs). Review of the TAR revealed the physician-ordered EBP were not implemented during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 12/28/25 to maintain the head of the HOB elevated every shift to alleviate shortness of breath related to COPD. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., DON confirmed the physician-ordered head-of-bed elevation and enhanced barrier precautions were not implemented on 02/22/26.6. Review of the EMR for Resident #43 revealed an admission date of 11/28/25 with diagnoses including monoplegia of the upper limb, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), hypertension (HTN), functional quadriplegia, dementia, dry eye syndrome, long-term use of insulin, major depressive disorder, anxiety, generalized muscle weakness, and oropharyngeal dysphagia.Review of the most recent quarterly MDS assessment dated [DATE] revealed an Interview BIMS score of 13, indicating the resident was relatively cognitively intact. Further review of the assessment revealed the resident had impairment of the upper and lower extremities on one side and required substantial to maximal assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transfers.Review of the EMR revealed a physician order for blood glucose monitoring every morning for diabetes management. Review of the MAR revealed the physician-ordered blood sugar check was not completed on 02/22/26.Review of the EMR revealed a physician order dated 12/23/25 to maintain the HOB elevated every shift to alleviate shortness of breath related to COPD. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26.Review of the EMR revealed a physician order for a sign to be placed in Resident #43's room instructing the resident to call for assistance prior to self-transferring every shift. Review of the TAR revealed this physician-ordered intervention was not implemented during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON the physician-ordered behavior monitoring, blood sugar checks, and head-of-bed elevation were not implemented on 02/22/26.7. Review of the EMR for Resident #75 revealed an admission date of 07/24/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), moderate protein-calorie malnutrition, obstructive sleep apnea (OSA), acute renal failure (ARF), heart disease, anxiety, hypertension (HTN), hypothyroidism, transient ischemic attack (TIA), mild neurocognitive disorder, schizoaffective disorder, convulsions, and restless leg syndrome (RLS).Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident's cognition was intact. Further review of the assessment revealed Resident #75 required assistance with activities of daily living including toileting, bathing, dressing, hygiene, repositioning in bed, transferring, ambulation, and locomotion via wheelchair.Review of the EMR further revealed a physician order dated 09/25/24 to maintain the HOB elevated every shift to alleviate shortness of breath related to COPD. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 02/18/24 for a pain assessment using a 0-10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 10/24/25 for thromboembolic deterrent (TED) hose to be applied in the morning and removed at night for hypotension. Review of the TAR revealed this physician-ordered intervention was not implemented on 02/22/26.Review of the EMR revealed a physician order dated 08/18/25 to monitor behaviors and document interventions every shift. Review of the TAR revealed behavior monitoring and documentation of interventions were not completed during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed the physician-ordered behavior monitoring, pain assessment, head-of-bed elevation, and other ordered interventions were not implemented on 02/22/26.8. Review of the EMR for Resident #77 revealed an admission date of 07/27/19 with diagnoses including monoplegia of the upper limb following a cerebral infarction affecting the left non-dominant side, HTN, depression, GERD, hyperlipidemia, atherosclerotic heart disease, aphasia following cerebral infarction, DM2, drug-induced secondary parkinsonism, dysarthria and anarthria, and peripheral vascular disease.Review of Resident #77's most recent annual MDS assessment, dated 12/05/25, revealed a BIMS score of 11, indicating moderate cognitive impairment. Further review of this assessment revealed Resident #77 had impairment in one upper and one lower limb and required assistance with all functional abilities, including eating, hygiene, bathing, dressing, transferring, and toileting.EMR review also revealed a physician order dated 07/03/19 for a 0-10 pain scale assessment every shift. MAR review revealed this ordered pain assessment was not completed during the day shift on 02/22/26.EMR review revealed a physician order dated 08/18/25 to monitor behaviors and document interventions every shift. TAR review revealed this physician-ordered behavior monitoring and documentation was not completed during the day shift on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #77 did not receive the physician-ordered assessment and behavior monitoring were not implemented on 02/22/26.9. Review of the EMR revealed Resident #85 had an admission date of 07/25/25 with diagnoses including COPD, major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), nightmare disorder, colostomy status, personal history of military deployment, personal history of other malignant neoplasm of rectum, rectosigmoid junction and anus, severe protein-calorie malnutrition, unspecified abnormalities of gait and mobility, non-pressure chronic ulcer of skin of other sites with fat layer exposed, HTN, hearing loss, repeated falls, and bradycardia.The most recent quarterly MDS assessment, dated 02/01/26, revealed a BIMS score of 14, indicating the resident was cognitively intact. Further review of this assessment revealed Resident #85 required partial to maximal assistance with functional abilities including, but not limited to, eating, hygiene, bathing, dressing, repositioning, transferring, and wheeling in a wheelchair.EMR review also revealed a physician order dated 08/18/25 to monitor behaviors and document interventions every shift. TAR review revealed this physician-ordered behavior monitoring and documentation of interventions were not completed during the day shift on 02/22/26.Additionally, EMR review revealed a physician order dated 01/30/26 for increased supervision after meals to assist the resident with transfers in and out of bed for safety. TAR review revealed this physician-ordered intervention was not completed after breakfast and lunch on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed the physician-ordered behavior monitoring and increased supervision after meals to assist with transfers in and out of bed for safety were not implemented on 02/22/26.10. Review of the EMR revealed Resident #89 had an admission date of 05/06/25 with diagnoses including chronic respiratory failure, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, benign prostatic hyperplasia (BPH), other idiopathic peripheral autonomic neuropathy, atrial fibrillation, HTN, obstructive sleep apnea (OSA), COPD, generalized anxiety disorder, fracture of unspecified part of the neck of the right femur, elevated white blood cells (WBC), chronic peripheral venous insufficiency, nasal congestion, urinary retention, and idiopathic progressive neuropathy.The most recent quarterly MDS assessment, dated 01/10/26, revealed a BIMS score of 11, indicating moderate cognitive impairment. Further review of this assessment revealed Resident #89 required maximal assistance or was dependent for functional abilities including, but not limited to, oral hygiene, toileting, bathing, dressing, hygiene, repositioning, transferring, and wheeling in a wheelchair.EMR review further revealed physician orders dated 02/27/26 for enhanced barrier precautions (EBP) every shift; 10/20/25 to maintain the HOB elevated every shift to alleviate shortness of breath related to chronic respiratory failure; 10/07/25 for oxygen at three liters per minute via nasal cannula each shift; 10/20/25 for transfer and range-of-motion exercises with PT/OT two times daily; and 02/23/26 to utilize the blue Acapella device at bedside four times daily with nebulizer treatments for secretion clearance. TAR review revealed the physician-ordered EBP and HOB elevation were not implemented during the day shift on 02/22/26, and monitoring associated with the oxygen and therapy interventions was not documented during the day shift. TAR review also revealed the physician ordered Acapella device intervention was not completed on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., DON confirmed the physician-ordered EBP and HOB elevation were not implemented on 02/22/26.Review of the facility Resident Agreement, dated 11/24/24, reveled the facility must protect and promote the rights of the residents. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that will compromise necessary and appropriate care consistent with the program for which the resident is contracted.Review of the undated facility policy titled, Medication Administration, revealed medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number 2793023.

Based on resident interview, staff interview, electronic medical record (EMR) review, review of the Medication Administration Record (MAR), review of the Treatment Administration Record (TAR), review of staff time punches, review of facility policies, and review of the facility's Self-Reported Incident (SRI) #271289, the facility failed to protect residents from neglect when it failed to ensure staff providing resident care were able to safely perform their duties and failed to intervene when Licensed Practical Nurse (LPN) #100 was reported by staff and residents to be exhibiting behaviors consistent with being under the influence of an unknown substance while providing resident care on 02/22/26.Despite multiple reports from staff and residents that LPN #100 appeared impaired, was falling asleep while standing, dozing off during conversations, and dropping medications, the facility failed to remove the nurse from resident care or ensure residents received physician-ordered medications, treatments, monitoring, and interventions.As a result, residents assigned to LPN #100 did not receive numerous physician-ordered medications, tube feedings, treatments, assessments, monitoring, and safety interventions on 02/22/26, affecting 10 residents (Residents #9, #12, #15, #24, #34, #43, #75, #77, #85, and #89) and placing residents at risk for physical harm, pain, and decline in health status. The facility census was 89.Findings include:Interview on 03/10/26 at 7:48 A.M. with Resident #40 revealed that on 02/22/26 she observed LPN #100 working and appearing to be under the influence of an unknown substance. Resident #40 stated that LPN #100 administered her medications late. Interview on 03/10/26 at 8:03 A.M. with Resident #22 revealed that on 02/22/26 she observed LPN #100 working and appearing to be under the influence of an unknown substance. Resident #22 stated that LPN #100 told her she had been up for three days. Resident #22 further stated she observed LPN #100 administer medication to Resident #81 after dropping the medications on the floor. Resident #22 stated that LPN #223 and Certified Nursing Assistant (CNA) #101 telephoned the on-call manager, LPN #105, from the facility to notify her of LPN #100's erratic behaviors. Interview on 03/10/26 at 10:13 A.M. with the Director of Nursing (DON) revealed that neither she nor the Administrator were made aware of LPN #100's erratic behavior on 02/22/26. The DON stated that calls placed by CNA #101 and LPN #223 were directed to LPN #105 and not to herself or the Administrator. The DON stated that LPN #105 notified her that facility staff reported LPN #100 was acting strange but did not notify her of the extent of the erratic behavior. The DON stated that LPN #100 completed her scheduled shift on 02/22/26 and returned to work on 02/23/26, working part of her shift. The DON stated that LPN #105 told her LPN #100 reported being tired due to not sleeping well in the days immediately prior. Review of time punches for LPN #100 revealed she worked on 02/22/26 from 6:17 A.M. through 6:18 P.M., with a lunch break from 10:30 A.M. through 11:00 A.M. Further review of time punches revealed that on 02/23/26 LPN #100 worked from 6:20 A.M. through 12:38 P.M. Interview on 03/10/26 at 10:59 A.M. with LPN #105 verified she received calls from CNA #101 and LPN #223 on 02/22/26 regarding LPN #100's behavior. LPN #105 stated she notified the DON of the staff's concerns and was directed to call the facility and speak with LPN #100. LPN #105 stated that when she spoke with LPN #100 she appeared coherent and reported she was tired due to not sleeping well in the days immediately prior. LPN #105 stated she received no additional direction from the DON on 02/22/26. LPN #105 further stated that on 02/23/26 facility residents began complaining about LPN #100 and it was at that time the facility made the decision to drug test LPN #100. LPN #100 tested positive for cocaine. Interview on 03/10/26 at 11:35 A.M. with the DON revealed she asked LPN #223 why she did not contact herself or the Administrator regarding the concerns on 02/22/26. The DON stated that LPN #223 reported that LPN #105 told her she was going to contact the Administrator. Interview on 03/10/26 at 11:41 A.M. with Resident #81 revealed that on 02/22/26 LPN #100 appeared to be under the influence of an unknown substance. Resident #81 stated that LPN #100 administered his pain medication after dropping it on the floor. Resident #81 stated he reported his concerns to the DON and Administrator on 02/23/26 at approximately 10:00 A.M. Interview on 03/10/26 at 11:58 A.M. with Resident #9 revealed he did not receive his medications on 02/22/26. Interview on 03/10/26 at 12:27 P.M. with LPN #223 revealed that on 02/22/26 she observed LPN #100 appearing to be under the influence of an unknown substance. LPN #223 stated that Resident #81 informed her that LPN #100 dropped his medications and was slamming items. LPN #223 stated that LPN #100 appeared disheveled and very tired. LPN #223 stated she contacted LPN #105 to report her concerns and was told by LPN #105 she would investigate the situation and notify the Administrator. Interview on 03/11/26 at 9:52 A.M. with CNA #101 revealed she contacted LPN #105 three times on 02/22/26 at approximately 11:30 A.M., 12:41 P.M., and 2:52 P.M. CNA #101 stated she informed LPN #105 that LPN #100 was acting weird, appeared to be under the influence of an unknown substance, was falling asleep while standing up, and dozing off mid-conversation. CNA #101 further stated she informed LPN #105 that LPN #100 entered Resident #40's room and fell asleep on the resident's bed. CNA #101 stated that throughout her shift residents voiced concerns to her about not receiving medications, tube feedings, treatments, and other interventions. CNA #101 stated she observed LPN #100 drop Resident #81's medications on the floor prior to administering them. Review of the facility's substantiated Self-Reported Incident #271289 revealed residents reported to another nurse that LPN #100 was dropping pills and appeared to be under the influence of an unknown substance. The report indicated that LPN #223 contacted LPN #105; however, LPN #105 did not report the incident to the Administrator. When the Administrator was notified of the events of 02/22/26, LPN #100 was drug tested on [DATE] and tested positive for cocaine, (a highly addictive and powerful central nervous system stimulant derived from the leaves of the South American coca plant). Upon receiving the positive test result, LPN #100 was immediately suspended pending the facility investigation. 1. Review of the EMR for Resident #9 revealed an admission date of 02/13/26 with diagnoses including alcohol abuse, depression, anxiety, hypertension (HTN), insomnia, vitamin B12 deficiency, and vitamin D deficiency. Review of Resident #9's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed the resident required supervision or touching assistance with functional tasks including eating, hygiene, toileting, dressing, transferring, and walking. Review of the EMR revealed a physician orders dated 02/14/26 for cholecalciferol oral tablet 25 micrograms (mcg), administer two tablets by mouth every morning (total dose 50 mcg) for supplement, cyanocobalamin oral tablet 500 mcg, administer one tablet by mouth once daily for supplement, hydrochlorothiazide (HCTZ) 25 milligrams (mg) by mouth once daily for hypertension, paroxetine HCl 30 mg by mouth once daily for depression. Review of the MAR revealed the resident did not receive the physician-ordered doses of cholecalciferol, cyanocobalamin, hydrochlorothiazide, and paroxetine HCl on 02/22/26. Review of the EMR revealed a physician order dated 02/13/26 for a pain assessment using a 0–10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26. During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #9 did not receive the physician-ordered doses of cholecalciferol, cyanocobalamin, hydrochlorothiazide, and paroxetine HCl on 02/22/26. The DON further confirmed the ordered day shift pain assessment was not completed on 02/22/26. 2. Review of the EMR for Resident #12 revealed an admission date of 09/17/23 with diagnoses including anoxic brain damage, personal history of sudden cardiac arrest, dissection of abdominal aorta, non-ST-elevation myocardial infarction (NSTEMI), depression, heart failure, anxiety, chronic respiratory failure with hypoxia, stage 3B chronic kidney disease (CKD3B), oropharyngeal dysphagia, seizures, pseudobulbar affect (PBA), urinary incontinence, incontinence of feces, sleep apnea, gastroesophageal reflux disease (GERD), insomnia, hyperlipidemia, dilated cardiomyopathy, major depressive disorder, and hypertension (HTN). Review of Resident #12's most recent quarterly MDS assessment revealed a BIMS score of 02, indicating severe cognitive impairment. Further review of the assessment revealed the resident required extensive assistance to total dependence for activities of daily living, including eating, hygiene, bathing, dressing, repositioning, and transferring. Review of the EMR revealed a physician order dated 02/22/26 for amlodipine 10 mg by mouth in the morning for dilated cardiomyopathy. Review of the MAR revealed the resident did not receive the physician-ordered dose of amlodipine on 02/22/26. Review of the EMR revealed a physician order dated 08/13/25 for aspirin (ASA) 81 mg by mouth in the morning for antiplatelet therapy. Review of the MAR revealed the resident did not receive the physician-ordered dose of ASA on 02/22/26. Review of the EMR revealed a physician order dated 11/13/25 for lidocaine external patch 5% to be applied topically to the lower back in the morning for pain. Review of the MAR revealed the resident did not receive the physician-ordered lidocaine patch on 02/22/26. Review of the EMR revealed a physician order dated 01/31/26 for two capsules of Nuedexta 20-10 mg by mouth in the morning for major depressive disorder. Review of the MAR revealed the resident did not receive the physician-ordered dose of Nuedexta on 02/22/26. Review of the EMR revealed a physician order dated 08/13/25 for one and one-half tablets of sertraline HCl 100 mg by mouth in the morning for major depressive disorder. Review of the MAR revealed the resident did not receive the physician-ordered dose of sertraline HCl on 02/22/26. Review of the EMR revealed a physician order dated 02/02/26 for carvedilol 3.125 mg by mouth two times a day for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered dose of carvedilol on 02/22/26. Review of the EMR revealed a physician order dated 11/12/25 for two capsules of Depakote Sprinkles 125 mg by mouth two times a day for increased behaviors. Review of the MAR revealed the resident did not receive the physician-ordered dose of Depakote Sprinkles on 02/22/26. Review of the EMR revealed a physician order dated 12/02/25 for diazepam 5 mg/5 mL, administer 2 mL by mouth two times a day for agitation. Review of the MAR revealed the resident did not receive the physician-ordered dose of diazepam on the morning of 02/22/26. Review of the EMR revealed a physician order dated 02/21/26 for levetiracetam 100 mg/mL, administer 5 mL by mouth two times a day for anoxic brain damage. Review of the MAR revealed the resident did not receive the physician-ordered dose of levetiracetam on the morning of 02/22/26. Review of the EMR revealed a physician order dated 02/21/26 for minoxidil 5 mg by mouth two times a day for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered dose of minoxidil on the morning of 02/22/26. Review of the EMR revealed a physician order dated 02/25/26 for buspirone 10 mg by mouth three times a day for anxiety. Review of the MAR revealed the resident did not receive two of the three physician-ordered doses of buspirone on 02/22/26 at 6:00 A.M. and 1:00 P.M. Review of the EMR revealed a physician order dated 08/13/25 for gabapentin 600 mg by mouth three times a day for agitation. Review of the MAR revealed the resident did not receive two of the three physician-ordered doses of gabapentin on 02/22/26 at 6:00 A.M. and 1:00 P.M. Review of the EMR revealed a physician order dated 08/13/25 for the head of the bed (HOB) to be elevated every shift to alleviate shortness of breath related to chronic respiratory failure. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 02/13/26 for a pain assessment using a 0–10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26. Review of the MAR revealed a physician order dated 09/17/25 for a diet communication order of regular diet, mechanical soft consistency, with thin liquids. Review of the TAR revealed the resident did not receive the physician-ordered diet communication on 02/22/26. Review of the EMR revealed a physician order dated 08/18/25 to monitor behaviors and document interventions every shift. Review of the TAR revealed physician-ordered behavior monitoring and interventions were not completed during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 08/13/25 for the resident to wear t-shirts instead of nightgowns as tolerated every shift. Review of the TAR revealed the resident did not receive the physician-ordered clothing on the day shift of 02/22/26. During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #12 did not receive the physician-ordered doses of sertraline, aspirin, gabapentin, amlodipine, lidocaine patch, buspirone, Depakote Sprinkles, diazepam, Nuedexta, carvedilol, minoxidil, and levetiracetam on 02/22/26. The DON further confirmed the ordered day shift pain assessment, head-of-bed elevation, behavior monitoring, diet communication, and ordered clothing were not completed on 02/22/26. 3. Review of the EMR for Resident #15 revealed an admission date of 10/20/25 with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, personal history of sudden cardiac arrest, congestive heart failure (CHF), other specified diseases of the liver, and cerebral infarction. Review of the most recent quarterly MDS assessment dated [DATE] revealed an Interview BIMS score of 99, indicating the cognitive assessment was unable to be completed. Further review of the assessment revealed Resident #15 required total assistance for functional areas including hygiene, dressing, repositioning, transferring, and locomotion via wheelchair. Review of the EMR revealed a physician order dated 02/22/26 for aspirin (ASA) 81 mg by mouth once daily for history of sudden cardiac arrest. Review of the MAR revealed the resident did not receive the physician-ordered dose of ASA on 02/22/26. Review of the EMR revealed a physician order dated 11/11/25 for lactulose 10 grams (g)/15 milliliters (mL), administer 10 mL by mouth once daily for elevated ammonia level. Review of the MAR revealed the resident did not receive the physician-ordered dose of lactulose on 02/22/26. Review of the EMR revealed a physician order dated 10/31/25 for MiraLAX 17 g by mouth every morning for constipation. Review of the MAR revealed the resident did not receive the physician-ordered dose of MiraLAX on 02/22/26. Review of the EMR revealed a physician order dated 10/20/25 for chlorhexidine gluconate mouth/throat solution 15 mg orally two times a day to prevent infection. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician orders dated 02/21/26 for clobazam oral film 10 mg two times per day for seizures, levetiracetam oral solution 15 mL two times a day for seizures, and valproic acid oral solution 10 mL two times per day for seizures. Review of the MAR revealed the resident did not receive the physician-ordered morning dose on 02/22/26. Review of the EMR revealed a physician order dated 02/12/26 for omeprazole 20 mg two times a day for gastroesophageal reflux disease (GERD). Review of the MAR revealed the resident did not receive the physician-ordered morning dose on 02/22/26. Review of the EMR revealed a physician order dated 10/21/25 for a pain assessment using a 0–10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 10/24/25 to flush the resident's percutaneous endoscopic gastrostomy (PEG) tube with 60 mL of water before and after each bolus feeding and every four hours. Review of the MAR revealed the resident did not receive the physician-ordered PEG tube flushes at 10:00 A.M. and 2:00 P.M. on 02/22/26. Review of the EMR revealed a physician order dated 10/24/25 for Jevity 1.5, administer 237 mL bolus feeding every four hours for tube feeding. Review of the MAR revealed the resident did not receive the physician-ordered Jevity 1.5 bolus feedings at 10:00 A.M. and 2:00 P.M. on 02/22/26. Review of the EMR revealed a physician order dated 10/22/25 to check PEG tube placement prior to medication administration and feedings every shift. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 10/22/25 to check gastric residuals and, if greater than 100 cubic centimeters (cc), hold the feeding for one hour, recheck after one hour, and notify the physician if still greater than 100 mL. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 10/21/25 to maintain the HOB in an elevated position as tolerated every shift to prevent or alleviate shortness of breath related to the resident's tracheostomy. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 12/09/25 to check the resident's peripheral oxygen saturation (SpO2) every shift and as needed. Review of the TAR revealed this physician-ordered intervention was not completed during the day shift on 02/22/26. During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #15 did not receive the physician-ordered doses of MiraLAX, lactulose, omeprazole, valproic acid, aspirin, levetiracetam, clobazam, chlorhexidine gluconate mouth/throat solution, Jevity 1.5 tube feeding, or PEG tube flushes on 02/22/26. The DON further confirmed the ordered day shift pain assessment, head-of-bed elevation, PEG tube placement checks, and residual checks were not completed on 02/22/26. 4. Review of the EMR for Resident #24 revealed an admission date of 07/13/25 with diagnoses including malignant neoplasm of the prostate, severe protein-calorie malnutrition, chronic gastritis without bleeding, viral hepatitis C, supraventricular tachycardia (SVT), thrombocytosis, alcohol abuse, osteoarthritis, chronic pain, rash, altered mental status (AMS), hypertension (HTN), urinary retention, and allergic rhinitis. Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating the resident had moderately impaired cognition. Further review of the assessment revealed the resident required assistance with activities of daily living including eating, showering/bathing, hygiene, and transfers. Review of the EMR revealed a physician order dated 02/22/26 for amlodipine besylate 10 mg by mouth once daily for supraventricular tachycardia. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician orders dated 07/14/25 for bicalutamide 50 mg by mouth once daily for prostate cancer, cetirizine 10 mg by mouth once daily for allergies, magnesium 400 mg by mouth once daily for supplement, a multivitamin by mouth once daily for supplement, pantoprazole 40 mg by mouth every morning for gastroesophageal reflux disease (GERD), and tamsulosin HCl 0.4 mg by mouth once daily for benign prostatic hyperplasia (BPH). Review of the MAR revealed the resident did not receive the physician-ordered doses on 02/22/26. Review of the EMR revealed a physician order dated 08/24/25 for potassium chloride (KCl) 20 milliequivalents (mEq) by mouth once daily for hypokalemia. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order dated 07/19/25 for Vitamin D3 50 micrograms (mcg) by mouth once daily for general health and osteoporosis prevention. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order dated 07/14/25 for a pain assessment using a 0–10 pain scale every shift. Review of the TAR revealed the ordered pain assessment was not completed during the day shift on 02/22/26. During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #24 did not receive the physician-ordered doses of bicalutamide, pantoprazole, vitamin D3, potassium chloride, amlodipine, multivitamin, magnesium, cetirizine, or tamsulosin on 02/22/26. The DON further confirmed the physician-ordered pain assessment during the day shift was not completed on 02/22/26. 5. Review of the EMR for Resident #34 revealed an admission date of 01/29/24 with diagnoses including central cord syndrome at the C5 level of the cervical spinal cord, severe protein-calorie malnutrition, transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), asthma, epilepsy, quadriplegia, acute renal failure (ARF), gangrene and necrosis of lung, acquired absence of kidney, pneumonia, dysphagia, sepsis, displaced intertrochanteric fracture of the right femur, generalized muscle weakness, cognitive communication deficit, anemia, sensorineural hearing loss, peripheral vascular disease, age-related nuclear cataract, left knee contracture, major depressive disorder, hyperlipidemia, nicotine dependence, hypertension (HTN), cervical spondylosis, right knee contracture, post-traumatic seizures, and hypotension. Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed Resident #34 had bilateral impairment of the upper and lower extremities and required total assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transferring. Review of the EMR revealed a physician order dated 02/22/26 for Anoro Ellipta 62.5–25 mcg per actuation (mcg/act), administer one puff by mouth once daily for COPD. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed physician orders dated 10/31/25 for aspirin (ASA) 81 mg by mouth once daily for anticoagulation, clopidogrel bisulfate 75 mg by mouth once daily, and a lidocaine external patch 5% to be applied topically to the lower back in the morning for pain. Review of the MAR revealed the resident did not receive the physician-ordered doses on 02/22/26. Review of the EMR revealed a physician order dated 02/24/25 for lisinopril 5 mg by mouth once daily for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order dated 02/23/25 for sertraline 12.5 mg (one-half tablet of 25 mg) by mouth every morning for depression. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order dated 02/16/26 for enhanced barrier precautions (EBP) every shift. Enhanced barrier precautions require staff to wear gloves and gowns during high-contact resident care activities for residents at risk of or colonized with multidrug-resistant organisms (MDROs). Review of the TAR revealed the physician-ordered EBP were not implemented during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 12/28/25 to maintain the HOB elevated every shift to alleviate shortness of breath related to COPD. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 10/30/25 for levetiracetam 750 mg by mouth two times a day for seizures. Review of the MAR revealed the resident did not receive the physician-ordered dose during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 11/25/25 for metoprolol tartrate 25 mg by mouth two times a day. Review of the MAR revealed the resident did not receive the physician-ordered dose during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 10/30/25 for acetaminophen (APAP) 1000 mg by mouth three times a day for pain. Review of the MAR revealed the resident did not receive the physician-ordered doses in the morning and afternoon on 02/22/26. Review of the EMR revealed a physician order for baclofen 10 mg by mouth three times a day for muscle relaxation. Review of the MAR revealed the resident did not receive the physician-ordered doses in the morning and afternoon on 02/22/26. During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #34 did not receive the physician-ordered doses of baclofen, acetaminophen, aspirin, lisinopril, lidocaine patch, levetiracetam, sertraline, Anoro Ellipta, clopidogrel, or metoprolol on 02/22/26. The DON further confirmed the physician-ordered head-of-bed elevation and enhanced barrier precautions were not implemented on 02/22/26. 6. Review of the EMR for Resident #43 revealed an admission date of 11/28/25 with diagnoses including monoplegia of the upper limb, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), hypertension (HTN), functional quadriplegia, dementia, dry eye syndrome, long-term use of insulin, major depressive disorder, anxiety, generalized muscle weakness, and oropharyngeal dysphagia. Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident was relatively cognitively intact. Further review of the assessment revealed the resident had impairment of the upper and lower extremities on one side and required substantial to maximal assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transfers. Review of the EMR revealed a physician order for aspirin (ASA) 81 mg by mouth every morning for cerebrovascular accident (CVA). Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order for blood glucose monitoring every morning for diabetes management. Review of the MAR revealed the physician-ordered blood sugar check was not completed on 02/22/26. Review of the EMR revealed a physician order for ergocalciferol 2000 units by mouth once daily for vitamin D deficiency. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order for vitamin B-12 500 micrograms (mcg) by mouth once daily for supplement. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order for apixaban 5 mg by mouth two times a day for cerebrovascular accident. Review of the MAR revealed the resident did not receive the physician-ordered morning dose on 02/22/26. Review of the EMR revealed a physician order for buspirone 5 mg by mouth once daily for anxiety. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26. Review of the EMR revealed a physician order for carvedilol 25 mg by mouth two times a day for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered morning dose on 02/22/26. Review of the EMR revealed a physician order for metformin 1000 mg by mouth two times a day for type 2 diabetes mellitus. Review of the MAR revealed the resident did not receive either of the physician-ordered doses on 02/22/26. Review of the EMR revealed a physician order dated 01/13/25 for magnesium 400 mg by mouth once daily for hypomagnesemia. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order for insulin aspart FlexPen 100 units/milliliter (u/mL) to be administered subcutaneously per sliding scale before meals and at bedtime. Review of the MAR revealed the resident did not receive the physician-ordered doses at 11:00 A.M. or 4:00 P.M. on 02/22/26. Review of the EMR revealed a physician order dated 12/23/25 to maintain the HOB elevated every shift to alleviate shortness of breath related to COPD. Review of the TAR revealed the HOB was not elevated during the day shift on 02/22/26. Review of the EMR revealed a physician order dated 03/18/25 to monitor behaviors and document interventions every shift. Review of the TAR revealed behavior monitoring and documentation of interventions were not completed during the day shift on 02/22/26. Review of the EMR revealed a physician order for a sign to be placed in Resident #43's room instructing the resident to call for assistance prior to self-transferring every shift. Review of the TAR revealed this physician-ordered intervention was not implemented during the day shift on 02/22/26. During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #43 did not receive the physician-ordered doses of aspirin, buspirone, vitamin B12, carvedilol, metformin, apixaban, ergocalciferol, insulin aspart, and magnesium on 02/22/26. The DON further confirmed the physician-ordered behavior monitoring, blood sugar checks, and head-of-bed elevation were not implemented on 02/22/26. 7. Review of the EMR for Resident #75 revealed an admission date of 07/24/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), moderate protein-calorie malnutrition, obstructive sleep apnea (OSA), acute renal failure (ARF), heart disease, anxiety, hypertension (HTN), hypothyroidism, transient ischemic attack (TIA), mild neurocognitive disorder, schizoaffective disorder, convulsions, and restless leg syndrome (RLS). Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident's cognition was intact. Further review of the assessment revealed Resident #75 required assistance with activities of daily living including toileting, bathing, dressing, hygiene, repositioning in bed, transferring, ambulation, and locomotion via wheelchair. Review of the EMR revealed multiple physician orders for medications including amlodipine, aspirin (ASA), Breo Ellipta, doxazosin mesylate, duloxetine HCl, fexofenadine HCl, tamsulosin (Flomax), furosemide, Incruse Ellipta, insulin glargine, isosorbide mononitrate extended release, losartan potassium, paliperidone ER, potassium chloride, ProStat sugar free nutritional supplement, vitamin C, carvedilol (Coreg), cyclosporine ophthalmic emulsion, famotidine, glipizide, levetiracetam (Keppra), metformin, quetiapine fumarate, buspirone HCl, hydralazine HCl, and insulin aspart per sliding scale. Review of the MAR revealed the resident did not receive numerous physician-ordered medications on 02/22/26, including the morning doses of amlodipine, aspirin, Breo Ellipta, doxazosin, duloxetine, fexofenadine, tamsulosin, furosemide, Incruse Ellipta, insulin glargine, isosorbide mononitrate ER, losartan, palipe

Based on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), staff interview, and review of facility documentation, the facility failed to ensure residents were free from significant medication errors. Specifically, the facility failed to administer numerous physician-ordered medications, including antihypertensives, anticoagulants, antiepileptics, psychotropic medications, insulin, and respiratory medications, as prescribed for 10 (#9, #12, #15, #24, #34, #43, #75, #77, #85, and #89) of 10 residents reviewed for medication administration. The facility census was 89.Findings include: 1. Review of the EMR for Resident #9 revealed an admission date of 02/13/26 with diagnoses including alcohol abuse, depression, anxiety, hypertension (HTN), insomnia, vitamin B12 deficiency, and vitamin D deficiency.Review of Resident #9's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed the resident required supervision or touching assistance with functional tasks including eating, hygiene, toileting, dressing, transferring, and walking.Review of the EMR revealed physician orders dated 02/14/26 for hydrochlorothiazide (HCTZ) 25 milligrams (mg) by mouth once daily for hypertension and paroxetine HCl 30 mg by mouth once daily for depression. Review of the MAR revealed the resident did not receive the physician-ordered dose of hydrochlorothiazide or the dose of paroxetine HCL on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the Director of Nursing (DON) confirmed Resident #9 did not receive the physician-ordered doses of cholecalciferol, cyanocobalamin, hydrochlorothiazide, and paroxetine HCl on 02/22/26.2. Review of the EMR for Resident #12 revealed an admission date of 09/17/23 with diagnoses including anoxic brain damage, personal history of sudden cardiac arrest, dissection of abdominal aorta, non-ST-elevation myocardial infarction (NSTEMI), depression, heart failure, anxiety, chronic respiratory failure with hypoxia, stage 3B chronic kidney disease (CKD3B), oropharyngeal dysphagia, seizures, pseudobulbar affect (PBA), urinary incontinence, incontinence of feces, sleep apnea, gastroesophageal reflux disease (GERD), insomnia, hyperlipidemia, dilated cardiomyopathy, major depressive disorder, and hypertension (HTN).Review of Resident #12's most recent quarterly MDS assessment revealed a BIMS score of 02, indicating severe cognitive impairment. Further review of the assessment revealed the resident required extensive assistance to total dependence for activities of daily living, including eating, hygiene, bathing, dressing, repositioning, and transferring.Review of the EMR revealed a physician order dated 02/22/26 for amlodipine 10 mg by mouth in the morning for dilated cardiomyopathy. Review of the MAR revealed the resident did not receive the physician-ordered dose of amlodipine on 02/22/26.Review of the EMR revealed a physician order dated 01/31/26 for two capsules of Nuedexta 20-10 mg by mouth in the morning for major depressive disorder. Review of the MAR revealed the resident did not receive the physician-ordered dose of Nuedexta on 02/22/26.Review of the EMR revealed a physician order dated 02/02/26 for carvedilol 3.125 mg by mouth two times a day for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered dose of carvedilol on 02/22/26.Review of the EMR revealed a physician order dated 11/12/25 for two capsules of Depakote Sprinkles 125 mg by mouth two times a day for increased behaviors. Review of the MAR revealed the resident did not receive the physician-ordered dose of Depakote Sprinkles on 02/22/26.Review of the EMR revealed a physician order dated 12/02/25 for diazepam 5 mg/5 mL, administer 2 mL by mouth two times a day for agitation. Review of the MAR revealed the resident did not receive the physician-ordered dose of diazepam on the morning of 02/22/26.Review of the EMR revealed physician orders dated 02/21/26 for levetiracetam 100 mg/mL, administer 5 mL by mouth two times a day for anoxic brain damage, and minoxidil 5 mg by mouth two times a day for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered dose of levetiracetam or the dose of minoxidil on the morning of 02/22/26.Review of the EMR revealed a physician order dated 02/25/26 for buspirone 10 mg by mouth three times a day for anxiety. Review of the MAR revealed the resident did not receive two of the three physician-ordered doses of buspirone on 02/22/26 at 6:00 A.M. and 1:00 P.M.Review of the EMR revealed a physician order dated 08/13/25 for gabapentin 600 mg by mouth three times a day for agitation. Review of the MAR revealed the resident did not receive two of the three physician-ordered doses of gabapentin on 02/22/26 at 6:00 A.M. and 1:00 P.M.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #12 did not receive the physician-ordered doses of sertraline, gabapentin, amlodipine, buspirone, Depakote Sprinkles, diazepam, Nuedexta, carvedilol, minoxidil, and levetiracetam on 02/22/26.3. Review of the EMR for Resident #15 revealed an admission date of 10/20/25 with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, personal history of sudden cardiac arrest, congestive heart failure (CHF), other specified diseases of the liver, and cerebral infarction.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating the cognitive assessment was unable to be completed. Further review of the assessment revealed Resident #15 required total assistance for functional areas including hygiene, dressing, repositioning, transferring, and locomotion via wheelchair.Review of the EMR revealed a physician order dated 11/11/25 for lactulose 10 grams (g)/15 milliliters (mL), administer 10 mL by mouth once daily for elevated ammonia level. Review of the MAR revealed the resident did not receive the physician-ordered dose of lactulose on 02/22/26.Review of the EMR revealed physician orders dated 02/21/26 for levetiracetam oral solution 15 mL two times a day for seizures, and valproic acid oral solution 10 mL two times per day for seizures. Review of the MAR revealed the resident did not receive the physician-ordered doses of levetiracetam and valproic acid in the morning on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #15 did not receive the physician-ordered doses of lactulose, omeprazole, valproic acid, levetiracetam, and clobazam on 02/22/26.4. Review of the EMR for Resident #24 revealed an admission date of 07/13/25 with diagnoses including malignant neoplasm of the prostate, severe protein-calorie malnutrition, chronic gastritis without bleeding, viral hepatitis C, supraventricular tachycardia (SVT), thrombocytosis, alcohol abuse, osteoarthritis, chronic pain, rash, altered mental status (AMS), hypertension (HTN), urinary retention, and allergic rhinitis.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating the resident had moderately impaired cognition. Further review of the assessment revealed the resident required assistance with activities of daily living including eating, showering/bathing, hygiene, and transfers.Review of the EMR revealed a physician order dated 02/22/26 for amlodipine besylate 10 mgs by mouth once daily for supraventricular tachycardia. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 07/14/25 for bicalutamide 50 mg by mouth once daily for prostate cancer. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 07/14/25 for tamsulosin HCl 0.4 mg by mouth once daily for benign prostatic hyperplasia (BPH). Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #24 did not receive the physician-ordered doses of bicalutamide, amlodipine,, or tamsulosin on 02/22/26.5. Review of the EMR for Resident #34 revealed an admission date of 01/29/24 with diagnoses including central cord syndrome at the C5 level of the cervical spinal cord, severe protein-calorie malnutrition, transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), asthma, epilepsy, quadriplegia, acute renal failure (ARF), gangrene and necrosis of lung, acquired absence of kidney, pneumonia, dysphagia, sepsis, displaced intertrochanteric fracture of the right femur, generalized muscle weakness, cognitive communication deficit, anemia, sensorineural hearing loss, peripheral vascular disease, age-related nuclear cataract, left knee contracture, major depressive disorder, hyperlipidemia, nicotine dependence, hypertension (HTN), cervical spondylosis, right knee contracture, post-traumatic seizures, and hypotension.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Further review of the assessment revealed Resident #34 had bilateral impairment of the upper and lower extremities and required total assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transferring.Review of the EMR revealed a physician order dated 02/22/26 for Anoro Ellipta 62.5-25 mcg per actuation (mcg/act), administer one puff by mouth once daily for COPD. Review of the Medication Administration Record (MAR) revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 02/24/25 for lisinopril 5 mg by mouth once daily for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 02/23/25 for sertraline 12.5 mg (one-half tablet of 25 mg) by mouth every morning for depression. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order dated 10/30/25 for levetiracetam 750 mg by mouth two times a day for seizures. Review of the MAR revealed the resident did not receive the physician-ordered dose during the day shift on 02/22/26.Review of the EMR revealed a physician order dated 11/25/25 for metoprolol tartrate 25 mg by mouth two times a day. Review of the MAR revealed the resident did not receive the physician-ordered dose during the day shift on 02/22/26.Review of the EMR revealed a physician order for baclofen 10 mg by mouth three times a day for muscle relaxation. Review of the MAR revealed the resident did not receive the physician-ordered doses in the morning and afternoon on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #34 did not receive the physician-ordered doses of baclofen, lisinopril, levetiracetam, sertraline, Anoro Ellipta, clopidogrel, or metoprolol on 02/22/26.6. Review of the EMR for Resident #43 revealed an admission date of 11/28/25 with diagnoses including monoplegia of the upper limb, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), hypertension (HTN), functional quadriplegia, dementia, dry eye syndrome, long-term use of insulin, major depressive disorder, anxiety, generalized muscle weakness, and oropharyngeal dysphagia.Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident was relatively cognitively intact. Further review of the assessment revealed the resident had impairment of the upper and lower extremities on one side and required substantial to maximal assistance with activities of daily living including eating, hygiene, dressing, repositioning, and transfers.Review of the EMR revealed a physician order for apixaban 5 mg by mouth two times a day for cerebrovascular accident. Review of the MAR revealed the resident did not receive the physician-ordered morning dose on 02/22/26.Review of the EMR revealed a physician order for buspirone 5 mg by mouth once daily for anxiety. Review of the MAR revealed the resident did not receive the physician-ordered dose on 02/22/26.Review of the EMR revealed a physician order for carvedilol 25 mg by mouth two times a day for hypertension. Review of the MAR revealed the resident did not receive the physician-ordered morning dose on 02/22/26.Review of the EMR revealed a physician order for metformin 1000 mg by mouth two times a day for type 2 diabetes mellitus. Review of the MAR revealed the resident did not receive either of the physician-ordered doses on 02/22/26.Review of the EMR revealed a physician order for insulin aspart FlexPen 100 units/milliliter (u/mL) to be administered subcutaneously per sliding scale before meals and at bedtime. Review of the MAR revealed the resident did not receive the physician-ordered doses at 11:00 A.M. or 4:00 P.M. on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #43 did not receive the physician-ordered doses of buspirone, carvedilol, metformin, apixaban, and insulin aspart on 02/22/26.7. Review of the EMR for Resident #75 revealed an admission date of 07/24/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM2), moderate protein-calorie malnutrition, obstructive sleep apnea (OSA), acute renal failure (ARF), heart disease, anxiety, hypertension (HTN), hypothyroidism, transient ischemic attack (TIA), mild neurocognitive disorder, schizoaffective disorder, convulsions, and restless leg syndrome (RLS).Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident's cognition was intact. Further review of the assessment revealed Resident #75 required assistance with activities of daily living including toileting, bathing, dressing, hygiene, repositioning in bed, transferring, ambulation, and locomotion via wheelchair.Review of the EMR revealed multiple physician orders for medications including amlodipine, Breo Ellipta, doxazosin mesylate, duloxetine HCl, fexofenadine HCl, tamsulosin (Flomax), furosemide, Incruse Ellipta, insulin glargine, isosorbide mononitrate extended release, losartan potassium, paliperidone ER, carvedilol (Coreg), cyclosporine ophthalmic emulsion, famotidine, glipizide, levetiracetam (Keppra), metformin, quetiapine fumarate, buspirone HCl, hydralazine HCl, and insulin aspart per sliding scale.Review of the MAR revealed the resident did not receive numerous physician-ordered medications on 02/22/26, including the morning doses of amlodipine, Breo Ellipta, doxazosin, duloxetine, fexofenadine, tamsulosin, furosemide, Incruse Ellipta, insulin glargine, isosorbide mononitrate ER, losartan, paliperidone ER, carvedilol, cyclosporine ophthalmic drops, famotidine, glipizide, levetiracetam, metformin, and quetiapine, multiple scheduled doses of buspirone at 8:00 A.M. and 11:00 A.M., hydralazine at 8:00 A.M. and 2:00 P.M., and sliding scale insulin doses of the insulin aspart at 7:00 A.M., 11:00 A.M., and 4:30 P.M.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #75 did not receive multiple physician-ordered medications on 02/22/26, including Breo Ellipta, famotidine, quetiapine, fexofenadine, cyclosporine ophthalmic drops, glipizide, insulin glargine, tamsulosin, Incruse Ellipta, furosemide, duloxetine, metformin, insulin aspart, levetiracetam, isosorbide mononitrate, amlodipine, carvedilol, doxazosin, losartan, paliperidone, hydralazine, buspirone, and glipizide.8. Review of the EMR for Resident #77 revealed an admission date of 07/27/19 with diagnoses including monoplegia of the upper limb following a cerebral infarction affecting the left non-dominant side, HTN, depression, GERD, hyperlipidemia, atherosclerotic heart disease, aphasia following cerebral infarction, DM2, drug-induced secondary parkinsonism, dysarthria and anarthria, and peripheral vascular disease.Review of Resident #77's most recent annual MDS assessment, dated 12/05/25, revealed a BIMS score of 11, indicating moderate cognitive impairment. Further review of this assessment revealed Resident #77 had impairment in one upper and one lower limb and required assistance with all functional abilities, including eating, hygiene, bathing, dressing, transferring, and toileting.Additionally, EMR review revealed a physician order dated 05/13/25 for insulin aspart FlexPen 100 u/mL, to be administered subcutaneously per sliding scale before meals and at bedtime. MAR review revealed the resident did not receive the physician-ordered doses at 7:00 A.M., 11:00 A.M., or 4:00 P.M. on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #77 did not receive the physician-ordered doses insulin aspart on 02/22/26.9. Review of the EMR revealed Resident #85 had an admission date of 07/25/25 with diagnoses including COPD, major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), nightmare disorder, colostomy status, personal history of military deployment, personal history of other malignant neoplasm of rectum, rectosigmoid junction and anus, severe protein-calorie malnutrition, unspecified abnormalities of gait and mobility, non-pressure chronic ulcer of skin of other sites with fat layer exposed, HTN, hearing loss, repeated falls, and bradycardia.The most recent quarterly MDS assessment, dated 02/01/26, revealed a BIMS score of 14, indicating the resident was cognitively intact. Further review of this assessment revealed Resident #85 required partial to maximal assistance with functional abilities including, but not limited to, eating, hygiene, bathing, dressing, repositioning, transferring, and wheeling in a wheelchair.Review of the EMR revealed a physician order for Coreg 3.125 mg two times a day for HTN. MAR review revealed the resident did not receive the physician-ordered morning dose on 02/22/26. EMR review revealed a physician order dated 02/21/26 for minoxidil 2.5 mg two times a day for HTN. MAR review revealed the resident did not receive the physician-ordered morning dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #85 did not receive the physician-ordered doses of Coreg and minoxidil on 02/22/26.10. Review of the EMR revealed Resident #89 had an admission date of 05/06/25 with diagnoses including chronic respiratory failure, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, benign prostatic hyperplasia (BPH), other idiopathic peripheral autonomic neuropathy, atrial fibrillation, HTN, obstructive sleep apnea (OSA), COPD, generalized anxiety disorder, fracture of unspecified part of the neck of the right femur, elevated white blood cells (WBC), chronic peripheral venous insufficiency, nasal congestion, urinary retention, and idiopathic progressive neuropathy.The most recent quarterly MDS assessment, dated 01/10/26, revealed a BIMS score of 11, indicating moderate cognitive impairment. Further review of this assessment revealed Resident #89 required maximal assistance or was dependent for functional abilities including, but not limited to, oral hygiene, toileting, bathing, dressing, hygiene, repositioning, transferring, and wheeling in a wheelchair.EMR review revealed a physician order dated 10/08/25 for amiodarone 100 mg once daily for arrhythmia. MAR review revealed the resident did not receive the physician-ordered dose on 02/22/26. EMR review further revealed physician orders dated 11/25/25 for citalopram hydrobromide 10 mg once daily for depression; 10/08/25 for Lasix 40 mg once daily for edema; 10/08/25 for loratadine 10 mg once daily for inflammation; 10/08/25 for a multivitamin once daily for supplement; 10/08/25 for polyethylene glycol powder 17 g once daily for constipation; and 10/08/25 for vitamin D 2000 units once daily for vitamin deficiency. MAR review revealed the resident did not receive these physician-ordered medications on 02/22/26.EMR review also revealed physician orders for Spiriva Respimat inhalation aerosol solution 2.5 mcg/act, two puffs once daily for COPD, and Advair Diskus inhalation powder 250/50 mcg/act two times daily for COPD. MAR review revealed the resident did not receive these physician-ordered medications on 02/22/26.Additional EMR review revealed physician orders dated 02/26/25 for apixaban 5 mg two times daily for anticoagulation therapy; 10/07/25 for azelaic acid external gel 15% applied topically two times daily for rash; and 10/07/25 for tamsulosin 0.4 mg two times daily for prostate symptoms. MAR review revealed the resident did not receive the physician-ordered morning doses of these medications on 02/22/26.Further EMR review revealed a physician orders dated 02/22/26 for guaifenesin 600 mg, two tablets two times daily for COPD. MAR review revealed the resident did not receive the physician-ordered morning dose on 02/22/26. EMR review also revealed a physician order dated 02/21/26 for buspirone 30 mg three times daily for anxiety. MAR review revealed the resident did not receive the physician-ordered morning and afternoon doses on 02/22/26.Additional EMR review revealed a physician order dated 02/12/26 for ipratropium-albuterol solution 0.5-2.5 mg/mL, 3 mL every six hours for COPD. MAR review revealed the resident did not receive the physician-ordered afternoon dose on 02/22/26.During an interview on 03/11/26 at 12:54 P.M., the DON confirmed Resident #89 did not receive the physician-ordered doses of buspirone, guaifenesin, citalopram, Lasix, Advair Diskus, Spiriva, loratadine, amiodarone, azelaic acid, apixaban, tamsulosin, sennosides-docusate, and ipratropium-albuterol on 02/22/26.Review of the facility Resident Agreement, dated 11/24/24, reveled the facility must protect and promote the rights of the residents. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that will compromise necessary and appropriate care consistent with the program for which the resident is contracted.Review of the undated facility policy titled, Medication Administration, revealed medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number 2793023.

Based on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), staff interview, and review of facility documentation, the facility failed to ensure a resident receiving enteral nutrition received tube feeding and associated care in accordance with physician orders and professional standards of nursing practice. Specifically, the facility failed to administer physician-ordered tube feedings and required percutaneous endoscopic gastrostomy (PEG) tube flushes for one of one resident (#15) reviewed for tube feeding management. The facility census was 89. Findings include: Review of the EMR for Resident #15 revealed an admission date of 10/20/25 with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, personal history of sudden cardiac arrest, congestive heart failure (CHF), other specified diseases of the liver, and cerebral infarction.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the cognitive assessment was unable to be completed. Further review of the assessment revealed Resident #15 required total assistance for functional areas including hygiene, dressing, repositioning, transferring, and locomotion via wheelchair.Review of the EMR revealed a physician order dated 10/24/25 to flush the resident's PEG tube with 60 milliliters (mLs) of water before and after each bolus feeding and every four hours. Review of the MAR revealed the resident did not receive the physician-ordered PEG tube flushes at 10:00 A.M. and 2:00 P.M. on 02/22/26.Review of the EMR revealed a physician order dated 10/24/25 for Jevity 1.5, administer 237 mL bolus feeding every four hours for tube feeding. Review of the MAR revealed the resident did not receive the physician-ordered Jevity 1.5 bolus feedings at 10:00 A.M. and 2:00 P.M. on 02/22/26.Review of the facility Resident Agreement, dated 11/24/24, revealed the facility must protect and promote the rights of the residents. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that will compromise necessary and appropriate care consistent with the program for which the resident is contracted.Review of the undated facility policy titled, Medication Administration, revealed medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number 2793023.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, resident interview, staff interview, surveillance video review, facility Self-Reported Incident review, review of the facility investigation, review of staff schedules, and review of facility policy, the facility failed to ensure an allegation of abuse was reported timely. This affected one (#10) of three residents reviewed for abuse and had the ability to affect 23 residents (#33, #35, #36, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57, #58, #59, #60) who reside in the secured behavioral unit. Facility census was 83.Findings include:Review of Resident #10's medical record revealed an admission date of 04/16/25 and resided on the secured behavioral unit. Diagnoses included schizophrenia, post-traumatic stress disorder, anxiety, and depression. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive function. Resident #10 was noted to have verbally abusive behaviors and often rejected care.Review of Resident #10's nursing progress note written by Licensed Practical Nurse (LPN) #115, dated 01/03/26 and timed 6:11 P.M. revealed Resident #10 was leaving the dining room and Certified Nursing Assistant (CNA) #200 asked the resident to place her food tray on the food cart. The resident stated, I did not think there is any more room in the tray cart. CNA #200 stated, Let me just push these other trays back for you. Resident #10 stated Why are you looking at me like that? and CNA #200 responded I am not looking at you any kind of way. I would just like for the food trays to be brought back up to the front, please. The resident then got into CNA #200's face and with an aggressive attitude stated, I am not going to let nobody gaslight me. At that point another aide, CNA #210 stepped in between CNA #200 and Resident #10 to defuse the situation. The resident walked outside to calm down with CNA #210. The resident and both CNAs were safe, and no physical harm was done, but the aide stated she should be able to come to work and feel safe to do her job. The note stated the Unit Manager #320 and physician were notified.Review of the facility's Self-Reported Incident dated 01/13/25 and timed 1:31 P.M. revealed Unit Manager #320 went to an appointment with Resident #10 and while at the appointment Resident #10 shared with the provider that an aide had gotten in her face a few days ago. Upon returning to the facility Unit Manager #320 reported the possible allegation of abuse between Resident #10 and an aide. An investigation was immediately started. Review of the investigation notes revealed Social Worker #325 interviewed Resident #10 on 01/13/26 at 3:00 P.M. and discovered there was an incident that occurred on 01/03/26 that was causing the resident emotional distress. Resident #10 stated the incident occurred in the dining room at dinner time when CNA #200 stood in close proximity to her, raised her voice, and demanded that Resident #10 return her meal tray to the food cart. Further review of the facility investigation notes dated 01/14/26 revealed it was discovered that Resident #10 had left a voicemail on admission Manager #326's phone line on 01/05/26 describing the incident. Review of the video surveillance (no sound) with the Administrator on 01/29/26 revealed on 01/03/26 at approximately 5:25 P.M. Resident #10 was eating dinner at a table in the dining room with Resident #15, and when Resident #10 stood up to walk away from the dining room table CNA #200, who was sitting on a heater along the wall with CNA #210 looking at their phones, said something to the resident at which time Resident #10 walked over to CNA #200. When Resident #10 reached CNA #200 there was an exchange of words, followed by both CNA #200 and Resident #10 flailing their arms and pointing fingers at each other in an aggressive manner. CNA #200 was in close proximity to Resident #10 with assertive body language, Resident #10 was observed as becoming visibly distressed and crying at which time CNA #210 stood up and stepped between CNA #200 and Resident #10. CNA #210 was seen saying something to Resident #10 and then lead Resident #10 out of the dining room. While this incident was occurring Resident #15 stop eating, picked up Resident 10's tray, went over to the tray cart, placed Resident #10's tray in the food cart and then returned to the table to finish his dinner. Review of the staff schedules from 01/03/26 through 01/19/26 revealed CNA #200 worked from 2:00 P.M. until 10:00 P.M. on the secured behavioral unit on 01/03/26, 01/04/26, 01/06/26, 01/07/26, 01/08/26, 01/09/26 and 01/12/26. Interview with the Administrator on 01/29/26 at 3:50 P.M. verified on 01/03/26 Resident #10 was in an altercation with CNA #200 on the secured behavior unit dining room. The Administrator stated on 01/13/26 Resident #10 informed Unit Manager #320 that CNA #200 verbally abused her, at which time the incident was immediately reported and an investigation was started. The Administrator verified that CNA #200 was suspended on 01/13/26 when she was made aware of the incident and further verified that CNA #200 had worked multiple shifts between 01/03/26, when the incident occurred, and 01/13/26 when the she was made aware of the incident. Continued interview with the Administrator revealed on 01/14/26 Admissions Manager #326 found a voicemail left on her phone messages dated 01/05/26 from Resident #10 regarding the abuse allegation. The Administrator stated it was the CNA's job to take care of the residents' trays, and that CNA #200 should have handled the situation differently. The Administrator also verified that LPN #115 should have reported the incident on 01/03/26 when writing the progress note in Resident #10's medical record.Interview with Resident #10 on 02/10/26 at 9:24 A.M. revealed she had an altercation with CNA #200 in the dining room because the aide was mean to her and the aide did not like her. The resident revealed CNA #200 yelled at her and was mean.Telephone interview with CNA #200 on 02/10/26 at 10:45 A.M. revealed on 01/03/26 she was sitting on a heater in the dining room by the smoker's door observing dinner. CNA #210 was sitting with her. CNA #200 stated all residents usually bring their food tray up to the food cart when they were done eating in the dining room. CNA #200 stated that Resident #10 usually slept through dinner, but on 01/03/26 she was eating at a table with Resident #15 and when Resident #10 stood up and walked over by the food cart she asked the resident if she was going to bring her tray up and the resident became upset and started yelling. CNA #200 stated Resident #10 got in her face and kept asking her questions like Why are you looking at me? Why are you screaming at me? Why are you gas lighting me? that was when CNA #210 then came between the two of them and took Resident #10 out of the area. CNA #200 stated she has worked at the facility for 15 years and claims to have reported the incident to LPN #155 right after the incident occurred.Review of the undated facility policy titled Abuse, Neglect, and Exploitation, revealed all alleged violations of abuse should be reported to the Administrator, State Agency, Adult Protective Services and to all other required agencies immediately but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury, and no later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 01/20/26:On 01/13/26 at 10:30 A.M. the abuse allegation was reported Unit Manager #320 by Resident #200. Unit Manager #320 reported the allegation to the Administrator, and an investigation was started immediately, and CNA #200 was placed off on Administrative leave. On 01/13/26 from 11:37 A.M. until 12:03 P.M. all interviewable residents in the secured behavioral unit were interviewed about concerns for abuse and being made to return food trays to the food cart. Interviews revealed no concerns for abuse, verbal of physical and residents stated they are not required to return food trays to the cart. On 01/13/26 at 1:31 P.M. the Administrator filed a Self-Reported Incident with the State Agency.On 01/13/26 starting at 2:16 P.M. the Nurse Managers completed skin assessments on the 23 residents of the secured behavioral unit. Assessments were completed at 3:05 P.M. with no negative findings. On 01/13/26 at 3:00 P.M. Social Worker #325 conducted an interview with Resident #10 and obtained a statement from the resident regarding the 01/03/26 incident and completed an assessment. On 01/14/26 Social Worker #325 further assessed Resident #10 with plans for continued daily check ins with Resident #10. As of 01/29/26 there had been no adverse findings. On 01/14/26 investigation into how the voicemail on admission Manager #326's was missed revealed the mailbox for which the voicemail was left was a dummy personal voicemail box set up for spam. The spam voicemail box was deleted. The Administrator provided education to Admissions Manager #326 that voicemail messages are be checked on a daily basis.On 01/15/26 at 2:46 P.M. the Administrator obtained a witness statement from CNA #210. On 01/16/26 Resident #10's family/responsible party were notified of the incident by the Administrator.On 01/16/26 Social Work #325 obtained resident witness statements. On 01/16/26 at 1:26 P.M. the Administrator interviewed and obtained a witness statement form CNA #200. On 01/17/26 the video surveillance of the 01/03/26 incident was reviewed by the Administrator.On 01/19/26 at 10:26 A.M. LPN #115 was educated by the Administrator on reporting allegations of abuse. On 01/19/26 the Administrator and designee re-educated all staff on the Abuse policy, including on where and how to report abuse, appropriate communication, maintaining personal space, trauma informed approaches when interacting with behavioral residents, how to deescalate expectations and early intervention techniques including separation between the resident and the involved staff member to prevent recurrence. The Administrator also reinforced with staff that meal tray delivery and removal are staff responsibilities and residents were not expected to perform these tasks.On 01/19/26 all residents were educated on where and how to report abuse.On 01/20/26 CNA #200 received corrective action and was told she would no longer be permitted to work in the secure behavioral unit. CNA also received education on the Abuse policy, Resident Rights, and Meal Supervision and Assistance. Starting 01/20/26 ongoing the Administrator or designee will conduct ongoing monitoring daily and reinforcement of facility policies with on the spot re-education as needed. This deficiency represents non-compliance investigated under Complaint Number 2721200.

Based on closed medical record review, staff interviews, review of staff witness statements, review of the hospital notes, and review of the facility policy, the facility failed to ensure bed rails were properly installed. This resulted in Actual harm to Resident #89 when on 10/11/25 the facility applied bed rail broke off during resident care, causing the resident to roll out of bed, be lowered to the floor by staff, and maneuvered onto a Hoyer pad. Consequently, Resident #89 sustained a displaced fracture of the right humeral neck (upper arm). This affected one (#89) of three residents reviewed for falls. The facility census was 86.Findings include:Review of the closed medical record revealed Resident #89 was admitted on [DATE] and discharged on 10/25/25. Diagnoses included unspecified displaced fracture of surgical neck of right humerus (10/14/25), Type two diabetes mellitus with diabetic polyneuropathy, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), primary pulmonary hypertension, and complete traumatic amputation at level between knee and ankle of the right lower leg. Review of the care plan, dated 05/05/25, revealed Resident #89 had an activities of daily living (ADLs) self-care performance deficit and required maximum assistance by staff with shower/bathing and bed mobility by one to two staff. Review of the Device Observation documentation, dated 09/19/25, revealed Resident #89 expressed a desire to have bed rails. Bilateral bed rails/assistive devices were indicated for the resident to assist with autonomy. Review of the Minimum Data Set (MDS) assessment, dated 10/19/25, revealed Resident #89 was cognitively intact, dependent for toileting, showering, upper and lower body dressing, and personal hygiene. The assessment indicated a bed rail was not used. Review of a progress note, dated 10/11/25 and authored by Licensed Practical Nurse (LPN) #425, revealed that while providing care, including incontinence care and a bed bath, Resident #89 was rolled to the side (in bed). The side rail fell off the bed, and the staff lowered the resident to the floor. The writer and two other staff members were in the room providing care. The resident stated he was rolled out of bed onto the floor and stated his right shoulder popped/cracked. The writer called more staff to assist. The resident was soiled and assisted to roll onto a Hoyer pad to lift the resident back into bed. Vital signs were obtained, and the resident was assessed for injury. The resident complained of pain to the right shoulder and was unable to perform range of motion prior to the incident and was not attempted per resident refusal. Resident demanded to go to the hospital to have an X-ray completed. All notifications were completed, and the resident was transported to the hospital. Review of a written statement, dated 10/11/25 and completed by Certified Nursing Assistant (CNA) #440, revealed that while providing a bed bath for Resident #89, he was rolled over, the bed rail broke off, and the resident was lowered to the ground by staff. The nurse was also present giving care. Review of a written statement, dated 10/11/25 and completed by CNA #493, revealed CNA #493 and CNA #440 were giving Resident #89 a bed bath and when they turned him on his side, the bed rail broke, and CNA #440 caught the first (top) half of his body, so he did not hit the ground hard. LPN #425 was present in the room, and she was helping change a dressing on his bottom and she also helped get him down to the ground safely. Review of a written statement, dated 10/11/25 and completed by LPN #425, revealed she was assisting with a bed bath and when rolling the resident, the side rail fell off, and one staff held (the resident) as long as she could while the other staff went around the bed to assist and the writer was holding the left leg. The resident was soiled and wet when it was realized he could not be held. Staff lowered him to the ground and called more staff to assist with getting him onto a Hoyer pad and assisted him back to bed. Review of the hospital notes, dated 10/11/25, revealed Resident #89 was being rolled in his bed when he fell on his right side and hurt his shoulder. The X-ray of the right shoulder showed a mildly displaced fracture of the right humeral neck. Swelling and signs of injury were present during the musculoskeletal examination. The resident's arm was placed in a sling, Tylenol and oxycodone were ordered for pain, and an orthopedic referral was made. A telephone interview on 11/25/25 at 10:41 A.M. with CNA #493 verified that on 10/11/25, she and another aide (CNA #440) were giving Resident #89 a bed bath. An aide was on each side of the resident, and the nurse (LPN #425) was at the foot of the bed. CNA #493 stated that when they turned him, the resident was holding on to the bed rail, and the entire bed rail broke off because he was leaning on it. All three staff lowered him to the ground, and the resident reported his shoulder cracked. CNA #493 stated the resident had told her the bed had just been fixed. Interview on 11/25/25 at 11:23 A.M. with Maintenance Director (MD) #403 revealed Resident #89 had a bariatric air mattress and mobility bars (bed rails) placed on each side of the bed. MD #403 stated the day prior to the bed rail falling off the bed, he received notification that the resident's bed rails were loose, and he found they had been moved to an unsecure area on the bedframe (near the crossbar). MD #403 stated he moved the bars to the correct location on the bedframe at that time. However, after the fall it was found the bed rails had been moved. MD #403 explained that the bed rails used worked well on the resident's bed, if applied correctly; however, they had been moved near the crossbar on the bedframe, which made them unstable. MD #403 revealed he did not know who had moved the bed rails again and verified Resident #89 would not have been able to move or adjust the bed rails himself. A telephone interview 11/25/25 at 11:58 A.M. with CNA #440 verified there were three staff in the room providing care for Resident #89 at the time of his fall on 10/11/25. CNA #440 stated they rolled the resident over, the resident held onto the bedrail, and the bedrail fell off. CNA #440 stated she held on to the middle of his body for as long as she could while the other aide came around the side of the bed. CNA #440 stated Resident #89 was nearly 400 pounds and they lowered him to the ground with the sheets that surrounded him. CNA #440 stated Resident #89 was rolled to his right side and onto the Hoyer pad to lift him back into the bed. CNA #440 stated Resident #89 complained that his right arm was hurting and told the staff that they made him fall. CNA #440 verified Resident #89 requires two to three staff for ADL care due to his size. A follow up interview on 11/25/25 at 3:19 P.M. with MD #403 revealed that after Resident #89 returned from the hospital, he confirmed that a facility staff had moved the bed rails prior to the fall. MD #403 did not know who the staff was that moved the bed rails. MD #403 stated the bed rails could not clamp down on the crossbar and there was a knob to tighten, loosen, or move the bed rails and the bed rails were clamped on the crossbar at the time they fell off the bedframe, and the resident fell out of bed. MD #403 confirmed staff had adjusted the mobility bars in the past and put them on incorrectly. In addition, MD #403 confirmed the facility did not have a user manual for the bed rails that were used on Resident #89's bed and the bed rail user manual provided to the surveyor was not for the bed rails that were in use on the resident's bedframe. Review of the facility policy titled, Proper Use of Bed Rails, dated 2025, revealed the facility would assure the correct installation and maintenance of bed rails prior to use. This included checking with the manufacturer to make sure the bed rails, mattress and bed frame are compatible, confirming the bed rails are appropriate for the size and weight of the resident using the bed, installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit, inspecting and regularly checking the mattress and bed rails of possible entrapment, checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. The facility will continue to provide necessary treatment and care to the resident who has bed rails, and to include them in the care plan. This violation represents non-compliance investigated under Complaint Number 2675165.

Based on medical record review and staff interview, the facility failed to obtain blood pressures to monitor the ordered parameters for administering medication for one (#91) of three residents reviewed for medication administration. The facility census was 86. Findings include: Review of the medical record revealed Resident #91 had an admission date of 06/18/25. Diagnoses included dementia, morbid obesity, end stage renal disease (ESRD), type two diabetes mellitus (DM2), obstructive sleep apnea (OSA), hypertension (HTN), metabolic encephalopathy, and dependence on renal dialysis. Review of the record revealed a physician order dated 08/16/25 for Midodrine 5 milligrams (mg) three times a day for hypotension, hold for a systolic blood pressure (SBP) greater than 90. Review of Resident #91's medication administration record (MAR) for September 2025 revealed no documentation of blood pressures being obtained prior to the administration of Midodrine to Resident #91 from 09/01/25 through 09/30/25. Review of Resident #91's MAR for October 2025 revealed no documentation of blood pressures being obtained prior to the administration of Midodrine to Resident #91 from 10/01/25 through 10/31/25. Review of Resident #91's MAR for 11/01/25 through 11/11/16/25 revealed no documentation of blood pressures being obtained prior to the administration of Midodrine to Resident #91 on 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/06/25, 11/07/25, 11/08/25, 11/09/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, or 11/14/25. Interview on 12/02/25 at 11:45 A.M. with Registered Nurse (RN) #432 verified no evidence of blood pressures being obtained prior to the administration of Midodrine to Resident #91 for the entire month of September and October, or on 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/06/25, 11/07/25, 11/08/25, 11/09/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, and 11/14/25. This is an example of non-compliance identified during the investigation of Complaint Number 2656377 and 2676659.

Based on observation, staff interview, and facility policy the facility failed to ensure call lights were functioning properly. This affected two (#7 and #55) of ten residents reviewed for call lights. The facility census was 86. Findings include:1.Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included Alzheimer's disease with late onset, essential hypertension, major depressive disorder recurrent, hyperlipidemia, unspecified dementia, liver disease, and chronic kidney disease stage III. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #7 was severely cognitively impaired and was dependent for all care, except eating. Review of the care plan, dated [DATE], revealed Resident #7 had a communication problem, increased risk of falls, and bladder incontinence. Interventions included to ensure the call light was within reach. Observation on [DATE] at 9:20 A.M. of Resident #7's call light revealed the call light button on the wall and hand held call light device were missing. The call light was not functional. Interview on [DATE] at 9:36 A.M. with Certified Nursing Assistant (CNA) #511 verified Resident #7's call light did not work and confirmed the resident was capable of using the call light.2. Review of the medical record revealed Resident #55 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type two diabetes mellitus with diabetic nephropathy, blindness right eye, delusional disorders, cognitive communication deficit, and major depressive disorder recurrent. Review of the MDS assessment, dated [DATE], revealed Resident #55 was rarely understood and was dependent for all care. Review of the care plan, dated [DATE], revealed the resident was at risk of falls and bladder incontinence. Interventions included to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Observation on [DATE] at 9:20 A.M. of Resident #55's call light revealed the call light did not work when pressed by the resident. Interview on [DATE] at 9:36 A.M. with CNA #511 verified Resident #55's call light was not functioning and confirmed the resident was capable of using the call light. Review of the facility policy titled, Call Lights: Accessibility and Timely Response, dated 2025, revealed the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The staff would report problems with a call light or the call system immediately to the supervisor and/or maintenance director and would provide immediate or alternate solutions until the problem could be remedied. This violation represents non-compliance investigated under Complaint Number 2656377.

Based on medical record review, observation, and staff interview, the facility failed to ensure comfortable room temperatures. This affected three (#49, #57, and #95) of ten residents reviewed reviewed for room temperatures. The facility census was 86.Findings include:1. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included Alzheimer's disease, heart failure, essential hypertension, chronic kidney disease stage three, hypotension, hyperkalemia, and muscle weakness.Review of the Minimum Data Set (MDS) assessment, dated 11/12/25, revealed the resident was severely cognitively impaired and dependent for care. 2. Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included unilateral primary osteoarthritis, unspecified dementia, altered mental status, iron deficiency anemia secondary to blood loss, essential hypertension, and cognitive communication deficit. Review of the MDS assessment, dated 09/13/25, revealed the resident was severely cognitively impaired. 3. Review of the medical record revealed Resident #95 was admitted on [DATE]. Diagnoses included encounter for other orthopedic aftercare, schizophrenia, hypothyroidism, depression, fracture of the unspecified part of neck of left femur, ileus, cognitive communication deficit, and third nerve palsy right eye.Review of the MDS assessment, dated 11/12/25, revealed the resident was cognitively intact.Observation on 12/02/25 at 9:35 A.M. revealed Resident #49 and #57 shared a room. Both residents were laying in bed. The room air temperature felt cool. Continued observation of Resident #95's room revealed the air temperature felt cool. Observation on 12/02/25 at 10:26 A.M. of Resident #49 and Resident #57's room, with Maintenance Director (MD) #403, revealed the ambient room temperature ranged from 59 degrees Fahrenheit (F) to 62 degrees F. Resident #49 and Resident #57 remained in their beds. Further observation of Resident #95's room revealed the resident had returned to his room. The ambient air temperature temperature ranged from 59 degrees F to 63 degrees F. Concurrent interview with MD #403 verified the low resident room temperatures. This violation represents non-compliance investigated under Complaint Number 2656377 and 2675165.

Based on review of facility policy, review of personnel files, and staff interview, the facility failed to ensure background checks were completed for one employee (Licensed Practical Nurse #607) of seven employees files reviewed. This had the potential to affect all residents. The facility census was 86.Findings include: Review of Licensed Practical Nurse (LPN) #607's personnel file revealed a hire date of 12/04/24 and a termination date of 02/17/25. Further review revealed no evidence a background check was completed for LPN #607. Interview on 11/26/25 at 2:00 P.M. with Human Resources (HR) #452 revealed a background check was submitted for LPN #607 on 12/04/24, but it was rejected and never rerun. HR #452 verified a background check had not been completed for LPN #607. Review of the facility policy titled, Abuse, Neglect and Exploitation, undated, revealed potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credential checks would be conducted on potential employees, contacted temporary staff, students affiliated with academic institutions, volunteers, and consultants. This violation represents non-compliance investigated under Complaint Number 2628333.

Based on medical record review, staff and resident interview, review of employee timecards, review of facility Self Reported Incident, review of facility investigations, and review of facility policy, the facility failed to thoroughly and accurately investigate alleged occurrences of abuse and misappropriation of medications. This affected two (#21 and #88) of four residents reviewed for abuse prohibition and one Self Reported Incident (#256925) in a facility census of 86. Findings include: 1.Review of a statement written on 09/22/25 (no time recorded) by Certified Nurse Aide (CNA) #605 documented he was told there was an issued with him and Resident #88. CNA #605 documented he was unaware what the resident was talking about. Review of a facility investigation on 09/23/25 at 12:00 P.M. revealed administration received a complaint from CNA #497 that Resident #88 was upset with CNA #605 and did not want him in his room. The Administrator advised the Director of Nursing and scheduler to keep CNA #605 out of the area. After further assessment the Administrator suspended CNA #605 that morning. Review of timecard report for CNA #605 noted hours worked on 09/21/25 to be between 10:00 P.M. and 6:00 A.M., 09/22/25 between 10:00 P.M. and 6:00 A.M., 09/23/25 between 2:00 P.M. and 5:30 P.M., and 09/23/25 between 6:13 P.M. and 10:00 P.M. Review of facility witness statement revealed on 09/24/25 CNA #497 informed the Administrator regarding an incident on 09/23/25. CNA #497 informed the Administrator Resident #88 was upset with CNA #605 and reported the resident felt threatened by him. Resident #88 stated to CNA #497 he sat up in his chair all night because he was afraid to ask CNA #605 to put him to bed. No further statement or investigation was initiated. Result of investigation noted CNA #605 denying mistreatment of Resident #88. According to personnel file no previous disciplines have been issued regarding staff to resident treatment. Review of the personnel file revealed on 09/30/25 CNA #605 received an employee disciplinary form related to professionalism and customer service. First warning for customer service training, one on one with the Director of Nursing, and professionalism policy reviewed. Interview on 12/01/25 at 9:40 A.M. with the Administrator confirmed the investigation lacked statements from all potential witnesses. Review of facility the undated policy titled Abuse, Neglect, and Exploitation revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. Protection of resident included; The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation and staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Reporting and response included the facility will have written procedures that include reporting of all alleged violations to the Administrator. 2.) Review of the medical record for the Resident #21 revealed an admission date of 11/07/25. Diagnoses included acute and chronic respiratory failure with hypercapnia, dependence on respirator (ventilator), asthma, chronic obstructive pulmonary disease (COPD), anxiety, depression, cognitive communication deficit, chronic pain, and Raynaud's syndrome. Review of Resident #21's most recent quarterly Minimum Data Set (MDS) assessment, dated 09/23/25, revealed the resident was relatively cognitively intact. Interview on 12/01/25 at 12:46 P.M. with Resident #21 revealed CNA #426 smacked her hand while changing her brief. Resident #21 stated she did not suffer any physical or psychosocial harm and she cannot remember the exact date or time which this incident occurred, but thinks it happened approximately one to one and a half months ago. Resident #21 states she reported the incident to Registered Nurse (RN) #491 but was unsure of how low after the incident occurred that she reported it to RN #491. Resident #21 stated she received no follow-up regarding this incident or the facility's investigation after she reported it to RN #491. To the best of her knowledge the only intervention put in place by the facility was to have CNA #426 not provide care to her. Interview on 12/01/25 at 12:52 P.M. with RN #491 revealed Resident #21 reported the incident of CNS #426 smacking the resident's hand. RN #491 reported this to the former Director of Nursing (DON), who then asked RN #491 to ask Resident #21 what occurred. RN #491 stated she was unsure of the exact date or time when this incident occurred. RN #491 stated when Resident #21 demonstrated to her how this event occurred it was more of a brushing motion than a smack, slap, or hit. RN #491 stated at the request of the former DON she conducted the investigation into this incident. She stated she did not conduct interviews with other residents CNA #426 provided care to, there was no ongoing monitoring, skin sweeps were not performed, and no staff education was given as a result of this incident. Interview on 12/01/25 at 12:54 P.M. with the Administrator revealed the former DON spoke to CNA #426 regarding this incident. The Administrator initially stated CNA #426 was suspended pending investigation, but through further investigation it was determined the aid was not suspended. The Administrator revealed there was no ongoing monitoring, skin sweeps were not performed, and no staff education was given as a result of this incident. Interview on 12/01/25 at 3:50 P.M. with the Administrator revealed discipline for CNA #426 regarding the incident with Resident #21 cannot be located. Review of the facility investigation dated 10/13/25 revealed a thorough investigation of this incident was not conducted. 3. Review of the facility Self Reported Incident #256925 dated 02/07/25 revealed 30 Norco were missing from a narcotic drawer of a medication cart. One of the nurses identified as the last having access included Licensed Practical Nurse (LPN) #607. Review of the facility investigation revealed Former Human Resources #606 documented she administered a drug screen to LPN #607 on 02/05/25 with the results being negative. Review of LPN #607's personnel file revealed a hire date of 12/04/24 and a termination date of 02/17/25. Interview on 11/26/25 at 2:00 P.M. with Human Resources #452 verified an occurrence happened before he began employment with the facility during which a drug test was allegedly initiated on 02/05/25 for LPN #607. However, upon investigation there was no evidence the drug test was complete. Human Resources #452 stated based on the documentation there was no evidence the required drug test for LPN #607 was completed and the drug test form was forged. Interview on 11/26/25 at 2:53 P.M. with the Administrator verified Former Human Resources #606 forged a drug test for LPN #607. The drug test paperwork indicated LPN #607 was negative for all panels, however there was no evidence the drug test was completed by Former Human Resources #606. Review of the Employee Handbook, dated 06/27/24, verified when the facility has reasonable suspicion to believe that an employee's behavior, and/or performance is included by controlled substances, the facility may require the employee to submit blood, breath, or urine samples for testing. This deficiency represents non-compliance investigated under Complaint Numbers 2675165, 2656377, 2631520, 2628333.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure accurate and timely documentation in the medical record. This affected two (#87 and #91) of three residents reviewed for accurate documentation. The facility census was 86. Findings include: 1. Review of the medical record for Resident #87 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic respiratory failure with hypercapnia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), dementia, osteomyelitis of sacral and sacrococcygeal vertebra, heart failure, cerebral infarction, dependence on a respirator, heart disease, and atrial fibrillation. Review of the nursing progress note for Resident #87, dated [DATE] at 7:30 P.M., revealed it was created on [DATE] at 2:53 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 7:38 P.M., revealed it was created on [DATE] at 8:45 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 9:00 P.M., revealed it was created on [DATE] at 2:54 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 9:00 P.M., revealed it was created on [DATE] at 2:54 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 9:00 P.M., revealed it was created on [DATE] at 2:54 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 11:00 P.M., reveled it was created on [DATE] at 3:07 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 11:30 P.M., revealed it was created on [DATE] at 3:14 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 2:14 A.M., revealed it was created on [DATE] at 3:21 P.M. Review of the nursing progress note for Resident #87, dated [DATE] at 2:46 A.M., revealed it was struck out on [DATE] at 3:29 P.M., citing incorrect documentation. Review of the nursing progress note for Resident #87, dated [DATE] at 3:18 P.M., revealed it was struck out on [DATE] at 2:25 P.M., with no reason given. Review of the nursing progress note for Resident #87, dated [DATE] at 3:08 P.M., revealed it was struck out on [DATE] at 2:09 P.M., citing incorrect documentation. Interview on [DATE] at 11:41 A.M. with Licensed Practical Nurse (LPN) #434 revealed she was a new LPN and she did not feel she documented Resident #87's death properly at the time it happened. She stated she was assisted by Registered Nurse (RN) #609, who was the Assistant Director of Nursing (ADON) when Resident #87 passed away, with documenting Resident #87's death on [DATE]. She stated she was not asked to falsify her documentation. Interview on [DATE] at 1:05 P.M. with RN #494 revealed she did not participate in the investigation into SR #87's death, nor did she have any part in the documentation that was in the medical record. Additional interview on [DATE] at 4:26 P.M. with RN #494 revealed RN #609 assisted LPN #434 with documentation regarding Resident #87's death. Interview on [DATE] at 9:19 A.M. with the Administrator revealed documentation should be corrected when it is noted to be inaccurate and she does not feel two weeks is an appropriate timeframe for correcting documentation. She stated documentation should be entered correctly and accurately the first time and only changed, or corrected, when needed. She stated the facility has a consulting firm that noticed the issues with the documentation in Resident #87's record on [DATE]. Review of facility policy titled Documentation in Medical Record, dated [DATE], revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of services, but no later than the shift in which the assessment, observation, or care service occurred. 2. Review of the medical record for Resident #91 revealed an admission date of [DATE]. Diagnoses included dementia, morbid obesity, end stage renal disease (ESRD), type two diabetes mellitus (DM2), obstructive sleep apnea (OSA), hypertension and dependence on renal dialysis. Review of the record revealed a physician order dated [DATE] at 2:00 P.M. for chest physiotherapy (PT) and oral suctioning every six hours for 48 hours per respiratory therapist. Review of the medication administration record (MAR) revealed this order was completed on [DATE] at 2:00 P.M. Further review of the MAR for revealed this order was not completed on [DATE] at 8:00 P.M. and this administration time was documented with chart code 9. Review of the record revealed chart code 9 means other/see nurse notes effective.Review of a nursing progress note dated [DATE] at 10:42 P.M. revealed this order was not completed on [DATE] at 8:00 P.M. as Resident #91 was documented as being deceased . Review of the MAR for Resident #91 revealed this order was not completed on [DATE] at 12:00 A.M., 8:00 A.M., or 2:00 P.M. and he was documented as being out of the facility. Review of the record for Resident #91 revealed he was not deceased and he was not transferred to the hospital until [DATE] at approximately 3:25 P.M.Interview on [DATE] at 9:39 A.M. with RN #432 verified Resident #91 was not deceased and he did not transfer out of the facility until [DATE] at approximately 3:25 P.M. RThis deficiency represents non-compliance investigated under Complaint Number 267165.

Based on medical record review and staff interview, the facility failed to ensure residents were suctioned per order. This affected one (#91) resident reviewed for respiratory therapy. The facility census was 86. Findings include: Review of the medical record for Resident #91 revealed an admission date of 06/18/25. Diagnoses included dementia, morbid obesity, end stage renal disease (ESRD), type two diabetes mellitus (DM2), obstructive sleep apnea (OSA), hypertension (HTN), metabolic encephalopathy, anemia, delirium, depression, anxiety, sepsis, dependence on renal dialysis, and convulsions.Review of the record revealed a physician order dated 11/15/25 at 2:00 P.M. for chest physiotherapy (PT) and oral suctioning every six hours for 48 hours per respiratory therapist for chest congestion for two days.Review of the medication administration record (MAR) revealed this order was completed on 11/15/25 at 2:00 P.M. Further review of the MAR for Resident #91 revealed this order was not completed on 11/15/25 at 8:00 P.M. and this administration time was documented with chart code 9. Review of the record revealed chart code 9 means other/see nurse notes effective.Review of the MAR revealed this order was not completed on 11/16/25 at 12:00 A.M., 8:00 A.M., or 2:00 P.M. and he was documented as being out of the facility. Interview on 12/02/25 at 9:39 A.M. with Registered Nurse (RN) #432 verified Resident #91 did not transfer out of the facility until 11/16/25 at approximately 3:25 P.M. RN #432 verified Resident #91 did not receive chest PT or suctioning on 11/15/25 at 8:00 P.M. or on 11/16/25 at 12:00 A.M., 8:00 A.M., or 2:00 P.M. while he was still alive and in the facility. This deficiency represents non-compliance investigated under Complaint Numbers 2675165 and 2656377.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a facility investigation, resident and staff interview, review of a facility policy, and review of facility corrective action documents, the facility failed to ensure a resident was free from verbal abuse. This affected one (#5) of three residents reviewed for abuse. The facility census was 86. Findings include: Review of Resident #5's medical record revealed an admission date of 12/27/21. Diagnoses included central cord syndrome at cervical vertebra 5 (C5), severe protein calorie malnutrition, stroke, epilepsy, quadriplegia, post-traumatic seizures, muscle weakness, cognitive communication deficit, peripheral vascular disease, and major depressive disorder. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #5 was cognitively intact. Resident #5 was dependent on staff for toilet use, bathing, dressing, bed mobility, and transfer. Resident #5 displayed no behaviors during the review period. Review of Resident #5's care plan, revised 02/10/25, revealed supports and interventions for smoking, self-care deficit, behavioral disturbance, increased risk for falls, risk for impaired skin integrity, seizures, and quadriplegia. Review of the facility SRI created on 05/05/25, and review of related facility investigation documents, revealed on 05/05/25 at 9:00 A.M. Receptionist #490 became aware of an incident involving Resident #5. Resident #9 reported Certified Nurse Aide (CNA) #400 humiliated Resident #5 while out smoking on 05/03/25 at approximately 3:00 P.M. It was reported CNA #400 said he would, slap the (expletive) out of Resident #5, mocked him, and threatened to wipe Resident #5's behind with an alcohol wipe. The facility assessed Resident #5 and no injury or pain was found. The facility took statements from residents who were smoking. Social services staff completed ongoing and as needed psychosocial checks with Resident #5. The allegation was verified by the facility based on interviews with the victims and witnesses. Follow-up interview with Resident #5 revealed he did reported the incident immediately but would do so in the future if needed. Resident #5 stated CNA #400 told him he would slap the (expletive) out of him and teased him for his disabilities. Resident #9 was interviewed and stated he reported the incident to Receptionist #490 and reported he witnessed CNA #400 say he would slap the (expletive) out of Resident #5, mocked him, then threatened to wipe Resident #5's behind with an alcohol wipe. CNA #400's statement denied threatening Resident #5 and indicated they (he and the residents) were all joking around. Interview on 05/19/25 at 11:14 A.M. with Resident #9 verified he was witness to CNA #400 degrading and threatening Resident #5. Resident #9 stated he did not report the incident right away for fear of retaliation from CNA #400. Resident #9 stated when no one else said anything and he did not see CNA #400 working, he told the receptionist what happened. Resident #9 stated he had not seen CNA #400 before the incident and had not seen him since. Resident #9 reported he felt safe in the facility. Interview on 05/19/25 at 11:25 A.M. with Resident #5 verified CNA #400 threatened him during a smoke break and was disrespectful to him. Resident #5 stated he now knew to make a report if something like that happens again. Interview on 05/19/25 at 12:01 P.M. with the Administrator verified CNA #400 was terminated due to threatening to slap Resident #5 and threatening to use an alcohol wipe on his behind. The Administrator reported she had been on staff at the facility for approximately two days when the incident was reported. After learning CNA #400 had previously been terminated and rehired, and hearing verification of his misconduct from witnesses regarding the 05/05/25 incident with Resident #5, the facility terminated him and flagged CNA #400 as not eligible for rehire. Interview on 05/19/25 at 2:17 P.M. with Resident #10 verified she was a witness to the verbal abuse from CNA #400 to Resident #5. Resident #10 reported CNA #400 was not acting like himself and brought his bad day into the facility. CNA #400 threatened Resident #5 and made them all feel uncomfortable. Resident #10 reported she had not seen CNA #400 working in the facility since the incident and she felt safe living there. Review of the undated facility policy titled, Abuse, Neglect, and Exploitation, revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse. As a result of the incident, the facility took the following actions to correct the deficient practice by 05/12/25: • On 05/05/25, Residents #5 was assessed for injuries and psychosocial impact with no concerns noted. Director of Social Services (DSS) #443 continued with ongoing monitoring of Resident #5's psychosocial with no additional findings related to the incident on 05/03/25. • On 05/05/25, CNA #400 was terminated from employment for misconduct and abuse. • Beginning on 05/05/25, all staff were educated on abuse policies and procedures by the Director of Nursing (DON). All staff education was completed on 05/06/25. • On 05/09/25, Resident #5 and Resident #9 were interviewed regarding the incident with no additional findings identified. • On 05/12/25 interviews and assessments were completed with all residents who smoked. There were no other concerns identified regarding abuse. • Interviews conducted between 05/19/25 and 05/21/25 at random times with 11 licensed practical nurses (LPNs), seven CNAs, two housekeeping and laundry staff, two respiratory therapists, and one social services staff member confirmed they were provided abuse education and were able to identify types of abuse and recalled aspects of the educational content. • On 05/19/25, two additional residents (#9 and #10) were sampled and reviewed for abuse with no concerns identified. • On 05/19/25, review of additional facility SRIs and related investigation documentation revealed there were no further concerns identified regarding abuse. This deficiency represents non-compliance investigated under Master Complaint OH00165637.

Based on observation, medical record review, review of hospital documents, staff interview, and facility policy, the facility failed to ensure peripherally inserted central catheters (PICC) were maintained in accordance with physician orders and dressing changes were completed using appropriate appropriate technique. This affected two (#7 and #8) of two residents reviewed for PICC line care and treatment in a facility census of 86. Findings include: 1. Review of Resident #7's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including type II diabetes mellitus with a foot ulcer, chronic kidney disease stage four (4), atrial fibrillation, anemia, heart failure, depression, absence of the left leg above the knee, non-pressure chronic ulcer of part of the right foot, absence right toes, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with intact cognition, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, was at risk for pressure ulcer development with two stage 4 pressure ulcers (full-thickness skin and tissue loss), and a diabetic foot ulcer. Review of a hospital community referral form (CRF) revealed Resident #7 was admitted to the hospital from the facility on 05/08/25 and discharged back to the facility on [DATE]. The CRF documented Resident #7 with a PICC single lumen in place to the right brachial vein originally placed on 04/10/25. On 05/15/25, site assessment documented an occlusive, transparent dressing to the PICC insertion site. There was no physician order indicated frequency of dressing changes to the PICC line site. Review of Resident #7's medical record revealed on 05/16/25 a physician order was initiated for a PICC line dressing change to the right arm weekly and as needed scheduled for every Friday on the night shift to maintain function and infection control. Observation and interview on 05/19/25 at 10:21 A.M. with Licensed Practical Nurse (LPN) #328, during observation of Resident #7's PICC line dressing, noted the dressing pealing away from the site. The dressing was dated 05/08/25. LPN #328 verified Resident #7's PICC dressing was dated 05/08/25 and stated the dressing was to be changed every week or as needed. Additional observation noted LPN #328 washed hands and applied a mask, clean gloves, and a disposable gown. LPN #328 opened a sterile central venous line dressing change kit and place the contents on the surface of a overbed table inside Resident #7's room. No clean field including a disposable cloth or linen saver was placed on the overbed table followed by a sterile drape. LPN #328, with gloved hands, placed a disposable mask to Resident #7. With non-sterile gloved hands, LPN #328 removed the existing dressing. LPN #328 proceeded to wash hands and donned non-sterile gloves, obtained a packet of chlorhexidine applicators, and cleansed the catheter insertion site. LPN #328 handled a sterile disposable measuring tape and measure the catheter from insertion site placing the measuring tape on the exposed catheter. LPN #328 handled the sterile kit contents after removing gloves and requested a second sterile kit. LPN #326 obtained a second kit and LPN #328 placed the kit to the overbed table surface. LPN #328 opened the kit and obtained sterile gloves while handling contents of the kit with non-sterile hands. LPN #328 donned the sterile gloves, obtained a skin protectant packet, opened the packet, and wiped the pad back and forth wiping toward the insertion site and exposed catheter. LPN #328 proceeded to obtain a catheter stabilizer applied it to the site and covered with an transparent dressing. On 05/19/25, immediately following the observation, interview with LPN #328 verified multiple occurrences of cross contamination to the PICC line insertion site and sterile central line catheter kit contents. 2. Review of Resident #8's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, open wound to the lower back and pelvis, biliary cirrhosis, chronic obstructive pulmonary disease, cerebral infarction, type II diabetes mellitus, chronic kidney disease stage five (5), urinary tract infection, anemia, and hypertension. Review of the most current MDS assessment dated [DATE] assessed Resident #8 with intact cognition, substantial to maximal assistance with activities of daily living, incontinent of bowel and bladder, and at risk for pressure ulcer development admitted with an unstageable pressure ulcer (obscured full-thickness skin and tissue loss). Review of Resident #8's medical record revealed on 05/12/25 a physician order was initiated to change the midline dressing to the resident's right upper arm every seven (7) days and as needed. Observation on 05/19/25 at 8:06 A.M. revealed Resident #8 was observed in bed. Resident #8 was noted with a PICC line placed to the right upper arm. A transparent dressing was dislodged and pealing and the dressing was dated 05/06/25. On 05/19/25 at 8:57 A.M. interview with LPN #314, during observation of Resident #8, verified the PICC line dressing to the resident's right arm was dated 05/06/25. The site appeared with dried blood around perimeter of the insertion site. LPN #314 verified the PICC line dressing was to be changed weekly. Review of the undated facility PICC dressing change policy revealed the staff are to change peripherally inserted central catheter (PICC), midline, or central venous catheters dressing weekly or if soiled, in a manner to decrease potential infection and or cross-contamination. Physician's orders will specify type of dressing or frequency of changes. Compliance guidelines noted the following; 1. Perform hand hygiene and put on mask. Place mask on the resident if they cannot keep their head turned away. Perform hand hygiene. Set-up a clean field on the overbed table with needed supplies for the dressing change. Place a disposable cloth or linen saver on the overbed table. Perform hand hygiene. Open the sterile dressing change kit, lay out the sterile drape, and place supplies on the sterile field being careful not to contaminate them. Wash hands and put on clean gloves. Remove the old dressing beginning at device hub and pull dressing toward the insertion site. Remove and discard engineered stabilization device. Inspect the catheter and hub for any defects. Remove and discard gloves. Perform hand hygiene and put on sterile gloves. Use sterile measuring tape to measure external length of the catheter from the hub to skin entry to ensure that it has not migrated. Clean the insertion site with antiseptic. Apply chlorhexidine with an applicator using side to side motion for at least 30 seconds. Allow to dry completely. Apply skin barrier. Secure catheter with engineered stabilization device. Apply transparent semi-permeable dressing to insertion site. Discard used supplies and perform hand hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00165335.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to provide timely interventions to prevent urinary incontinence. This affected one (#22) of three residents reviewed for incontinence care and services in a facility census of 86. Findings include: Review of Resident #22's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, chronic obstructive pulmonary disease, type II diabetes mellitus, schizoaffective bipolar type, thyroid disorder, irritable bowel syndrome, coronary artery disease, and mild dementia with psychotic disturbance. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #22 with severe cognitive impairment, no resistive behavior, utilized a walker for mobility, required supervision and touching assistance with ambulation and toileting, was always continent of bladder, and had no rated bowel continence. Review of a nursing plan of care dated 01/27/25 revealed it was revised to address Resident #22's activity of daily living (ADL) self-care deficit with an intervention for toileting requiring maximum assist of one staff for toileting. Review of nurses notes discovered on 04/04/25 at 5:20 P.M. Resident #22's daughter indicated the resident told her she had no knowledge of when she has to urinate or when she was, in fact, urinating. Review of social services progress notes on 04/07/25 at 12:28 P.M. revealed the Social Service Director (SSD) had approached Resident #22 multiple times to go and have her aide help her change when she was in the common areas and had a bowel movement. Resident #22 hesitates to ask for help and often her daughter was the one doing her changes, rinsing soiled clothing, and changing her linen. Resident #22's daughter asked the SSD to look into her aides helping more. Review of a nursing plan of care dated 04/08/25 revealed it was developed to address Resident #22's bowel incontinence due to irritable bowel syndrome and confusion. An intervention included to check the resident every two hours and assist with toileting as needed, and staff to encourage and assist the resident to toilet during night. On 04/08/25, a nursing plan of care was developed to address Resident #22's occasional bladder incontinence related to confusion and impaired mobility with interventions including to check as needed/required for incontinence. Review of Resident #22's electronic task documentation between 04/22/25 and 05/21/25 contained in the medical record lacked documentation indicating Resident #22 was checked every two hours for bladder elimination and documented the resident as mostly continent with two episodes of incontinence charted on 04/28/25 and 05/09/25. Observation on 05/21/25 at 7:27 A.M. discovered Resident #22 seated on the toilet in her room. The resident was incontinent of bladder through an adult brief onto her pants. No staff were observed assisting the resident. On 05/21/25 at 7:32 A.M., Licensed Practical Nurse (LPN) #326 was summonsed to Resident #22 room. LPN #326 stated she had assumed care of Resident #22 at 6:00 A.M.; however, LPN #326 had not observed the resident yet. LPN#326 stated Resident #22 was incontinent of bowel and bladder frequently during the day and required frequent clothing changes due to soiling. Continued observation verified Resident #22 was incontinent of bladder which was not contained in the adult brief and resulting in urine soiling through a folded bath blanket and top sheet onto the mattress. The top sheet was also observed with a brown stain on the surface. On 05/21/25 at 7:41 A.M. interview with Certified Nurse Aide (CNA) #479 revealed she assumed shift and Resident #22 care at 6:00 A.M. CNA #479 stated she did not provided notification regarding Resident #22 incontinence checks and verified the resident required two hour checks due to heavy incontinence. CNA #479 was unaware when Resident #22 was last checked for incontinence and had not observed Resident #22 since assuming care at 6:00 A.M. On 05/21/25 at 7:55 A.M. interview with the Director of Nursing (DON), during a review of Resident #22's medical record, verified the resident required two hour checks for incontinence. The DON confirmed Resident #22 required frequent incontinence checks due to having a history of heavy incontinence episodes. Review of facility's undated incontinence policy revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00165335.

Based on observation, medical record review, review of hospital documentation, staff interview, and facility policy, the facility failed to ensure wound treatments and dressing applications were applied in accordance with physician orders. This affected one (#7) of three residents reviewed for wound care and treatment services in a facility census of 86. Findings include: Review of the medical record for Resident #7 revealed the resident admitted to the facility on [DATE] with the diagnoses including, type II diabetes mellitus with a foot ulcer, chronic kidney disease stage four (4), atrial fibrillation, anemia, heart failure, depression, absence the left leg above the knee, non-pressure chronic ulcer part of the right foot, absence the right toes, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with intact cognition, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, was at risk for pressure ulcer development with two stage 4 pressure ulcers (full-thickness skin and tissue loss), and a diabetic foot ulcer. Review of the hospital community referral form physician orders dated 05/15/25 revealed Resident #7 was admitted to the hospital from the facility on 05/08/25 and discharged back to the facility on [DATE]. Wound care orders included a treatment to the right foot and heel to cleanse with normal saline, apply cavilon periwound, paint the heel with betadine, cover with abdominal dressing (ABD) pad, loosely secure with kerlix, and wrap loosely with all cotton elastic (ACE) from the base of the toes up toward the calf. The treatment was to be performed twice daily and as needed. Treatment of the resident's right calf wound revealed to cleanse with mild soap and water, rinse and pat dry, apply Triad paste thinly over the wound, cover with silicone boarder foam, and change every three (3) days and as needed. Review of Resident #7's medical record revealed physician orders dated 05/18/25 for a treatment to the right calf to include for staff to cleanse with mild soap and water, rinse well and pat dry, apply a thin layer of Triad cream, cover with silicone border foam, and change the dressing every 3 days. Further review also revealed on 05/18/25 a treatment was modified to the right foot and heel to cleanse the foot and heel with normal saline, apply skin prep to periwound areas, paint the heel with betadine, pack openings of the foot with 0.125% Dakins solution, cover all with ABDs pads, loosely secure with kerlix, and wrap with ACE wrap to the calf and complete the treatment every shift. Observation on 05/19/25 at 7:48 A.M. noted Resident #7 seated in a wheelchair with a gauze wrapped dressing and a fracture boot to the right lower extremity. Continued observation revealed the dressing was soiled with red and green drainage and no border foam dressing was in place to the right calf. On 05/19/25 at 11:20 A.M. observation and interview with the Wound Specialist Certified Nurse Practitioner (CNP) and Registered Nurse (RN) #499 verified no dressing was applied to Resident #7's right calf. RN #499 also verified the dressing was heavily soiled and no date was applied to the dressing indicating when the dressing was last changed. Continued observation of Resident #7's right calf wound was identified as a partial thickness venous ulcer with a moderate amount of serous drainage. The measurements of the wound were were 5.20 centimeters (cm) long by (x) 0.80 cm wide x 0.10 cm deep. Additional observation verified a gauze wrap dressing was heavily soiled to the resident's right foot and heel with red and green drainage. Resident #7's right lateral foot was described as a full thickness diabetic ulcer measuring 27.20 cm long x 21.50 cm wide x 1.30 cm deep and draining a moderate amount of serosanguineous exudate. The resident's right anterior foot was described as a full thickness diabetic ulcer measuring 24.30 cm long x 24.40 cm wide x 2.20 cm deep and draining a moderate amount of serosanguineous exudate. Review of Resident #7's medical record lacked documentation indicating the dressings were changed to the right calf since returning to the facility from the hospital on [DATE]. Review of the resident's treatment administration records noted the right foot dressing was last changed on 05/17/25. On 05/19/25 at 12:42 P.M. interview with the Director of Nursing (DON), during review of Resident #7's medical record, verified the dressing to the resident's right calf had not been changed since readmission to the facility and the right foot dressing had not been changed since 05/17/25. The DON confirmed the wound treatments were not completed as ordered. Review of an undated facility wound treatment management policy revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Dressing changes may be provided outside the frequency parameters in certain situations including the dressing is dislodged or the dressing is soiled otherwise, or is wet. This deficiency represents non-compliance investigated under Complaint Number OH00165335.

Based on review of the facility incident and accident log, review of the Electronic Information Dissemination and Collection (EIDC - system used by facilities to report incidents to the State Survey Agency [SSA]) system, review of the facility Self-Reported Incidents (SRI), staff interview and review of the facility policy, the facility failed to report an incident of resident elopement to the SSA for Resident #3 and further failed to ensure allegations of abuse were thoroughly investigated for four (#26, #28, #30, and #31) residents reviewed for abuse. The facility census was 87. Findings include: 1. Review of the incident and accident log for the past three months revealed an incident of elopement for Resident #3 on 04/12/25. Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with diagnoses of senile degeneration of the brain, anxiety, and diabetes mellitus type II. Review of the admission Minimum Data Set (MDS) assessment, dated 04/04/25, revealed Resident #3 was cognitively impaired and had no wandering behaviors. Review of the nursing progress note dated 04/12/25 at 6:08 P.M. revealed Resident #3 was spotted in the parking lot of the facility, walking and heading toward [NAME] Road (a four-lane road). Staff were notified and Resident #3 was brought back into the facility and nurses and aides were informed of the situation and told to keep an eye on the patient. The Director of Nursing (DON) and Nurse Practitioner (NP) were notified. Interview on 4/29/25 at 2:40 P.M. with Licensed Practical Nurse (LPN) #354 verified Resident #3 eloped from the facility on 04/12/25. LPN #354 stated she was in the parking lot, attending to another resident, when she noticed Resident #3 heading toward the road. LPN #354 stated she alerted another staff member and Resident #3 was returned to the facility. Review of the EIDC system from 04/01/25 through 04/29/25 revealed the facility did not report Resident #3's elopement to the SSA. 2. Review of the medical record for Resident #26 revealed an admission date of 01/28/25 with diagnoses of acute respiratory failure, chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment, dated 03/21/25, revealed Resident #26 was cognitively intact. Review of the facility submitted SRI, created on 04/05/25 at 3:17 P.M. and completed on 04/11/25 at 3:32 P.M., revealed the facility reported an allegation of verbal abuse after Resident #26 alleged a facility Certified Nursing Assistant (CNA) was verbally abusive. Review of the facility investigation for the SRI revealed the file only included a copy of the SRI submitted to the SSA. Further review revealed no evidence a thorough investigation, including staff interviews or statements, resident statements, assessment of like residents, or staff education was completed. 3. Review of the medical record for Resident #28 revealed an admission date of 05/31/23 with a diagnosis of dementia. Review of the annual MDS assessment, dated 03/15/25, revealed Resident #28 was cognitively impaired. Review of the facility submitted SRI, created on 04/18/25 at 11:33 A.M. and completed on 04/28/25 (one day past the investigation due date) at 1:12 P.M., revealed the facility reported an injury of unknown source to the SSA when Resident #28 was found with a bump and a bruise to the eyebrow. Review of the facility investigation for the SRI revealed the file only included a copy of the SRI submitted to the SSA. Further review revealed no evidence a thorough investigation, including staff interviews or statements, resident statements, assessment of like residents, or staff education was completed. 4. Review of the medical record for Resident #30 revealed an admission date of 03/30/25 with diagnoses of Alzheimer's dementia and Parkinson's. Review of the admission MDS assessment, dated 04/06/25, revealed Resident #30 was cognitively intact. Review of the facility submitted SRI, created on 04/08/25 at 6:24 P.M. and completed on 04/18/25 (one day past the investigation due date) at 11:56 A.M., revealed the facility reported an allegation of physical abuse to the SSA when Resident #30 alleged another resident hit him with a cane. Request for the facility investigation related to the allegation revealed the facility had no documentation related to an investigation. 5. Review of the medical record for Resident #31 revealed an admission date of 03/31/23 with a diagnosis of Parkinson's and multiple sclerosis. Review of the quarterly MDS assessment, dated 03/19/25, revealed Resident #31 was cognitively intact. Review of the facility submitted SRI, created on 04/08/25 at 10:58 A.M. and completed on 04/18/25 (three days past the investigation due date) at 11:51 A.M. revealed Resident #31 alleged a facility Certified Nursing Assistant (CNA) did not treat her properly. Review of the facility investigation for the SRI revealed the file only included a copy of the SRI submitted to the SSA. Further review revealed no evidence a thorough investigation, including staff interviews or statements, resident statements, assessment of like residents, or staff education was completed. Interview on 4/29/25 at 3:20 P.M. with the Administrator revealed her first day in her role at the facility was the day prior. The Administrator stated that what was included in the investigation files for the SRIs was all of the information she had and. Further interview with the Administrator verified complete and thorough investigations were not completed for each of the SRIs and further confirmed she was unable to locate any file or documentation for the SRI created on 04/18/24 involving Resident #30's allegation of resident-to-resident physical abuse. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated January 2025, revealed investigation would occur immediately when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect or exploitation occurred. Further review revealed the written procedure included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations and providing complete and thorough documentation of the investigation. Additionally, reporting of alleged violations to the Administrator, state agency, adult protective services, and all other required agencies would occur no later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number OH00164991 and is continued non-compliance from the survey dated 04/11/25.

Based on observation, medical record review, review of a fire and rescue run report, review of hospital documentation, review of narcotic/controlled drug records, staff interviews, interview with the pharmacist, and review of the policy on controlled substances, the facility failed to ensure Resident #86 was free from a significant mediation error, failed to report missing Fentanyl medication patches, failed to accurately assess the resident, and failed to immediately investigate and implement immediate interventions to ensure an accurate system was in place for monitoring Fentanyl patch placement. This resulted in Immediate Jeopardy and potential serious life-threatening harm, injuries, negative health outcomes, and/or death for Resident #86 when on 03/29/25 at 9:47 A.M., Licensed Practical Nurse (LPN) #355 administered Resident #86 a Fentanyl 50 microgram (mcg) 72-hour patch (potent opioid medication used to treat pain) after not being able to locate or remove the resident's previously administered Fentanyl patch. LPN #355 had not reported the missing patch until after the resident overdosed. On 03/29/25 at approximately 1:30 P.M., Resident #86 was lethargic, and unable to walk or sit upright. LPN #242 checked the resident's vital signs but failed to complete a head-to-toe assessment. LPN #242 called Nurse Practitioner (NP) #359 who ordered to send the resident to the emergency room . Emergency Medical Services (EMS) arrived at 1:52 P.M. and after assessment, the resident was found wearing two Fentanyl patches requiring the administration of one milligram of Narcan (a medication which rapidly reverses an opioid overdose). Resident #86 was transferred to the hospital for further evaluation and diagnosed with an accidental overdose requiring laboratory testing, a computed tomography (CT) scan, and intravenous fluids. The resident returned to the facility on [DATE] after 5:30 P.M. This affected one (#86) of three residents (#42, #50, and #86) reviewed for controlled substance use. The facility identified one current resident (#86) with physician orders for Fentanyl. The facility census was 89. On 04/07/25 at 11:38 A.M., the Administrator, Director of Nursing (DON), and Registered Nurse Clinical Consultant (RNCC) #302 were notified Immediate Jeopardy began on 03/29/25 at 9:47 A.M. when LPN #355 administered Resident #86 a second Fentanyl pain patch without reporting the previously administered Fentanyl patch could not be located and was not reported. LPN #242 then failed to complete a thorough assessment of Resident #86 when the resident was found to be lethargic, and unable to walk or sit upright. LPN #242 called Nurse Practitioner (NP) #359 who ordered to send the resident to the emergency room . EMS arrived and found the resident unable to ambulate, drooling, with pinpoint pupils and unable able to sit up. EMS administered Narcan one milligram and removed a second Fentanyl patch found on the resident before transporting the resident to the hospital and diagnosed with an accidental overdose. The facility had not initiated an incident investigation or implemented immediate interventions to ensure an accurate monitoring system for Fentanyl patch placement was established. The Immediate Jeopardy was removed on 04/07/25 at 4:33 P.M., when the facility implemented the following corrective actions: On 04/03/25, the DON completed a skin sweep on Resident #86 to ensure there were no additional patches applied. On 04/03/25, the DON completed a review of Resident #86's care plan and verified to show chronic pain and potential side effects. On 04/03/25, the DON completed a skin sweep on a like resident (Resident #50) who had discontinued orders for Fentanyl patches. The DON verified there were no patches present. On 04/03/25, RNCC #302 educated the Administrator and DON on reporting risk events and initiating investigation and implementing interventions. On 04/03/25, the Narcotic Pain Patch Policy was updated to include: Both nurses, oncoming and off going to check placement and document in medication administration record at shift change beginning on 04/06/25, and removal of Fentanyl pain patch to be completed by two nurses and documented in the controlled substance/narcotic log with two nurses for disposal beginning on 04/04/25. On 04/04/25, the DON updated Resident #86's orders to include documentation of Fentanyl patch location. On 04/04/25, the DON updated Resident #86's order to check Fentanyl patch placement every shift to also include location observed. On 04/07/25, the DON provided a standard list of locations and abbreviations placed on the unit for staff reference to ensure correct abbreviation documentation. On 04/06/25, the DON placed a reminder sheet in the narcotic book for the nurses to physically go to check narcotic placement at shift change. On 04/06/25 and 04/07/25, the DON provided education on the narcotic pain patch policy to include: Checking patch physically during count and documenting in the record; disposal of patch with two nurses and to fold patch and dispose by flushing and both nurses to document on the controlled substances/narcotic log with both nurses signing the log; using the standard list of locations and abbreviations to ensure correct abbreviation of location of Fentanyl patch; and on call manager to be notified immediately if Fentanyl patch missing. On 04/07/25, a root cause analysis was completed by the Interdisciplinary Team (IDT) including Medical Director (MD) #102, the Administrator, the DON, Assistant Director of Nursing (ADON) #208, and RNCC #302 with an ad hoc QAPI meeting on 04/07/25. Auditing includes DON or designee to review shift to shift count with physical checking of patch placement is completed, validating placement of patch to match the medical record once daily for two weeks, then four times a week for four weeks. Initial audit date of 04/04/25. Auditing to include DON or designee to audit removal of Fentanyl patch to be with two nurses and documented accurately in the narcotic log daily for two weeks, then four times a week for four weeks. Interviews on 04/07/25 from 2:21 P.M. through 3:10 P.M., with LPN #248, LPN #244, LPN #242, and LPN #231 revealed education on the new policy and procedures had been provided. On 04/08/25, the DON provided education to LPN #242 on completing head-to-toe assessments. Interviews on 04/08/25 from 9:07 A.M. through 9:20 A.M., with LPN #233, LPN #311, and LPN #248 revealed education on anatomical location abbreviations had been provided and a list was observed in each controlled substance binder. Although the Immediate Jeopardy was removed on 04/07/25 at 4:33 P.M., the facility remained out of compliance at a 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 #86 revealed an admitted d of 07/10/23. Diagnoses included dementia, schizoaffective disorder, depression, anxiety, hypertension, Alzheimer's disease, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision with transfers, toileting, and set up assistance for ambulation. Review of the care plan initiated on 07/10/23 and last revised on 11/21/23 revealed the resident experienced chronic pain with an intervention to monitor and document side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician. Also, to observe/report changes in usual routine, sleep patterns, decreased in functional ability, decreased range of motion, and withdrawal or resistance to care. Review of a physician order dated 08/04/24 revealed an order for a Fentanyl transdermal patch 72-hour, 50 micrograms (mcg)/hour, apply 50 mcg transdermal every 72 hours for pain. Review of an order dated 05/21/24 revealed to verify placement of the Fentanyl patch every shift for patch placement. An order dated 03/23/25 revealed to remove the used Fentanyl patch prior to applying new patch in the morning every three days for patch disposal. There were no orders to remove and document the removal of the Fentanyl patch prior to 03/23/25. Review of the medication administration record (MAR) from 03/01/25 through 03/31/25 revealed no documentation of Fentanyl patch removal until 03/23/25. Further review of the MAR revealed Resident #86 was administered a Fentanyl 50 mcg 72-hour patch on 03/05/25 at 8:29 A.M. to the left front shoulder. Documented verification of patch placement on each shift from 03/05/25 through 03/08/25 at 6:00 A.M. revealed the patch was incorrectly documented as located on the right back shoulder or the right scapula. Review of the MAR on 03/08/25 at 12:20 P.M. revealed a new Fentanyl patch was administered on the left arm. Verification of patch placement from 03/08/25 through 03/11/25 at 6:00 A.M. revealed the patch was incorrectly documented as located either on the right shoulder or the right scapula. Review of the MAR on 03/11/25 at 7:01 A.M. revealed a new Fentanyl patch was administered to the left front shoulder. Verification of patch placement from 03/11/25 through 03/14/25 at 6:00 A.M. revealed the patch was located on the left chest, left scapula, and right scapula. Review of the MAR on 03/14/25 at 8:58 A.M. revealed a new Fentanyl patch was administered to the right forearm. Verification of placement from 03/14/25 through 03/17/25 at 6:00 A.M. revealed the patch was incorrectly documented as located on the right scapula, left arm, and left scapula. Review of the MAR on 03/17/25 at 9:56 A.M. revealed a new Fentanyl patch was administered to the right arm. Verification of patch placement from 03/17/25 through 03/20/25 at 6:00 A.M. revealed the patch was incorrectly documented as located on the left arm, and right scapula. There were two verifications of the patch located on the right upper arm. Review of the MAR on 03/20/25 at 8:04 A.M. revealed a new Fentanyl patch was administered to the left front shoulder. Verification of patch placement from 03/20/25 through 03/23/25 at 6:00 A.M. revealed the patch was incorrectly documented as located on the right scapula, left scapula, left chest, and right chest. Review of the MAR on 03/23/25 at 10:17 A.M., a new Fentanyl patch was administered to the right front shoulder and the prior patch had been removed. Verification of patch placement from 03/23/25 through 03/26/25 at 6:00 A.M. revealed the patch was located on the right chest, right scapula, left middle back and later was found not in place at 6:00 P.M. on 03/25/25. Review of an electronic medication administration record (EMAR) note dated 03/25/25 at 11:16 P.M. revealed no Fentanyl patch was found during verification of Fentanyl patch placement. There was no notification made to the physician or the Director of Nursing (DON). Further review of the nurses notes from 03/01/25 through 03/31/25 revealed there was no documentation the resident had any history of removing or relocating the Fentanyl patch. On 03/26/25 at 6:00 A.M. verification of patch placement was noted as yes with no location documented. Review of the MAR on 03/26/25 at 8:40 A.M., revealed a new Fentanyl patch was administered to the right front shoulder. Verification of patch placement from 03/26/25 through 03/29/25 revealed the patch was incorrectly documented as located on the left arm, right chest or right upper chest with one verification on 03/28/25 at 6:00 A.M. with no location documented. Review of the MAR dated 03/29/25 at 9:47 A.M. revealed a new Fentanyl patch was administered to the right front shoulder. Further review of the MAR revealed documentation stating not applicable indicating the previous Fentanyl patch had not been removed prior to applying the new patch. Review of a fire and rescue department patient care record dated 03/29/25 revealed the 911 called was received at 1:46 P.M. for stroke-like symptoms. EMS arrived at Resident #86 at 1:52 P.M. The primary impression was noted as an overdose. The resident signs and symptoms included altered mental status, stupor, drooling, and somnolence with pinpoint pupils with an onset time of 1:30 P.M. EMS arrived at the scene in a dining area with resident seated at a table, slumped over, drooling, responsive to verbal but disoriented and slurred speech following some commands. Per staff, the resident had his Fentanyl patch replaced, went outside for a walk, and upon coming back inside, could barely walk and progressed to current state, with no history of same. The resident was noted to have a new Fentanyl patch to his upper right chest, staff swears they removed the old one. The resident was checked from waist up while vitals obtained for additional patches, none found. Resident pupils pinpoint, presented more like overdose than stroke. One milligram Narcan given as diagnostic tool. Resident with some improvement after Narcan administration. Resident skin checked again; second Fentanyl patch found on right upper arm which was covered by the blood pressure cuff on initial assessment. Confirmed the other patch was present on the right upper chest as well. Patch removed from right upper arm and resident's mental status improving but transported to the emergency room at 2:25 P.M. for observation. The resident was noted as slightly combative at times during transport. Review of the hospital record dated 03/29/25 revealed the resident arrived at 2:23 P.M. from nursing home where he was found wearing two Fentanyl patches and then one Fentanyl patch was removed. One mg Narcan given and resident now alert and oriented to baseline. The resident was diagnosed with an accidental overdose. The resident received laboratory testing, a CT scan and was administered intravenous fluids. The resident was discharged at 5:07 P.M. and was awaiting transport back to the nursing home. Review of a nurses note dated 03/29/25 at 6:42 P.M. revealed the resident was sent to the emergency room . The resident was lethargic, could not walk or sit up and kept leaning to the left side. Nurse Practitioner (NP) #359 was notified and ordered to send the resident to the emergency room . EMS arrived and tried to start an intravenous line and removed the resident's sweater. Upon removing the sweater, EMS noticed there were two Fentanyl patches on the resident. EMS administered Narcan and the resident started to communicate. The resident's family was notified of transport to the emergency room . Review of the MAR revealed no verification of Fentanyl patch placement was completed on 03/29/25 on the 12-hour night shift. There was no verification of placement on 12-hour day shift or night shift on 03/30/25. On 03/31/25, the Fentanyl patch was noted on the right upper arm and right upper shoulder. Review of the MAR for Resident #86 revealed on 04/01/25 at 8:52 A.M., a new Fentanyl patch was administered to the left rear shoulder. On 04/01/25 verification of placement revealed the Fentanyl patch was incorrectly documented on the left upper arm. Observation on 04/02/25 at 9:42 A.M., with LPN #252 revealed Resident #86 had a Fentanyl patch dated 04/01/25 and initialed on his left upper back. There was tape in place over the Fentanyl patch. Interview on 04/02/25 at 9:53 A.M., Certified Nursing Assistant (CNA) #120 revealed on 03/29/25, Resident #86 had gone outside and came back in and could not sit up straight and the ambulance was called. Interview on 04/02/25 at 1:48 P.M., the Administrator revealed he was not sure he was aware of any specifics of Resident #86's overdose. The Administrator revealed he was not aware of an investigation, incident report or if anything was put in place. The Administrator revealed the DON should know and would be the one to investigate. Interview on 04/02/25 at 2:51 P.M., EMS Responder #301 revealed upon arrival to the facility, Resident #86 was sitting in a chair in the dining area drooling and nearly unresponsive. EMS Responder #301 revealed the resident was assessed. After about ten minutes they removed the blood pressure cuff and found a second Fentanyl patch on the resident's right upper arm. EMS Responder #301 revealed the resident was administered one milligram of Narcan intravenously and the resident perked right up. Interviews beginning on 04/02/25 at 12:50 P.M., the DON revealed Resident #86 was leaning to the side and the nurse questioned if the resident was having a cerebral vascular accident. The DON stated he told the nurse to assess the resident and to send to the emergency room if needed. The DON revealed the nurse notified him EMS arrived and found a second Fentanyl patch on the resident. The DON revealed the medication from the second patch should not have caused the overdose but then stated each patient metabolizes medications at different rates. The DON revealed he had not investigated the incident or implemented any new interventions because he had to work the floor over the weekend and was off work on Monday. The DON also verified he had not been notified of the Fentanyl patch missing on 03/25/25. Additional interview with the DON revealed the nursing staff were not accurately documenting the location of the resident's Fentanyl patch and education would be completed. The DON incorrectly stated documentation of the removal of the resident's patch would not require documentation by two nurses to dispose of a removed Fentanyl patch. Interview on 04/02/25 at 3:42 P.M., Assistant Director of Nursing (ADON) #208 revealed to administer a Fentanyl patch, first remove the old patch, apply the new patch with date and label and cover with Tegaderm. ADON #208 revealed the patch was to remain in the same location for 72 hours. ADON #208 revealed two nurses during shift change should witness disposal of the old patch but were not required to sign off on the disposal. ADON #208 revealed the physician, and DON should be notified when a Fentanyl patch was found missing during the verification of placement. Interview on 04/02/25 at 4:05 P.M., Staffing and Scheduling Coordinator (SSC) #266 revealed overhearing a resident on the locked unit was found wearing two or three Fentanyl patches. Review of the MAR revealed on 04/02/25, verification of the Fentanyl patch was completed at 6:00 A.M. and 6:00 P.M. The location placement was noted as back. Interview on 04/03/25 at 8:05 A.M., LPN #233 revealed before administering a Fentanyl patch, ensure there were no other patches on the resident. LPN #233 revealed nurses should have a witness when a new patch was administered and to sign and date the patch then place a clear adhesive dressing over the patch. LPN #233 revealed the location of the patch should be documented when applied and removed, and staff should sign with another nurse when the old patch was discarded. Review of the MAR dated 04/03/25 at 6:00 A.M., LPN #233 incorrectly documented the location of the Fentanyl patch as on the left shoulder. Observation on 04/03/25 at 8:14 A.M., with LPN #233 revealed Resident #86's Fentanyl patch was on his left upper back dated 04/01/25 and initialed. There was tape over the patch. Interview on 04/03/25 at 9:41 A.M., LPN #242 revealed a nursing assistant indicated Resident #86 was not acting his normal self. LPN #242 revealed there was an agency nurse working on the resident's behavioral unit. LPN #242 revealed she went and assessed Resident #86. LPN #242 revealed the resident was not with it, and was unable to stand. LPN #242 thought the resident could be having a stroke. LPN #242 revealed the resident's vital signs and blood sugar levels were within normal limits. LPN #242 revealed during the resident's assessment she had not looked over the skin on his body. LPN #242 revealed EMS was called. LPN #242 revealed she was unaware the resident was receiving Fentanyl during her assessment of the resident. LPN #242 revealed EMS removed the resident's shirt and the resident was wearing two Fentanyl patches, one on his front left chest and one on his back right shoulder. LPN #242 revealed EMS administered Narcan and the resident started to come to. LPN #242 revealed the agency nurse stated she had removed the resident's old Fentanyl patch before applying a new one. LPN #242 revealed two nurses should witness the removal and disposal of a Fentanyl patch and should make a progress note on who verified. LPN #242 revealed the location of the Fentanyl patch should be documented when administered and removed also during verification of placement. Further interview on 04/07/25 at 7:53 A.M., LPN #242 revealed the Fentanyl patch remained in place at the same location for 72 hours after it was administered. LPN #242 revealed incorrectly the anatomical location rsc refers to the right shoulder chest. Interview on 04/03/25 at 9:58 A.M., Pharmacist #303 revealed a patient wearing multiple Fentanyl patches could overdose if the old patch was not removed before administering a new patch. Interview on 04/03/25 at 2:44 P.M., LPN #241 revealed on 03/26/25 Resident #86 was administered a new Fentanyl patch. LPN #241 revealed she could not find the old Fentanyl patch to remove. LPN #241 revealed finding a Fentanyl patch in the resident's bed a couple of times. LPN #241 revealed she had not reported the missing patch on 03/26/25 or the patches previously found in the resident's bed to the physician or the nursing management team. LPN #241 revealed she had documented on 03/26/25 at 6:00 A.M. of the patch placement but not the location. LPN #241 revealed she was no longer employed by the facility. Interview on 04/07/25 at 1:41 P.M., RNCC #302 revealed the DON and Administrator had not notified her of Resident #86's overdose on 03/29/25 until 04/02/25. RNCC #302 revealed the DON should have reported the incident to the Administrator and the risk management team and immediately began an investigation and implemented interventions. Interview on 04/07/25 at 2:09 P.M., the DON revealed he was notified on 03/29/25 when Resident #86 was found wearing two Fentanyl patches. The DON revealed after Resident #86 overdosed, he found out LPN #355 could not locate the resident's previous Fentanyl patch and applied a new patch. The DON verified he notified the Administrator on 03/29/25 of the incident. The DON revealed the anatomical location rsc refers to the right scapula. The DON revealed the facility had no standard anatomical abbreviations in place for the nursing staff. Interview on 04/08/25 at 7:45 A.M., LPN #355 revealed she worked for agency and on 03/29/25 she was scheduled in the facility to work as a certified nursing assistant. LPN #355 revealed she had been a CNA for ten years and just received her nurse's license a couple weeks prior but had not yet worked as a nurse. LPN #355 revealed the facility needed a nurse on the secured behavioral unit and the DON told her she was going to be the nurse. LPN #355 revealed she had not trained in the facility as a nurse and felt pressured by the DON to take the assignment. LPN #355 revealed she told the DON she was not comfortable with the assignment. LPN #355 revealed it was a horrible day, just a nightmare. LPN #355 revealed she was handed the keys to the cart around 9:00 A.M. and had not received report from the previous nurse because she was upset about staying over. LPN #355 revealed Resident #86 was supposed to have a Fentanyl patch removed. LPN #355 revealed she looked up where the patch was last located in the electronic medical record. LPN #355 revealed she checked Resident #86, and the patch was not there. LPN #355 revealed she was unaware the missing patch needed to be reported. LPN #355 revealed Resident #86 was then administered a new Fentanyl patch. LPN #355 revealed later a nursing assistant notified her the resident had a change in condition. LPN #355 revealed she went and got LPN #242. LPN #355 revealed the resident had really small pupils. LPN #355 revealed LPN #242 took over the resident's care. Interview on 04/08/25 at 10:27 A.M., the DON revealed LPN #355 indicated she was licensed to work as a nurse but indicated she was scared but never said she had not wanted the assignment. The DON revealed LPN #355 was listed on the agency website as able to work as either a nurse or a nursing assistant. The DON revealed LPN #355 was competent to complete the assignment without additional training. Interview on 04/08/25 at 10:44 A.M. with Customer Service Representative (CSR) #360 from the staffing agency verified LPN #355 was approved to work as either a nurse or a nursing assistant. Review of the facility policy Controlled Substance Administration and Accountability, dated 2024, revealed the facility would have safeguards in place for controlled substances to prevent loss, diversion, or accidental exposure. All controlled drug patches removed from patients are disposed of in such a manner as to prevent diversion. Disposal of patches should be witnessed and cosigned in the MAR in the blanks provided with each controlled drug patch order. Two signatures are required for documentation of controlled drug patch disposal. Further review of the policy revealed no guidelines for the administration and verification of Fentanyl patch locations. This deficiency represents non-compliance investigated under Complaint Number OH00164275 and Complaint Number OH00164205.

Based on observation, interviews with facility staff and the nurse practitioner, review of open and closed medical records, review of skin assessments, review of wound assessment reports, review of physician orders, review of treatment administration records, and policy review, the facility failed to ensure a resident's skin impairment was timely identified and treatment provided. This resulted in Actual harm to Resident #88 on 05/13/24 when the facility failed to develop and implement a care plan that included skin integrity monitoring with the use of an abdominal binder and failed to assess and monitor the resident's skin every shift that resulted in Resident #88 developing a Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) caused by the abdominal binder the resident was required to wear. Additionally, the facility failed to ensure Resident #34, identified at risk for skin breakdown on admission (06/14/24), and who was assessed with excoriation/incontinence erosion to the coccyx area, received appropriate treatment and services to prevent the area from worsening by failing to document the initial wound assessment describing the wound, including measurements in accordance with facility policy, from 06/14/24 until the nurse practitioner evaluated the wound on 06/24/24. Furthermore, Resident #34 had no documented treatment in place for the coccyx until 06/20/24, six days after admission, placing the resident at risk for potential skin breakdown at a Severity Level 2 (no actual harm with the potential for more than minimal harm). This affected two (#88 and #34) of three residents reviewed for pressure ulcers. The facility census was 86. Findings include 1. Review of the closed medical record for Resident #88 revealed an admitted [DATE]. The resident was discharged to the hospital on 05/29/24 and had not returned to the facility. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, stage four pressure ulcer of the sacrum, hypertension, type two diabetes mellitus, gastrostomy, tracheostomy, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident was admitted with one Stage 4 pressure ulcer and one Unstageable pressure ulcer. The resident was dependent on staff for toileting, hygiene, and bed mobility. Review of the pressure ulcer risk assessments dated 03/21/24, 03/29/24, 04/11/24, and 04/18/24 revealed the resident was at very high risk for developing pressure ulcers. Review of the care plan initiated 03/26/24 revealed the resident was at risk for skin break down related to weakness, impaired mobility, history of cerebral vascular accident with right sided weakness, incontinence status, diuretic medication use, diabetes mellitus and anticoagulant use. Interventions included to apply barrier cream after each incontinent episode, assist to turn and reposition at frequent intervals to provide pressure relief, complete weekly skin assessment, keep skin clean and dry, monitor fit of clothing and footwear, change as needed and monitor for proper placement of tubes, catheters, and other devices, report changes in skin integrity to nurse, provide pressure redistribution surface to bed and chair as ordered, and obtain laboratory tests as ordered by physician. Further review of the care plan revealed the resident had actual impairment to skin including an Unstageable pressure ulcer to the sacrum, a Stage 1 pressure ulcer to the right shoulder (resolved on 04/08/24) and a skin tear to the left forearm. The care plan was not updated to include the Stage 3 pressure ulcer to the axilla identified on 05/13/24. Additional interventions included inspecting skin on a daily basis when performing and assisting with personal care and Activities of Daily Living (ADLs) and report any abnormalities to supervisor and to monitor/document location, size and treatment of skin injury, report abnormalities to physician, and provide treatment as ordered. Review of a physician order dated 04/22/24 revealed the resident was ordered an abdominal binder at all times every shift for proper placement. Review of a physician order dated 04/23/24 revealed the resident had orders for a premium low air loss mattress with safety bolsters every shift to promote wound healing. There were no orders to monitor the resident's skin integrity due to the use of the abdominal binder. Review of a skilled nurses note dated 05/12/24 at 1:33 P.M. revealed the resident had no new changes to skin integrity. Review of nursing assistant charting dated 05/12/24 at 9:59 P.M. revealed the resident had no new observed skin alterations. Review of a nurses note dated 05/13/24 at 2:27 A.M., revealed the resident had a new open wound on right upper extremity, in the crease of his armpit. The nurses note revealed, looks like it could be from abdominal binder rubbing against it. The wound measured two inches in width. The area was cleaned with soap and water, patted dry, and left open to air. The nurse practitioner was notified. Review of an incident report dated 05/13/24 at 2:34 A.M. revealed the nursing assistant noticed drainage coming from the resident's right side armpit when changing the resident. The resident had an abdominal binder that was rubbing against his armpit. Review of a nurse practitioner (NP) wound assessment report dated 05/13/24 revealed the resident had a new Stage 3 pressure area to the right axilla. The wound measured 0.6 centimeters (cm) in length by 3.3 cm in width by 0.5 cm in depth. The wound had one percent (%) to 24% epithelial tissue, 50% to 74% granulation tissue, and 25% to 49% slough. There was exposed subcutaneous tissue with unattached wound edges with moderate serosanguineous drainage. The periwound was fragile and reddened. A new treatment was initiated to cleanse with wound cleanser, treat with calcium alginate and antifungal powder to the periwound and cover with ABD (abdominal) pad daily. The NP also made a recommendation to be sure the abdominal binder was secured to the area of the abdomen. Review of the treatment administration record (TAR) dated 05/01/24 through 05/29/24 revealed the resident's order for the abdominal binder at all times as tolerated every shift for maintain proper placement was completed from 05/01/24 through 05/12/24 at 6:00 P.M. Further review of the TAR revealed the treatment to the axilla was completed per physician orders. Interview on 06/24/24 at 5:13 P.M., the Director of Nursing (DON) revealed the resident had an abdominal binder to prevent him from pulling on his feeding tube. The DON revealed the resident developed a Stage 3 pressure ulcer to the axilla from the abdominal binder. The DON revealed the nurses should have been checking the resident's skin integrity every shift when wearing the abdominal binder and when administering tube feedings to the resident. The DON verified there was no documentation the resident's skin integrity was monitored by the nurses every shift. Further interview on 06/25/24 at 2:50 P.M. with the DON revealed the resident's care plan had not included the use of the abdominal binder or the wound to the axilla. Continued interview with the DON revealed the facility had no policy on the use of an abdominal binder. Interview on 06/25/24 at 9:36 A.M., Licensed Practical Nurse (LPN) #200 stated the nursing assistants brought it to her attention the resident's abdominal binder was up under the resident's armpit. LPN #200 stated the area was red in the crease and there was a split in the skin. LPN #200 stated she removed the abdominal binder. LPN #200 stated the abdominal binder must have moved up under the arm from the resident moving. Interview on 06/25/24 at 1:03 P.M., Nurse Practitioner (NP) #500 revealed the wound to the resident's axilla was consistent with the resident's abdominal binder riding up under his arm. NP #500 revealed the resident had a Stage 3 pressure ulcer to the axilla. Interview on 06/26/24 at 12:30 P.M., LPN #280 revealed she completed a skin assessment on the resident on 05/12/24 and the resident had no skin alterations in his armpit. LPN #280 revealed the resident wore a gown and it was easy to check his skin. Review of the policy Prevention of Pressure Ulcers/Injuries, (revised 07/2017) revealed the facility would review the resident's plan of care and identify pressure ulcer risk factors and interventions designed to reduce or eliminate those considered modifiable. Further review of the policy revealed resident's skin would be inspected on a daily basis when performing or assisting with personal care or ADL's. There were no guidelines for monitoring skin when an abdominal binder was in use. 2. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, heart failure, hypertension, chronic obstructive pulmonary disease, chronic kidney failure, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required substantial/maximal assistance with toileting hygiene, and supervision/touching assistance for transfers and ambulation. The resident was noted with an Unstageable deep tissue injury (DTI) and two venous or arterial ulcers. Review of hospital documentation dated 06/07/24 revealed the resident had a DTI to the left buttock with non-blanchable erythema and no odor. The treatment included to apply Calmoseptine/zinc oxide with menthol to the wound. Review of an admission pressure risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of the admission skin assessment dated [DATE] at 7:10 P.M. revealed the resident was noted with redness to the coccyx area with no wound description. Review of an alteration in skin integrity report dated 06/14/24 at 7:12 P.M. revealed the resident had excoriation/incontinence erosion to the coccyx area; however, there was no assessment of the wound or wound measurements. Review of the nursing admission assessment dated [DATE] at 11:50 P.M. revealed there was no assessment of the resident's coccyx completed. Review of a skin assessment dated [DATE] at 1:38 P.M. noted no new skin abnormalities/areas. Review of a skin assessment dated [DATE] at 3:02 P.M. revealed the resident had a pressure area to the coccyx, but there was no description of the wound. Review of a weekly skin assessment dated [DATE] at 9:21 A.M. noted the resident had a pressure area on his coccyx; however, there was no description of the wound. Review of the physician orders from 06/14/24 through 06/19/24 revealed there were no treatment orders in place for the wound to the coccyx. Review of a physician order dated 06/20/24 revealed to cleanse the wound with wound wash, pat dry, apply calcium alginate and cover with bordered gauze dressing every shift. On 06/24/24 the treatment order for the coccyx changed to cleanse with wound wash, pat dry, apply Calmoseptine cream and cover with ABD (abdominal) pad every shift. Review of the treatment administration record from 06/14/24 through 06/25/24 revealed no documented treatments were completed for the coccyx wound until 06/20/24. Review of a nurse practitioner wound report dated 06/24/24 revealed the resident had a 3.5 centimeter (cm) in length by 2 cm in width by 0.1 cm in depth Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to the coccyx with 100% epithelial tissue, attached wound edges, and scant serosanguineous exudate with a fragile and red periwound. The nurse practitioner ordered to cleanse with soap and water, pat dry, apply Calmoseptine, and cover with an ABD and change twice daily. Observation on 06/25/24 at 11:08 A.M. of wound care with Registered Nurse (RN) #301 and the Director of Nursing (DON) revealed the resident had a Stage 2 pressure ulcer to the coccyx approximately three centimeters in length, by two centimeters in width and minimal depth. The area was red with scant drainage with no signs of infection. Interview on 06/25/24 at 1:11 P.M., RN #301 and the DON verified there was no documented initial wound assessment of the resident's coccyx from 06/14/24 until the nurse practitioner evaluated the wound on 06/24/24. RN #301 revealed the nurse practitioner evaluated the resident on 06/17/24 but could not evaluate his coccyx wound as he was in dialysis. RN #301 revealed the resident had no documented treatment in place for the coccyx until 06/20/24. RN #301 revealed prior to 06/20/24 the nursing assistants were applying barrier cream as needed to the wound. RN #301 revealed the resident had a reddened area to the coccyx that was non-blanchable since admission. Review of the policy Wound Care, revised 10/2010, revealed nurses would document all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting a wound. This deficiency represents non-compliance investigated under Master Complaint Number OH00154816.

Based on observation, medical record review, staff interview, review of the emergency cart checklist and review of facility policy, the facility failed to ensure necessary supplies and life sustaining equipment was available for staff to immediately respond to a medical emergency. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or negative health outcomes when Resident #93, who had a tracheostomy, did not have suction catheters available at her bedside or on the emergency cart. The lack of equipment at bedside and on the emergency cart delayed the clearing of secretions to maintain a patent airway when Resident #93 experienced shortness of breath, loss of consciousness, loss of respirations, and loss of pulse. This affected one (#93) of four residents reviewed for tracheostomy care. The facility identified three current residents (#11, #23, and #75) with tracheostomies. The facility census was 93. On 12/20/23 at 4:42 P.M., the Administrator was notified Immediate Jeopardy began on 12/17/23 at 7:32 P.M. when, after receiving report from the first shift Respiratory Therapist (RT) #514 regarding Resident #93 experiencing shortness of breath throughout the day, RT #513 went to check on the resident. RT #513 found Resident #93 on the side of the bed, having a difficult time breathing. RT #513 suctioned Resident #93 using the inline suction via her ventilator (vent), a large amount of secretions were returned, and the resident became more short of breath. Resident #93 was placed on the vent, was not receiving good tidal volumes (amount of air that moves in and out of the lungs), was removed from the vent, and RT #513 attempted to suction the resident with the inline suction again, with no secretions extracted. RT #513 manually bagged for ventilation with resistance felt, indicating inadequate ventilation. Resident #93 was extremely short of breath and became unresponsive. RT #513 pulled the call light cord, yelled for help, called a code, and 911 was called. A suction catheter was not available at Resident #93's bedside and the emergency cart did not have suction catheters available for use to aid in clearing the resident's airway. RT #513 subsequently reconnected the vent to provide inline suctioning, which was not effective in clearing the resident's airway. Emergency Medical Services (EMS) responded to the facility and took over Resident #93's care. Due to Resident #93 having a lot of secretions and resistance to ventilation, EMS inserted a tube for a larger airway. While EMS was able to adequately ventilate Resident #93, they were unable to get her heart rate back and Resident #93's time of death was called at 8:25 P.M. The Immediate Jeopardy was removed on 12/21/23 when the facility implemented the following corrective actions: On 12/20/23, Registered Nurse (RN) #526 updated the emergency cart checklist and procedure. On 12/20/23, RT #504 stocked the two emergency carts with all required equipment and ensured like residents had bedside emergency equipment available. On 12/20/23 by 7:00 P.M., RN #526 audited the emergency carts to ensure all required equipment was stocked and emergency equipment was located at bedside. On 12/20/23, RN #515 conducted a mock code on both shifts. No negative findings were identified. On 12/20/23, Licensed Practical Nurse (LPN) #509, LPN #516, LPN #517, LPN #518, LPN #519, LPN #520 and RN #515 completed head to toe assessments on all full code residents with no negative findings. On 12/20/23, Minimum Data Set (MDS) Nurse #521 reviewed and updated care plans for all residents with full code status. Interviews on 12/20/23 between 7:40 P.M. and 8:00 P.M. with RT #504 and RT #513 and LPN #518, LPN #522, LPN #523, LPN #524 and LPN #525 verified the emergency carts and bedside supply education had been completed and a mock code occurred with staff participation. Observations on 12/20/23 at 8:30 P.M. verified the emergency carts had been stocked, and the contents within the carts matched the required equipment identified on the checklist. Additionally, observations of Resident #11, Resident #23 and Resident #75 confirmed bedside equipment was in place. By 12/21/23, all licensed nurses and RTs were educated on the updated emergency cart checklist and procedure by the Director of Nursing (DON). Beginning 12/21/23, the DON will audit emergency carts to validate completion and accuracy of the crash cart checklist. These audits will be completed weekly for four weeks and then monthly for two months. Any noncompliance will be immediately addressed, and audit findings will be part of the monthly Quality Assurance (QA) process to determine the need for further monitoring. Beginning 12/21/23, the DON will interview licensed nurses and RTs to validate knowledge and understanding of the emergency cart checklist and procedure and bedside equipment. This audit will be completed weekly for four weeks and then monthly for two months. Any noncompliance will be addressed immediately, and corrective action will be implemented. Audit findings will be reviewed as part of the monthly QA process to determine the need for further monitoring. Review of three (#11, #23 and #75) additional resident records revealed no concerns were identified. Although the Immediate Jeopardy was removed on 12/21/23, the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is 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 #93 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), oxygen dependent, and pneumonia. Review of the hospital Continuation of Care documents, dated 12/08/23, revealed Resident #93 had been weaned to a tracheostomy collar, required skilled nursing for the continuation of treatment, weaning of ventilator dependence and strengthening. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/12/23, revealed Resident #93 was cognitively intact, had debilitating cardiorespiratory conditions, chronic respiratory failure with hypoxia, pneumonia, protein calorie malnutrition, and COPD. Additionally, Resident #93 required special treatments, which included continuous oxygen therapy, a tracheotomy, invasive mechanical ventilation and suctioning as needed. Review of physician orders, dated 12/08/23, revealed Resident #93's tracheostomy was to be verified as in place and secure every shift and as needed, tracheostomy care every shift and as needed, tracheostomy ties changed every Saturday and as needed, tracheostomy to be changed every 90 days per pulmonary as needed, emergency respiratory equipment at bedside, including Ambu bag, a spare tracheostomy tube (size seven extra-large) and suction equipment, suctioning completed as needed, and nocturnal ventilation as needed. Review of the Medication Administration Record (MAR) from 12/08/23 through 12/17/23 revealed the emergency respiratory therapy equipment was signed off each shift as being at bedside for Resident #93. Review of the plan of care, dated 12/12/23, revealed Resident #93 was at risk for developing complications secondary to ventilator dependent COPD and respiratory failure. Interventions included to administer aerosol treatments using an inline nebulizer, assess for signs and symptoms of hypoxia: altered level of consciousness, irritability, listlessness and cyanosis (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), head of bed elevated above 30 degrees, maintain spare tracheostomy tube at bedside, maintain ventilator settings as ordered, monitor for changes in respiratory rate or depth, observe for the use of accessory muscles and notify the physician of significant changes, monitor oxygen saturation while resident is on mechanical ventilator support and/or during the weaning process, routine tracheostomy changes by respiratory, tracheostomy care twice in 24 hours, change inner cannula once in 24 hours, reposition at least every two hours and record pulse oximetry reading every shift or more frequently as needed. Review of RT #513's progress note dated 12/17/23 at 7:30 P.M. revealed day shift RT #514 reported Resident #93 had been short of breath all day and when suctioning the resident, nothing came out. RT #513 suspected a plug (mucous accumulation in the tracheostomy blocking air from flowing through the airway) and went to check on Resident #93 after report and found Resident #93 hanging off the side of the bed. Resident #93 was alert and stated she could not breathe. The resident's color was pale. RT #513 repositioned Resident #93 into bed and immediately inline suctioned Resident #93, receiving copious amounts of yellow/tan secretions, and then placed Resident #93 on the ventilator. RT #513 was unable to receive good tidal volumes, removed Resident #93 from the ventilator and attempted to provide manual ventilation to the resident, with resistance felt. At 7:32 P.M., RT #513 pulled the call light cord from the wall and yelled for help. Nurses and aides responded with the emergency cart and EMS was called. The tracheostomy position was checked and found to be in position. Resident #93 was again inline suctioned, with copious amounts of secretions returned, and Resident #93 was blue and no longer alert. Upon checking for a pulse, there was no pulse and compressions were started and bag ventilation was provided until EMS arrived at 7:37 P.M., when they took over care. Resident #93's time of death was called at 8:25 P.M. Interview on 12/20/23 at 10:07 A.M. with RT #513 revealed she called the code for Resident #93 on 12/17/23. RT #513 stated first shift RT #514 had attempted to suction Resident #93 but was unable to extract any secretions. Following report, RT #513 went to check on Resident #93, who was having difficulty breathing. RT #513 inline suctioned the resident, attempted to bag ventilate the resident, received resistance (meaning inadequate ventilation), and Resident #93 became unresponsive. RT #513 verified a suction catheter was not available at Resident #93's bedside and when nursing staff arrived at the resident's room with the emergency cart, the cart also did not have suction catheters. RT #513 stated she had to reconnect Resident #93's ventilator for inline suctioning due to a suction catheter being unavailable. RT #513 stated suction catheters were the preferred method to provide suctioning as they were easier to manipulate in the event there was a mucous plug blocking the airway. RT #513 verified the necessary supplies needed to respond to the code for Resident #93 were not available at the bedside or on the emergency cart but were instead located on a respiratory cart located in the hallway. Once EMS arrived and assumed care of Resident #93, another tube was inserted in the resident's tracheostomy to create a larger airway. RT #513 noted a large amount of secretions were extracted when EMS removed the resident's inner cannula prior to inserting the larger tube. RT #513 stated EMS was able to adequately ventilate Resident #93, but they were unable to regain her heart rate. Additionally, RT #513 stated the emergency carts were to be checked by RTs nightly to ensure all needed supplies were stocked but stated this had not been done due to the carts being broken. RT #513 stated multiple reports had been made to the respiratory manager about the emergency carts being broken and missing equipment, with no action taken to address the concerns. Observation on 12/20/23 at 3:50 P.M. of the emergency carts with LPN #509, revealed two, wheeled carts located behind an unlocked door near the nurses' station, labeled Emergency Cart. Upon entrance to the room, a clipboard with an inventory list for the emergency carts was located on top of the cart to the left. The cart to the left of the door was not locked and the drawers would not open. The second cart, to the right of the door, was also unlocked, the drawers opened; however, the drawers were empty. Review of the Emergency Cart inventory, located on the clipboard on top of the emergency cart, revealed the document was dated December 2023. The document went on to direct the cart was to be checked daily, with the lock number documented and the person checking the emergency cart was to initial the date the cart was checked to ensure the following supplies were available: full oxygen cylinder, a working suction machine, an Ambu bag, and a back board. Additionally, the cart was to be checked when open for the following: blood pressure cuff, pulse oximeter, stethoscope, 10 ml syringe, carbon dioxide detector, nonrebreather mask (used to deliver oxygen in emergency situations), nasal cannula, oxygen tubing, oxygen connectors, suction catheter kits, Yankauer catheter (used for oral suctioning), sterile saline for suctioning, disposable gloves, goggles, masks, suction canister with tubing, biohazard bags, and an electric cord. Further review revealed the checklist had been initialed as checked on 12/01/23, 12/02/23, /12/03/23, 12/06/23, and 12/07/23. LPN #509 stated she had no knowledge of who was responsible for checking the carts to ensure all needed supplies were stocked. Additionally, LPN #509 verified the checklists had not been completed since 12/07/23, both carts were broken and were absent of emergency supplies and added the carts had been broken for a while. Interview on 12/20/23 at 4:00 P.M. with the Administrator confirmed the facility had no policies or procedures in place for the maintenance and stocking of emergency supplies for the emergency carts. Review of the facility policy titled Suctioning, undated, revealed the purpose of suctioning is to remove secretions, maintain a patent airway and prevent infection of the lower airway. This deficiency represents noncompliance investigated under Master Complaint Number OH00149288.

Based on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed to ensure assessments, care, and services were provided for a resident with a dialysis access port. This resulted in actual harm when Resident #100 was assessed with an elevated temperature and a decline in mental status. Resident #100 was transported to the hospital and required hospitalization and intervention to treat sepsis and dialysis line infection. This affected one (#100) of three residents reviewed for dialysis. The census was 68. Findings include: Review of Resident #100's medical record revealed an admitted [DATE]. Diagnoses included acute kidney failure with dialysis, encephalopathy, developmental disabilities, and diabetes mellitus type two. Review of Resident #100's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident had a moderate deficit of cognitive function. Review of Resident #100's care plan dated 10/03/23 revealed the resident required dialysis with a goal for the resident to have no signs and symptoms of complications from dialysis through the review date. Interventions included to monitor for bruit (an audible vascular sound associated with turbulent blood flow) and thrill (a vibration caused by blood flowing) of the dialysis port and monitor vital signs. Review of an admission dialysis assessment dated [DATE] revealed Resident #100 received hemodialysis through a port located on her right upper chest. An assessment was completed at that time for thrill and bruit, redness, edema, neck vein distention, and bleeding. The assessment was within normal limits. Review of Resident #100's medical record revealed she did not require dialysis treatments while in the facility, but the access port was kept in place incase the need for dialysis treatments arose. Review of Resident #100's physician orders dated 09/29/23 through 10/12/23 revealed there were no orders related to the care of the dialysis port. Review of Resident #100's medical record, including assessments, progress notes, and treatment records, revealed the facility failed to complete any additional dialysis assessments for Resident #100 since the assessment on 10/04/23. Review of a nursing progress note dated 10/12/23 at 7:12 P.M. revealed Resident #100 called for assistance from her room and informed staff she had abdominal pain. Resident #100 also reported complaints of dizziness. Resident #100's abdomen was noted to be visually distended (swollen outward), tender, and painful to light touch. The abdomen was hard and rounded. Resident #100's vital signs were obtained and the resident's temperature was elevated at 102.7 degrees Fahrenheit (F) and her verbal pain score was a 10 on a 10-point scale with a score of 10 being the most severe pain. Resident #100 was given the pain medication Tylenol and the physician was notified. Review of Resident #100's nursing progress note dated 10/12/23 at 8:00 P.M. revealed the nurse assessed the resident's abdomen and listened to Resident #100's bowel sounds. Resident #100 was found to have hyperactive bowel sounds in the right quadrants of the abdomen and hypoactive bowel sounds in the left quadrants. Resident #100 had a very large loose stool and two episodes of emesis. Resident #100 was also noted to be diaphoretic (sweating). The on-call physician was notified again of the situation, and the resident's family was notified as well. Review of Resident #100's nursing progress note dated 10/12/23 at 8:23 P.M. revealed the resident's temperature continued to rise and was obtained at 105.8 degrees F. The facility staff applied ice packs to Resident #100's axillary (arm pit) areas, to the bilateral lower extremities, and the groin region. Emergency medical services (EMS) were contacted, Resident #100's responsible party was notified, and Resident #100 was sent to the hospital on 10/12/23 at 8:39 P.M. Review of hospital documentation revealed Resident #100 was admitted to the hospital on 10/12/23 with a primary diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, sepsis due to the MRSA bacteremia, and suspected hemodialysis line infection. The resident also received emergency paracentesis (removing fluid from the abdominal cavity) at the bedside in which two liters of fluid was removed due to nonalcoholic steatohepatitis (NASH) cirrhosis. The sepsis was likely related to tunneled dialysis catheter infection as the insertion site was erythematous (reddened) and indurated (thickening or hardening of soft tissue). Review of laboratory studies for Resident #100 dated 10/12/23, while in the hospital, revealed a blood culture was positive for gram positive cocci in clusters, indicating bacteria in Resident #100's blood. Interview with Regional Nurse #500 on 11/01/23 at 2:23 P.M. verified the facility failed to obtain physician orders for dialysis port care, nor monitor or assess Resident #100's dialysis access site after the 10/04/23 assessment was completed. Review of the facility policy titled, Hemodialysis Access Care, revised 09/2010, revealed the care of arterio-venous fistulas (AVF) and arterio-venous grafts (AVG) were to prevent infection and maintain patency of the catheter. To prevent infection and/or clotting keep the access site clean at all times. Check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. The general medical nurse should document in the resident's medical record every shift the location of the catheter, condition of the dressing, if dialysis was done during the shift, and other observations. This deficiency represents non-compliance investigated under Master Complaint Number OH00147828.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of a facility investigation, review of staff statements, review of a facility timeline, review of an emergency medical services (EMS) run report, review of hospital reports, staff interview, family member interview, and review of the facility's policy on elopement, the facility failed to provide adequate supervision to prevent Resident #96, who had moderately impaired cognition and a diagnoses of Alzheimer's disease, dementia, and chronic obstructive pulmonary disease, from eloping from the facility's secured memory care unit unsupervised and without staff knowledge. This resulted in Immediate Jeopardy on 07/31/23 at 3:24 P.M. when Resident #96 was later observed on camera walking outside the facility fence near the secured dementia unit's garden unsupervised. This placed the resident at risk for potential serious life-threatening harm and/or injury when the resident was missing from the facility, without staff knowledge, for nearly two hours, ultimately being found by a family member on a main road approximately 2.2 miles away from the facility, requiring Resident #96 to cross at least one heavily traveled four-lane road with posted traffic speeds of up to 40 miles per hour. Resident #96 was evaluated by EMS then taken to the hospital by family and diagnosed with an acute kidney injury and pneumonia. This affected one (#96) of three residents (#08, #18, #96) reviewed for elopement. The facility identified 50 (#02, #03, #04, #05, #08, #09, #10, #16, #17, #18, #20, #23, #25, #30, #31, #36, #37, #38, #39, #41, #42, #44, #47, #49, #52, #56, #57, #58, #59, #60, #61, #63, #64, #65, #66, #67, #71, #75, #76, #77, #78, #80, #83, #87, #88, #90, #92, #93, #94, and #95) current residents at risk for elopement. The facility census was 95. On 08/17/23 at 12:33 P.M., the Administrator, Director of Nursing (DON), and Regional Clinical Director (RCD) #322 were notified Immediate Jeopardy began on 07/31/23 at approximately 3:24 P.M. when Resident #96 eloped from the facility's secured memory care unit and was not noticed missing by facility staff until Family Member #240 came to the facility at approximately 5:20 P.M. to check on Resident #96's whereabouts after hearing reports from others that her mother was seen walking on a city road approximately 2.2 miles from the facility. Resident #96 was assessed by EMS and taken to the hospital by family and diagnosed with an acute kidney injury and pneumonia. The Immediate Jeopardy was removed on 08/01/23 when Resident #96 was found and evaluated by EMS, and audits were performed on all residents at risk for eloping, all other residents currently in the facility were accounted for, and staff education about wandering risk, elopement protocols, and keeping locked door codes secure was completed. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 08/12/23 when the facility implemented the following corrective actions: On 07/31/23, at approximately 5:20 P.M., Family Member (FM) #240 arrived at the facility with police. The family member and police were notified the resident was not at the facility. On 07/31/23, at approximately 5:20 P.M., the facility staff began a search of the facility and grounds. A head count was completed and repeated every 30 minutes until a root cause was identified by nurse supervisor/designee. On 07/31/23 at approximately 5:40 P.M., Resident #96 was found and evaluated by EMS. On 07/31/23, at approximately 5:45 P.M., interviews were started with all staff present during the time Resident #96 eloped by the Administrator/designee. On 07/31/23, at approximately 6:00 P.M., all doors were checked to ensure proper functioning by Maintenance Director (MD) #124/designee with no concerns identified with door functioning. On 07/31/23 at approximately 6:10 P.M., Resident #96's room was checked to identify any possible means of exit by the Administrator/designee with no concerns noted. On 07/31/23 at approximately 7:40 P.M., the physician was notified by the DON/designee of Resident #96's elopement. On 07/31/23 at approximately 11:00 P.M., a root cause analysis was completed by the DON/designee. On 08/01/23, all staff education was completed by 2:00 A.M. All 106 staff members were in-serviced by the Administrator/designee on residents with wandering risks, elopement protocols, including but not limited to keeping the code to doors secure. On 08/01/23, all residents had wandering risk assessments updated and care plans updated as needed by 2:00 A.M. by the DON/designee. On 08/01/23, an elopement drill was completed on all shifts by 12:50 P.M. by DON/designee with no concerns. On 08/01/23, temporary keypad covers were placed on the keypad for doors on the secured memory care unit by approximately 2:00 A.M. by MD #124/designee. On 08/01/23, a Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss Resident #96's elopement and determine appropriate corrective action was taken. The Administrator, DON, Unit Manager Registered Nurse #302, Admissions Director #290, Business Office Manager #291, MD #124, Dietary Director #118, Activities Director #112, Housekeeping Supervisor #294, and Social Services #142 were all in attendance. On 08/01/23, audits were initiated by the DON/designee to be completed by the DON/designee two times a week for three weeks, then two times a week for two weeks, then weekly for two months to ensure the doors were alarmed and the entrance door was alarmed after hours with results of the audits reviewed in QAPI committee meetings. Review of the auditing tool revealed door alarm audits were completed twice in week one on 08/01/23 and 08/02/23, twice in week two on 08/07/23 and 08/09/23, and once in week three on 08/14/23 with no concerns. On 08/01/23 audits were initiated by DON/designee to be completed by DON/designee three times per week for two weeks, then two times per week for two weeks, then weekly for two months to ensure door alarms were answered immediately. The audits would be reviewed in QAPI committee meetings. Review of the auditing tool for door alarms answered by staff revealed the door was tested and answered immediately on 08/01/23, 08/02/23, 08/04/23, 08/07/23, 08/09/23, and 08/12/23 with no concerns. On 08/01/23 audits were initiated by DON/designee to be completed by DON/designee three times a week for two weeks, then two times per week for two weeks, then weekly for two months to ensure staff were properly securing the keypad code entered. Audits would be reviewed in QAPI committee meetings. Review of the auditing tool revealed securing the keypad code was observed on 08/01/23, 08/02/23, 08/04/23, 08/07/23, 08/09/23, and 08/12/23 with no concerns. On 08/15/23 between 1:56 P.M. and 4:26 P.M., 11 staff members (Receptionist #120, State tested Nurse Aide (STNA) #102, Licensed Practical Nurse (LPN) #202, LPN #204, LPN #206, STNA #104, STNA #106, Activity Director (AD) #112, STNA #108, STNA #110, and Activity Assistant (AA) #114), were interviewed and verified they were knowledgeable of the facility elopement policy and were able to voice the steps in locating a missing resident. Findings include: Review of Resident #96's medical record revealed the resident had an admitted [DATE]. The resident was discharged from the facility on 07/31/23. Diagnoses included dementia, Alzheimer's disease with late onset, cognitive communication deficit, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had moderate cognitive impairment. The resident required the limited assistance of one staff for bed mobility, transfers, walking, locomotion on the unit, toileting, and eating. The resident was assessed for wandering behavior on one to three days in the seven-day look back period. Review of a wandering risk assessment dated [DATE] revealed Resident #96 had wandered before, and the resident was cognitively impaired with poor decision-making skills. The resident's wandering significantly intruded on the privacy or activities of others. The resident ambulated independently and talked about a desire to go home. Review of the plan of care initiated 06/04/23 revealed Resident #96 was an elopement and wandering risk related to dementia and late onset Alzheimer's disease. Interventions included the resident resided on a secure unit for safety. Also, to reorient, validate, and redirect the resident as needed. On 08/01/23 the care plan had a revised intervention to round frequently on the resident verifying the resident was present, safe, and secure on the unit. Review of a skilled nursing note dated 07/31/23 at 11:29 A.M. revealed Resident #96's vital signs were within normal limits. The resident's respiratory assessment was also within normal limits. Review of a behavior monitoring assessment completed on 07/31/23 at 11:31 A.M. revealed Resident #96 had anxiety, restlessness, delusions, insomnia, wandering, continuous pacing, and was exit seeking. Staff provided redirection, distraction, one-to-one interaction, attempted to engage the resident in activity, and assisted the resident to a different area and calmer environment. The residents' behavior improved after the implemented interventions. Review of an incident report dated 07/31/23 revealed the charge nurse, LPN #210, received a call from FM #240 that Resident #96 had been seen by another family member walking down the sidewalk on a city street. The charge nurse notified the Administrator who then notified the DON. A code pink was called, and search of the building and premises were initiated. The resident was not located on the grounds or in the building. The Administrator, DON, and Social Worker #142 began a search of the neighborhood by car. The police had been notified by FM #240. During the search being performed by car, the charge nurse was able to contact FM #240 and was informed the resident had been found and was with family. It was reported the resident was experiencing shortness of breath and the family was having her medically evaluated. The Administrator was able to speak with the hospital emergency room (ER) and was informed the resident had been evaluated and released. Investigation was initiated and reviews of perimeter camera footage revealed the resident exited the building on 07/31/23 at approximately 3:24 P.M. Review of the facility timeline revealed Resident #96 was noted to be eating lunch at 2:00 P.M. in the dining room. At 2:30 P.M., the resident was noted to being sitting in the common area watching television. At 3:15 P.M., LPN #210 noted Resident #96 to be sitting in the dining room. At 3:24 P.M., the resident left the garden after entering the code to the back door (speculation) and made her way toward the street. At approximately 5:00 P.M., the resident's sister noted Resident #96 was walking on a city street, picked Resident #96 up, and took her to her home. At 5:20 P.M., FM #240 arrived at the facility with a police officer to check on the news of Resident #96 being picked up by a family member on a city street, and facility staff and FM #240 noted the resident was not in facility at this time. At 5:20 P.M., a facility headcount started, management went to look for the resident in the community, and corporate staff were notified. At 5:40 P.M., EMS was contacted by Resident #96's sister and Resident #96 was evaluated for shortness of breath. EMS did not take the resident to the hospital. No injuries were noted. At 6:00 P.M., the facility staff tried to contact Resident #96's daughter to see if Resident #96 was found as this was not known to staff at this time. At 6:23 P.M., the Administrator contacted the police department who explained the resident was found and assessed around 5:40 P.M. at Resident #96's sister's home but remained at the sister's home. Review of a statement dated 07/31/23 from the Administrator revealed from the facility camera on 07/31/23 at 3:24 P.M., Resident #96 appeared to be wearing a bright orange long-sleeved shirt, a pair of black athletic type pants, and a blue pair of tennis shoes. Review of a staff statement dated 07/31/23 by LPN #210 revealed he last saw Resident #96 at 3:15 P.M. on 07/31/23 eating lunch. LPN #210 wrote the resident possibly followed behind someone exiting the unit. LPN #210 wrote in his statement he heard no door alarms. Review of an undated staff statement by STNA #110 revealed Resident #96 was last seen approximately between 2:30 P.M. and 2:45 P.M. on 07/31/23 around lunch time. Review of a staff statement dated 07/31/23 by AA #114 revealed Resident #96 was last seen around 2:30 P.M. on 07/31/23 eating French fries and walking around. Review of a staff statement dated 07/31/23 by AD #112 revealed at 2:30 P.M. on 07/31/23 Resident #96 was sitting in front of the television with another resident. Review of the EMS run report dated 07/31/23 revealed EMS arrived on scene at 5:35 P.M. Resident #96 had a blood pressure of 100/64 millimeters of mercury (mmHg) with a pulse of 140 beats per minute. No complaints of injury or illness noted. The resident was found by another family member walking down a city street after having escaped her memory care ward. The family called EMS as they believed the resident was having difficulty breathing. EMS noted Resident #96 had rales (a crackling sound heard in the lungs) in the lower lobe of the right lung. FM #240 arrived on scene and refused transportation for Resident #96 to the closest hospital. FM #240 wished for the resident to be treated at a different local hospital and provided her own transportation to this hospital. Review of a hospital discharge summary history and physical dated 08/01/23 at 12:03 A.M. revealed Resident #96 presented with shortness of breath. The resident was brought to the ER for concerns of shortness of breath and hypoxic respiratory failure. The resident resided on a locked dementia unit in a nursing facility, was found wandering a far distance from the facility, and noted by responders to appear short of breath. FM #240 reported Resident #96 had a more pronounced cough. The resident's oxygen saturation was 93 percent (%) on room air. A chest x-radiation (x-ray) image showed bibasilar infiltrates (an abnormal finding in the lungs). The resident had an elevated white blood cell count as well. The resident was additionally noted with an acute kidney injury with an elevated creatinine level and large leukocytes (white blood cells) on urinalysis. The resident received intravenous antibiotics as treatment. The resident was noted as alert with a slightly poor memory. The resident was admitted to the hospital for concern of community-acquired pneumonia and acute kidney injury and was administered intravenous hydration. Review of a nursing progress note dated 08/01/23 at 3:24 P.M. revealed on 07/31/23 Resident #96 was noted to be outside by a family member. The family member took her to their home and spoke with FM #240 to notify her of the resident's whereabouts. The resident was noted to be short of breath while at the family home. EMS was called to evaluate the resident and the resident was left in the care of the family member. The resident was taken to the ER related to continued shortness of breath where she was evaluated and admitted to the hospital for pneumonia. Interview on 08/15/23 at 10:50 A.M., with the Administrator stated Resident #96 eloped from the building and believed she punched the code to the garden's patio door. The Administrator stated the resident was seen on camera going toward the road at 3:24 P.M. on 07/31/23. The Administrator stated the resident was highly functioning and believed the resident may have known the door security code. The Administrator revealed no door alarms went off and all the door alarms were tested . The Administrator revealed no one knew the resident was missing until around 5:00 P.M. on 07/31/23 when her daughter came to the facility and another family member called the facility to report the resident was noticed outside. The Administrator stated the facility completed a head count as they were not aware the resident was found by her sister. The resident's sister called the police and EMS. The Administrator stated the facility also called the police and were notified the resident was now with a family member. The Administrator stated the resident's room was checked for open windows with no concerns noted. The Administrator stated the facility completed 30-minute checks on all the residents and completed elopement drills on each shift. The Administrator stated the door keypad codes on the unit were changed and all staff were educated to cover the code during input. The Administrator stated secure covers were purchased to cover the door keypads. The Administrator stated the resident was later admitted to the hospital with pneumonia and no other illness or injury related to the incident. The Administrator stated there were always two nurse aides and an activity aide on the memory care unit. The Administrator stated no one noticed the resident was missing on 07/31/23. The Administrator stated LPN #210 last noticed the resident in the dining room at 3:15 P.M. on 07/31/23. The Administrator stated rounds were completed every two hours; however, the resident was fairly independent and did not require care during that time. The Administrator stated the facility had no policy on responding to door alarms. Interview on 08/15/23 at 2:09 P.M. with STNA #106 stated on 07/31/23 at 2:00 P.M., Resident #96 was in front of the television asleep when her shift ended. STNA #106 stated an agency nurse aide replaced her at 2:00 P.M. STNA #106 stated the agency nurse aide was the only aide on the memory care unit when her shift ended at 2:00 P.M. STNA #106 stated the second nurse aide did not arrive until 3:30 P.M. on 07/31/23. STNA #106 stated she thought someone let the resident out the side door of the unit and forgot about her, and the resident got away from the group. STNA #106 stated staff parked in the back parking lot and would enter the gate into the courtyard, and then enter the facility through the dementia unit door. STNA #106 believed staff had not shut the gate all the way and the resident was able to open the gate and leave. Interview on 08/15/23 at 2:53 P.M. with AD #112 stated she would always park in the back of the building and enter the facility through the memory care unit's garden door and had always done that. AD #112 stated the gate was always shut. AD #112 stated she last saw Resident #96 around 3:00 P.M. on 07/31/23 when she offered her French fries, but the resident did not want any. AD #112 stated she left work at 4:30 P.M. that day. Observation on 08/15/23 at 11:21 A.M. of the memory care unit courtyard with the Administrator revealed there was one exit door into the courtyard. The courtyard was enclosed by a fence with a side gate and a back gate which were shut but do not lock. Observation on 08/15/23 at 2:56 P.M., revealed STNA #106 was the only nurse aide on the memory care unit at this time. Additionally, there was no activity aide present on the unit at this time. Interview with STNA #106 stated the second nurse aide would arrive by 3:30 P.M. that day. Interview on 08/15/23 at 3:42 P.M. with STNA #108 stated on 07/31/23 he arrived to work on the memory care unit at 3:30 P.M. STNA #108 stated his assignment was to care for residents residing in the back half of the building which did not include Resident #96. STNA #108 stated he never saw the resident when starting his shift on 07/31/23. Interview on 08/15/23 at 3:58 P.M. with STNA #110 stated she last saw Resident #96 around 2:30 P.M. on 07/31/23 eating lunch as lunch was late that day. STNA #110 stated AD #112 had some residents inside and some residents were outside the secured memory care unit, and was going back and forth, in and out of the building. STNA #110 stated she was the only nurse aide back on the memory care unit on 07/31/23 until STNA #108 arrived at 3:30 P.M. Continued interview with STNA #110 stated while AD #112 was coming in and out, the residents outside on the patio were left unattended. STNA #110 stated the activity lasted until AD #112 left around 4:00 P.M. or 4:30 P.M. STNA #110 stated she heard no door alarms while she was on the unit. Interview on 08/15/23 at 4:26 P.M. with AA #114 stated he last saw Resident #96 around 2:30 P.M. walking around eating French fries. AA #114 stated he was in the memory care unit to take another resident outside to smoke. AA #114 stated he was outside about 20 minutes, and no other residents were outside. Interview on 08/15/23 at 4:39 P.M. with Resident #96's family member (FM #240) stated she received five to six calls asking her where Resident #96 was. FM #240 stated family told her they saw Resident #96 walking down the street and she looked weak. FM #240 went to the facility to look for her mother and the facility was not aware her mother was even gone. FM #240 stated no one knew how long Resident #96 had been walking around. FM #240 stated her aunt saw Resident #96 on the corner of two city streets about 2.2 miles from the facility, picked her up, and asked her where she was going. The aunt called the police and the rescue squad and met them at her home. FM #240 stated EMS wanted to take Resident #96 to the closest hospital, but she wanted the resident to go to a different hospital. FM #240 stated she took Resident #96 to the hospital, and she was admitted for dehydration and pneumonia. FM #240 stated the resident stayed in the hospital until they could find another facility for her. The resident reported to FM #240 that someone at the facility let her out and told her she could leave. FM #240 reported physically her mother was doing okay but was mentally lost at the new facility. Interview on 08/16/23 at 8:12 A.M. with LPN #210 stated he was the nurse on duty the day Resident #96 eloped. LPN #210 stated he last saw the resident around 3:15 P.M. on 07/31/23 when he collected her lunch tray from her. LPN #210 stated there was a lot of traffic and activities on the unit. LPN #210 stated residents were out with activities staff off and on while she was cooking French fries on the patio. LPN #210 stated most of the residents were inside the building for lunch. LPN #210 stated the nurse aide and himself were picking up trays, out in the common area, and at the nurse's station, unless they were doing patient care, in the hallway. LPN #210 stated activities staff were finishing up around 3:15 P.M. on 07/31/23 and brought food back into the facility for the residents. LPN #210 stated one resident went outside to smoke and was supervised. LPN #210 stated he thought Resident #96 could have followed someone out of the unit. LPN #210 stated if the code was put in the door keypad, the door could stay open up to a minute before it started to alarm. LPN #210 stated he never knew Resident #96 to touch a door keypad. LPN #210 stated he reactivated the door after the door alarm went off several times during the shift on 07/31/23 and checked the line of sight down the hallway. LPN #210 stated he was not instructed to do a head count each time the alarm went off on 07/31/23. LPN #210 was not sure if Resident #96 followed someone outside or not. LPN #210 stated the resident walked pretty fast and did not look like a typical resident unless you talk to her for a while. Interview on 08/22/23 at 11:12 A.M. with the Administrator stated staff should not be entering the facility through the memory care unit. The Administrator was unaware staff had been entering the building through the memory care unit. Review of the policy titled, Elopements, revised 12/2007, revealed staff would investigate and report all cases of missing residents. Staff would promptly report any resident who tried to leave the premises or was suspected of being missing to the charge nurse or Director of Nursing. This deficiency represents non-compliance investigated under Complaint Number OH00145418.

Based on medical record review, staff interviews, review of a fall investigation, review of hospital documentation, and review of facility policy, the facility failed to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury, for a resident with a known fall history and at risk for falls. This resulted in actual harm when a resident experienced a fall, which resulted in a laceration and a subdural hemorrhage that required hospitalization . This affected one resident (#01) out of four residents reviewed for falls. The census was 72. Findings include: Review of Resident #01's medical record revealed an admitted [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, [CONDITION(S)], essential hypertension, Vitamin D deficiency, and mild cognitive impairment. Review of nursing progress note from a previous nursing facility (Facility #100), and prior to admission to the current facility, dated 04/14/22 and 04/25/22, revealed Resident #01 sustained falls within Facility #100 on 04/13/22 and 04/25/22. The documentation on 04/14/22 did not identify the nature of the fall and only documented Resident #01 sustained no injuries from a fall on the previous day. Review of the documentation on 04/25/22 revealed staff found Resident #01 sitting on the floor in her bedroom with no apparent injuries. Review of an admission nursing assessment dated [DATE] revealed Resident #01 arrived at the current facility at 2:00 P.M. Resident #01 was assessed as alert and oriented to person and situation only, was independent for bed mobility, transfers, walking in her room and the corridor, and locomotion on the unit. Resident #01 was assessed with no balance concerns and did not require use of side rails. Review of an assessment titled, Brief Interview for Mental Status (BIMS), dated 05/12/22, revealed Resident #01 was assessed to have severely impaired cognition. Review of a skilled nursing note dated 05/13/22 revealed Resident #01 was alert and oriented to person only, and was confused, restless, anxious, and displayed impaired decision-making ability. Resident #01 was also assessed with impaired balance, unsteady gait requiring supervision, weakness, and required assistance with bed mobility and transfers. Review of an occupational therapy (OT) evaluation and plan of treatment document dated 05/13/22, revealed Resident #01 was referred to OT because she was recently admitted to the skilled nursing facility from an assisted living facility, however, her dementia progressed, and she was wandering with increased behaviors including agitation. Due to the transition into the new setting, Resident #01 required OT intervention to address decline and a new environment. Under the section titled, Fall Risk Assessment, Resident #01 was identified as having fallen in the last year without an exact number known. Resident #01 indicated she felt unsteady when standing, unsteady when walking, and was worried about falling. Resident #01's functional mobility was assessed and was scored a mobility function of one, with the rating scale measuring between zero and 12, with 12 being the highest function. Resident #01's mobility performance raw score was four. Further review of the OT evaluation and plan of treatment document revealed the reason for Resident #01 to receive OT, was because Resident #01 presented with significant impairments in functional strength, balance, and cognition that impacted activities of daily living (ADLs) independence and increasing risk of falls and injury. Resident #01 would benefit from skilled OT to address her deficits, as without intervention, Resident #01 was likely to develop further decline resulting in falls and hospitalization . Review of a skilled nursing note dated 05/14/22 revealed Resident #01 was alert and oriented to person only, and was confused, restless, anxious, and displayed impaired decision-making ability. Resident #01 was also assessed with an unsteady gait requiring supervision and required assistance with bed mobility and transfers. Review of a nursing progress note dated 05/14/22 at 4:30 P.M. revealed Resident #01 was found on the floor in her room laying on her right side. Resident #01 sustained a laceration to the right posterior aspect of her head that was bleeding. Resident #01 was not able to voice the nature of her fall. Resident #01 expressed she had minimal discomfort and assessment revealed Resident #01 had no impaired range of motion or level of consciousness. The nursing staff applied direct pressure to Resident #01's head laceration with an ice-covered cloth for 10 to 15 minutes and then was covered with a bandage and secured. The physician was notified, as well as Resident #01's family, and Resident #01 was sent out to the hospital for evaluation and treatment. Review of a fall investigation dated 05/14/22 at 4:30 P.M. revealed Resident #01 was observed laying on her bedroom floor with an injury to the right posterior portion of her head. Resident #01 could not explain to staff what happened, and she was sent to the hospital for evaluation and treatment. The contributing factors surrounding the fall included decreased safety awareness, wheelchair usage, and increased confusion. There were no recent changes to Resident #01's medication regimen, no new orders, and contributing medical factors were Resident #01's diagnosis of dementia and cognitive impairment. A care plan decision was made to order a floor mat for frequent fall status according to Resident #01's history and fall risk assessment. Review of a fall risk assessment dated [DATE] at 4:30 P.M. revealed Resident #01 was assessed as a moderate risk for falls. Further review of Resident #01's entire medical record revealed no previous fall risk assessments were completed after Resident #01 was admitted to the facility on [DATE]. Review of Resident #01's entire medical record revealed Resident #01 was admitted to the facility on [DATE] at 2:00 P.M. and was sent out to the hospital for treatment from a fall on 05/14/22 at 4:30 P.M. Resident #01 resided in the facility for 50 hours and 30 minutes, and review of the medical record revealed the facility did not complete a baseline care plan or a comprehensive care plan for Resident #01 as required. Review of hospital documentation revealed Resident #01 was admitted to the hospital on 05/14/22 at 5:55 P.M. with a primary diagnosis of traumatic subdural hemorrhage (bleeding between the brain and its outer most covering) with loss of consciousness. Further review of the hospital documentation revealed Resident #01 was sent to the hospital for an unwitnessed fall sustained in the skilled nursing facility where Resident #01 was found on the ground with blood around her head. Resident #01 was agitated in the emergency room and required a sedative to complete imaging of her head. During the assessment, Resident #01 was not able to answer hospital staff's questions. Resident #01 was documented to be combative in the hospital and required to be restrained by the hospital staff. Review of radiology imaging of Resident #01's brain in the hospital on 05/14/22 revealed Resident #01 had a small right frontal subdural hematoma and small sulcal areas of subarachnoid hemorrhage (bleeding in the grooved spaces of the brain between the tissue) in the right cerebral hemisphere. Interview on 05/23/22 at 9:31 A.M. State tested Nurse Aide (STNA) #100 stated she was working on the secured unit of the facility and provided care for Resident #01. STNA #100 stated Resident #01 would get up and walk on her own on the unit and she was not aware of any additional precautions or interventions the facility implemented to reduce Resident #01's fall risk. Interview on 05/23/22 at 9:59 A.M. Licensed Practical Nurse (LPN) #300 verified he was the staff member that discovered Resident #01 laying on the floor in her room on 05/14/22. LPN #300 stated Resident #01 was laying on her side with her hands under her head like a pillow when he entered the room and saw blood on the floor under Resident #01's head. LPN #300 stated he then discovered Resident #01 had a laceration to the right posterior portion of her head and he began first aid on the wound. LPN #300 stated once treatment was provided to Resident #01's laceration, he contacted the physician and sent Resident #01 to the hospital for treatment. LPN #300 stated Resident #01 was alert but could not answer questions as to how the fall occurred. LPN #300 verified Resident #01 would walk independently throughout the unit and was able to transfer herself from surface to surface. LPN #300 stated there were no individualized interventions the staff were implementing to reduce Resident #01's fall risk other than providing routine checks for safety and making sure the environment was free from tripping hazards. Interview on 05/23/22 at 10:38 A.M. Therapy Director #01 stated Resident #01 was evaluated for OT skilled services on 05/13/22. Therapy Director #01 verified the OT evaluation completed on 05/13/22 showed Resident #01's mobility function was very low, and OT skilled services were needed for Resident #01 to reduce her fall risk and improve her ADLs status. Therapy Director #01 verified Resident #01 did not receive any skilled therapy services as Resident #01 was scheduled to begin OT on 05/16/22. Interview on 05/23/22 at 3:07 P.M. the Administrator verified the facility did not complete a baseline care plan or a comprehensive care plan for Resident #01, and verified Resident #01 was in the facility from 05/12/22 at 2:00 P.M. to 05/14/22 at 4:30 P.M. The Administrator verified Resident #01 was sent to the hospital following the fall on 05/14/22 and hospital documentation revealed Resident #01 suffered subdural hemorrhage. The Administrator stated Resident #01 did not return to the facility and the facility staff had not received any additional information about Resident #01's status. Interview on 05/24/22 at 7:58 A.M. STNA #900 stated Resident #01 would walk around the secured unit all the time, and stated she even took her outside on the patio to walk one day. STNA #900 stated Resident #01 used a wheeled walker with a seat, and she never noticed any balance concerns when Resident #01 walked. STNA #900 stated she was working on 05/14/22 when Resident #01 fell . STNA #900 stated she checked on Resident #01 approximately 15 minutes before LPN #300 found her on the floor. STNA #900 stated at the time she observed Resident #01, she was sitting in her chair in her bedroom watching television. STNA #900 stated LPN #300 called for her to come to Resident #01's room and that was when she saw Resident #01's head bleeding. STNA #900 stated Resident #01 was alert and talking but could not state how she fell . STNA #900 verified LPN #300 performed first aid to Resident #01's head and Resident #01 was sent out to the hospital. STNA #900 stated Resident #01 did not return to the facility and her family came to get her belongings out of her bedroom. STNA #900 stated the nursing staff frequently checked on Resident #01 but could not quantify how frequently she was checked. STNA #900 stated she was not aware of any other individualized fall interventions implemented by the facility to reduce Resident #01's fall risk. Review of a facility policy titled, Managing Falls and Fall Risk, revised December 2007, revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls. This deficiency substantiates Complaint Number OH 799.