Every finding on record at Pheasant Ridge Nursing and Rehabilitation

Based on family interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 6 of 51 sampled residents, Resident #94, Resident #2, Resident #33, Resident #95, Resident #29, and Resident #43. For Resident #94, the facility staff failed to remove the anticoagulant, Eliquis from the resident's active medication supply when discontinued on [DATE]. 12 Eliquis tablets were missing from Resident #94's Eliquis supply and were unaccounted for. Lab results obtained on [DATE] revealed a critically low hemoglobin of 6.7, a low hematocrit of 20.9, and PT/INR levels that were unable to be determined due to no clotting endpoint on the lab instrument. Resident #94 died on [DATE] while actively bleeding from the nose, mouth, urinary tract, and rectum. This resulted in the identification of Immediate Jeopardy and Substandard Quality of Care for Resident #94. The survey team informed the facility on [DATE] at 6:10 PM of the Immediate Jeopardy situation regarding Resident #94.The scope and severity were originally cited at Level IV Isolated. On [DATE] at 5:30 PM, the Immediate Jeopardy was removed and lowered to a Level III Isolated. The findings included: 1. For Resident #94, the facility staff failed to remove the anticoagulant, Eliquis from the resident's active medication supply when discontinued on [DATE]. 12 Eliquis tablets were missing from Resident #94's Eliquis supply and were unaccounted for. Lab results obtained on [DATE] revealed a critically low hemoglobin of 6.7, a low hematocrit of 20.9, and PT/INR levels that were unable to be determined due to no clotting endpoint on the lab instrument. Resident #94 died on [DATE] while actively bleeding from the nose, mouth, urinary tract, and rectum. An admission Record indicated the facility admitted Resident #94 on [DATE]. According to the admission Record, the resident had a medical history that included atrial fibrillation, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and bladder-neck obstruction. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A [DATE] Change in Condition (SBAR) form indicated Resident #94's family member requested a re-evaluation of his medication to see if another medication could be substituted for Eliquis because it was very expensive. New medical provider orders were received on [DATE] to discontinue Eliquis and start Lovenox 80 mg/8ml inject one application subcutaneously every morning and bedtime for bridge therapy while transitioning to Coumadin (Warfarin), may discontinue when INR 2-3 for 24 hours and Warfarin (Coumadin) 5 mg by mouth. On [DATE], the medical provider ordered PT/INRs every 48 hours to start on [DATE] for transition to Warfarin (Coumadin) from Eliquis. A PT/INR was obtained on [DATE] and the INR was within therapeutic range at 2.75. PT/INRs were due on [DATE], [DATE], [DATE]; however, they were not obtained. On [DATE], the medical provider ordered a PT/INR. According to the lab report, the PT/INR blood sample was not collected until [DATE], received by the lab the following day on [DATE] at 11:14 AM and reported on [DATE] at 9:36 PM. The PT was greater than 90 (reference range 9.60-11.33) and confirmed by repeat analysis and the INR results could not be calculated as the result was greater than linearity. This result indicated the resident's blood clotting time was so prolonged that the lab's analyzer's range was exceeded. A [DATE] hospice nursing progress note read in part .Resident observed lying in bed with bloody nose from nosebleed.Resident's face cleaned and gown, sheets and pillowcase changed, soiled with blood.foley cath observed with blood-tinged urine in collection bag.instructed to hold bedtime dose of 5 mg Coumadin and AM dose of Lovenox 80 mg. According to Resident #94's [DATE] Medication Administration Record (MAR), he received the last dose of Coumadin on [DATE] and the last dose of Lovenox on [DATE] at 6:00 AM. A [DATE] hospice nursing progress note read in part Resident observed sitting up in bed with a small stream of blood coming from left nostril. Dark bloody urine observed in foley collection bag and tubing.Writer contacted [hospice physician] and given lab results for PTT and INR over the phone, order given and completed for 10mg/1ml of Vitamin K injection.At the completion of care, bleeding had stopped.Lovenox 80 mg injection discontinued and 5 mg of Coumadin held for Saturday and Sunday doses, with repeat labs for Monday morning. A [DATE] hospice nursing progress note read in part .Pt [patient] states he feels as he is dying. Pt has frank blood coming out of both nares, mouth and foley, BP 78/42. MD ordered STAT BMP [basic metabolic panel] CBC [complete blood count] and INR. Family present and repeatedly stated pt does not want to go to the hospital.foley catheter 24 F with frank blood in bag. Unable to note if any urine present due to blood. No noted clots. A second hospice nursing visit was made on [DATE], this progress note read in part Visit due to ongoing bleeding. Upon assessment, patient laying in bed oriented to person and pale in color. Blood noted to nose, in catheter bag, and out of rectum.Consulted with [hospice physician] and order received to start TXA [Tranexamic Acid] 650 mg tablet PO [by mouth] TID [three times a day] for 5 days. This nurse picked up medication from [area hospital] lobby pharmacy and delivered to facility. Tranexamic Acid is a medication used to prevent and control excessive bleeding. According to Resident #94's [DATE] MAR, he received Tranexamic 650 mg on [DATE] at 9:00 AM, 1:00 PM, and 9:00 PM. The [DATE] lab results revealed a white blood cell count of 21.81 (reference 4.5-10.5), red blood cell count of 2.51 (reference 4.3-5.8), hematocrit 20.9 (reference 42-52), critically low hemoglobin of 6.7 (reference 13.0-17.3), PT/INR results were not available as there was no clot endpoint obtained on the instrument. According to the National Institutes of Health, no end point detected indicates that the analyzer was unable to detect clot formation within the test window. Resident #94 was pronounced deceased on [DATE] at 11:20 AM in the facility. During an interview on [DATE] at 10:55 PM, Licensed Practical Nurse (LPN) #8 stated preceding his death, Resident #94 was bleeding from his nose, mouth, and foley. LPN #8 stated the bleeding was not profuse, but they had to keep wiping the blood from his nose. During an interview on [DATE] at 8:25 AM, the Hospice Registered Nurse (RN) stated Resident #94 was admitted to Hospice on [DATE] and she understood he was taking three anticoagulants and was waiting for the PT/INR results. She stated the resident was bleeding out from every orifice when he died. Resident #94's family was interviewed on [DATE] at 8:49 AM. She stated Resident #94 was taking Eliquis prior to admission to the facility and it was getting so expensive that the provider decided to switch him over to Coumadin and he was also to get Lovenox for five days. The family member stated the resident started with nose bleeds, then blood in the urine, and then bleeding from the rectum. She stated there was a steady stream of blood coming from his nose and they had to constantly wipe the blood from his nose. Nurse Practitioner (NP) #1 was interviewed on [DATE] at 11:43 AM. NP #1 stated she had spoken with Resident #94's family and they mentioned Eliquis was very expensive and they elected to switch to Coumadin using a Lovenox bridge. NP #1 stated she had trouble getting the PT/INRs completed and then Hospice took over his care, but she was still following his care to a degree. NP #1 stated she was present in the facility when the resident passed, and she went to his room, and his mouth and nose were completely caked with dried blood. She stated she assisted the staff in cleaning him up and it took over 20 minutes trying to get the caked blood out of his nose. NP #1 stated following the resident's death she asked Licensed Practical Nurse (LPN) #1 to check the medication cart to verify Resident #94's medications. NP #1 stated LPN #1 indicated the pharmacy supply card of Eliquis was still in the med cart. Based on the date of delivery and discontinuation date, there should have only been nine to ten doses missing from the card but there were 16 tablets missing and unaccounted for. NP #1 stated she immediately notified the Director of Nursing and Assistant Director of Nursing. During an interview on [DATE] at 12:15 PM, LPN #1 stated following Resident #94's death, she did discover his Eliquis medication supply card in the med cart with the card turned around backward. She stated she thought there were 11 tablets of Eliquis left in the card and stated she felt like staff were borrowing the Eliquis. When asked if she had any evidence of staff borrowing the Eliquis, she stated no. When asked why she counted the Eliquis following his death, LPN #1 stated NP #1 asked her to because she felt he was over medicated. Despite being the Unit Manager, LPN #1 denied any knowledge of Resident #94 bleeding or having blood present in the foley bag. LPN #1 stated nurses were supposed to take discontinued medications out of the med cart when discontinued. During an interview with the Director of Nursing and Assistant Director of Nursing on [DATE] at 10:06 AM, the DON stated the Eliquis medication card still being in the drawer and actually being given were two separate things. DON stated the card was turned backward and the number of Eliquis remaining in the card was correct and they were returned to the pharmacy. The DON stated she had no documentation of the NP's concern or investigation because the concern could not be substantiated. The pharmacy billing representative was interviewed on [DATE] at 11:36 AM. She stated on [DATE] a 14-day supply of 28 tablets of Eliquis was delivered to the facility and a supply of seven tablets were returned to the pharmacy on [DATE]. Based on calculations, with the Eliquis being delivered on [DATE] and two tablets administered on [DATE], [DATE], [DATE], [DATE], and one tablet administered prior to being discontinued on [DATE], that would equal a total of nine tablets used from the 28-tablet supply. However, based on the supply returned to the pharmacy, 21 tablets were used from Resident #94's Eliquis supply card leaving 12 missing doses unaccounted for. On [DATE] at 4:00 PM, when presented with the Eliquis count returned to the pharmacy, the DON stated she was aware of the Eliquis card remaining in the cart, but it was turned around and when she did interviews with the staff she was told they used the Eliquis for another resident. The DON was unable to provide evidence of staff borrowing Resident #94's Eliquis supply. When asked if the staff knew why Resident #94 was bleeding so much and if there were any investigations done concerning this she stated they had no investigations to provide. The facility's contracted lab service was contacted on [DATE] at 5:41 PM, the STAT Lab Specialist confirmed Resident #94 had only three PT/INRs obtained in [DATE], on [DATE], [DATE], and [DATE]. This information was conveyed to the DON at 5:47 PM and she stated that was not what she wanted to hear but it is what it is. The Administrator was interviewed on [DATE] at 6:06 PM and stated there was no documentation that the Eliquis was given to the resident after it was discontinued; however, they were unable to account for the missing Eliquis tablets or provide an explanation for the increasing PT/INR and continued bleeding up until Resident #94's death. On [DATE] at 6:10 PM the survey team notified the Administrator, DON, and ADON of the Immediate Jeopardy situation involving Resident #94. On [DATE] at 2:29 PM the Administrator presented the following Immediate Jeopardy Removal Plan: 1. Resident 94 is no longer at the facility as of [DATE] 2. An immediate MAR-to-cart audit of all medication carts was conducted by the Regional Director of Clinical services to ensure discontinued medications were removed from the cart. Medications were validated per physician order. 3. All licensed nurses received education by the Assistant Director of Nursing on the five rights of medication administration. Nurses who are unable to complete the education due to schedule will receive education prior to their next scheduled shift. 4. All licensed nurses received education by the Assistant Director of Nursing on facility medication management and removal of discontinued medication from carts. Nurses who are unable to complete the education due to schedule will receive education prior to their next scheduled shift. 5. The Director of Nursing/designee will review discontinued medication 5 days weekly for 3 months. Finally, the Director of Nursing/designee will ensure physical removal of any discontinued meds from the carts weekly for 3 months. Facility asserts completion [DATE] at 1pm The facility's removal plan was approved as presented on [DATE] at 2:55 PM and the Administrator was notified at 3:21 PM. The facility staff presented credible evidence that the removal plan had been implemented, including MAR to cart medication audits and staff education as outlined in the removal plan. Interviews with staff verified education as outlined in the removal plan. On [DATE] at 5:30 PM, the survey team verified that the Immediate Jeopardy had been cleared. The Administrator, ADON, and Regional [NAME] Present #1 and #2 were informed that the Immediate Jeopardy was cleared as of 5:30 PM. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 2. For Resident #2, the facility staff failed to administer sliding scale Insulin Lispro as ordered by the medical provider on 19 separate occasions from [DATE] through [DATE]. A facility policy titled, Medication Administration, revised [DATE], specified, Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. An admission Record indicated the facility admitted Resident #2 on [DATE]. According to the admission Record, the resident had a medical history that included type 2 diabetes mellitus with diabetic polyneuropathy. A significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. Resident #2's comprehensive person-centered care plan included a focus initiated [DATE], that indicated the resident had diabetes mellitus. Interventions included diabetes medication as ordered by the doctor. Resident #2's medical provider orders included an order which started on [DATE] for Insulin Lispro inject as per sliding scale subcutaneously as needed in addition to basal insulin: 151-200 = 1, 201-250 = 2, 251-300 = 3, 301-350 = 4, 351-400 =5 and notify provider if administering this dose, 401-500 call provider for instructions. Insulin Lispro is a rapid-acting insulin used to lower blood sugar. Resident #2's order for basal insulin, Insulin Glargine was also started on [DATE] and instructed staff to administer 8 units at bedtime. Insulin Glargine is a long-acting insulin used to lower blood sugar. According to Resident #2's documented bedtime blood sugar (BS) readings on the [DATE] Medication Administration Record, they should have received Insulin Lispro based on the SS order. However, the MAR indicated the SS Insulin Lispro was not administered on the following occasions with the identified BS readings: [DATE] BS 186, [DATE] BS 200, [DATE] BS 271, [DATE] BS 315, [DATE] BS 232, [DATE] BS 378, [DATE] BS 202, [DATE] BS 188, [DATE] BS 224, [DATE] BS 359, [DATE] BS 395, [DATE] BS 228, [DATE] BS 190, [DATE] BS 243, [DATE] BS 218, [DATE] BS 266, [DATE] BS 193, [DATE] BS 187, [DATE] BS 273. On [DATE] at 3:17 PM, the Administrator, Regional [NAME] President of Operations, and the Regional Director of Clinical Services were notified of the concern of staff failing to administer Resident #2's SS Insulin Lispro as ordered on 19 occasions. No further information regarding this concern was presented prior to the exit conference on [DATE]. 3. For Resident #33, the facility staff failed to administer Insulin Glargine as ordered by the medical provider on two separate occasions. A facility policy titled, Medication Administration, revised [DATE], specified, Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. An admission Record indicated the facility admitted Resident #33 on [DATE]. According to the admission Record, the resident had a medical history that included type 2 diabetes mellitus with diabetic neuropathy. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #33's comprehensive person-center care plan included a focus area which indicated the resident had diabetes mellitus with an intervention for diabetes medication as ordered. Resident #33's medical provider orders included an order dated [DATE] for Insulin Glargine 50 units subcutaneously every morning and at bedtime. Insulin Glargine is a long-acting insulin used to lower blood sugar. A review of Resident #33's [DATE] Medication Administration Record (MAR) revealed Insulin Glargine was not administered on [DATE] at 6:00 AM and [DATE] at 6:00 AM. There was no corresponding documentation explaining the reason the medication was not administered on [DATE]. A [DATE] 6:08 AM nursing progress note indicated Insulin Glargine was held due to a blood sugar reading of 150; however, the order did not include parameters to hold the medication based on the blood sugar reading. On [DATE] at 5:35 PM, the Administrator and Regional Director of Clinical Services were informed of the concern regarding the failure to administer Resident #33's Insulin Glargine as ordered. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 4. For resident # 95 the facility staff failed to begin administering intravenous antibiotics as ordered on admission. The admission Record for Resident #95 indicated the facility admitted the resident on [DATE] with diagnoses that included acute and subacute endocarditis, other streptococcal arthritis and bacteremia. The minimum data set (MDS) assessment with an assessment reference date of [DATE] was reviewed. Resident #95 was coded as being independent in making consistent and reasonable decisions and short-term memory was intact. The MDS captured the diagnoses of endocarditis, streptococcal arthritis and bacteremia but under the section for medications, there were no antibiotics or intravenous medications coded. The hospital Discharge summary dated [DATE] was reviewed. The primary diagnosis was listed as streptococcal bacteremia. Under the heading Start taking these medications was an entry that read, NS (normal saline) 0.9% SolP 500 ml with penicillin G potassium 20-million-unit S0lR 24 million units continuously by intravenous route through [DATE]. The facility History and Physical progress note dated [DATE] read in part, The primary focus of the visit is the transition of (resident's) intravenous antibiotic therapy. In the hospital, (resident) received a continuous infusion of 24 million units of Penicillin G. To improve mobility and allow for therapies, (the) regimen has been changed to an intermittent schedule of 4 million units infused over 30 minutes every 4 hours via PICC line (peripherally inserted central catheter placed in an upper arm vein for long-term treatments), which equates to the same total daily dose. This dosing strategy was confirmed to provide adequate medication coverage for over the four-hour intervals. The nurse progress notes were reviewed. A note dated [DATE] at 12:47 PM read, Resident arrived at facility at 11:50am via private transportation with family. DNR signed in facility. Resident takes pills whole. Last BM [DATE]. Resident 1x assist with ADLs (activities of daily living). Continent of b/b (bowel and bladder). Mechanical soft diet, thin liquids. PICC line to right arm. Continues IV abx (antibiotics) until [DATE]. Call light and personal items within reach. A progress note dated [DATE] at 2:38 PM read, Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Use 4 million units intravenously every 4 hours for Bacteremia. A progress note dated [DATE] at 8:33 PM read, Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Use 4 million units intravenously every 4 hours for Bacteremia until [DATE] 23:59 Held per MD. A progress note dated [DATE] dated at 1:09 AM read, Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Use 4 million units intravenously every 4 hours for Bacteremia until [DATE] 23:59 Medication held, MD aware. Awaiting arrival from pharmacy. A progress note dated [DATE] at 4:58 AM read, Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Use 4 million units intravenously every 4 hours for Bacteremia until [DATE] 23:59 Medication held, MD aware. Awaiting arrival from pharmacy. A progress note dated [DATE] at 8:12 AM read, Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Use 4 million units intravenously every 4 hours for Bacteremia until [DATE] 23:59 held per MD and RP aware. awaiting arrival from (name omitted) infusion center. A progress note dated [DATE] at 12:13 PM read, Penicillin G Potassium Injection Solution Reconstituted 20000000 UNIT Use 4 million units intravenously every 4 hours for Bacteremia until [DATE] 23:59 held per MD and RP aware. awaiting arrival from (name omitted) infusion center. A progress note dated [DATE] at 7:32 PM read, Resident started her IV abx this shift, no adverse reaction noted. PICC line patent, dressing dry, clean, and intact. The medication administration record for [DATE] was reviewed. There was an entry dated [DATE] at 12:00 PM that read, Penicillin G potassium injection solution reconstituted 20,000,000 unit use 4 million units intravenously every 4 hours for bacteremia. The doses scheduled for 12:00 PM and 4:00 PM were coded with a 5 which according to the chart codes meant, see nurses notes. This order was discontinued on [DATE] at 4:34 PM. There was another entry dated [DATE] at 8:00 PM that read, Penicillin G potassium injection solution reconstituted 20,000,000 unit use 4 million units intravenously every 4 hours for bacteremia. The dose scheduled on [DATE] at 8:00 PM was coded with a 5. On [DATE] the 12:00 AM dose, 4:00 AM dose, 8:00 AM dose and 12:00 PM dose were all coded with a 5. This order was discontinued on [DATE] at 1:00 PM. An order entered [DATE] at 4:00 PM read, Penicillin G potassium injection solution reconstituted 20,000,000 unit use 4 million units intravenously every 4 hours for bacteremia. The [DATE] 4:00 PM and 8:00 PM doses were signed as given. According to the facility documentation the resident missed 7 doses while waiting for the medication to arrive from the infusion center. On [DATE] Resident #95 was sent out emergently to the hospital and admitted for atrial fibrillation. The resident returned to the facility on [DATE] at 9:20 PM according to the nurses notes, with orders to continue the penicillin G as previously ordered. The MAR for May was reviewed. An order for the medication was entered on [DATE] at 11:59 PM and discontinued on [DATE] at 4:00 AM. No doses were given. Another order for the penicillin was entered on [DATE] at 8 PM and the medication was signed as given at that time. According to the documentation, Resident #95 missed 5 doses of the prescribed antibiotic. On [DATE] at 9:39 AM the NP (Nurse Practitioner) who wrote the admission history and physical on [DATE] was interviewed. When asked if they were aware that Resident #95 missed 7 doses in April and 5 doses in May they stated, No, I had no idea. On [DATE] at 1:20 PM Registered Nurse (RN) #1 was interviewed. They could not recall Resident #95. When asked about the delay in starting the antibiotics they stated, I'm not surprised, the infusion center where we get our drugs is all the way in Bristol, VA. It sometimes takes days to get the medications in. The surveyor requested a policy regarding unavailable medications, but none was received by exit. On [DATE] at 4:34 PM the survey team met with the Administrator, the Regional Director of Clinical Services and the [NAME] President of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to exit. 5. For Resident #29 the facility staff failed to ensure parameters for insulin were followed. Resident #29's admission Record revealed the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with neuropathy, obesity class 2 and long-term use of insulin. The annual minimum data set (MDS) assessment with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 10 indicating moderate cognitive impairment. The comprehensive care plan for Resident #29 included a focus for diabetes with an intervention that read, Administer insulin per order. The physician order for insulin read, Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 15 unit subcutaneously before meals and at bedtime for hyperglycemia related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) hold for glucose < [less than] 175. The MAR (medication administration record) for [DATE] was reviewed. On [DATE] at 6:00 AM resident had a blood sugar of 147 and the insulin was signed as given. On [DATE] at 6:00 AM the blood sugar was 156 and the insulin was documented as given. On [DATE] at 9:00 PM the blood sugar was 111 and the insulin was given. On [DATE] at 4:00 PM the blood sugar was 123 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 161 and the insulin was given. On [DATE] at 11:00 AM the blood sugar was 147 and the insulin was given. The MAR for May was reviewed. On [DATE] at 6:00 AM the blood sugar was 152 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 151 and the insulin was given. On [DATE] at 4:00 PM the blood sugar was 157 and the insulin was given. The June MAR was reviewed. On [DATE] at 11:00 AM the blood sugar was 148 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 156 and the insulin was given. On [DATE] at 11:00 AM the blood sugar was 124 and the insulin was given. On [DATE] at 9:00 PM the blood sugar was 140 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 132 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 131 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 110 and the insulin was given. On [DATE] at 4:00 PM the blood sugar was 165 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 111 and the insulin was given. The July MAR was reviewed. On [DATE] at 6:00 AM the blood sugar was 174 and the insulin was given. On [DATE] at 11:00 AM the blood sugar was 172 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 135 and the insulin was given. On [DATE] at 6:00 AM the blood sugar was 131 and the insulin was given. On [DATE] at 4:34 PM the survey team met with the Administrator, the Regional [NAME] President of Operations and the Regional Director of Clinical Services. This concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit. 6. For Resident #43, the facility staff failed to hold the medication Insulin aspart subcutaneous solution pen-injector (a rapid-acting, diabetic medication used to lower blood glucose) when the resident's blood glucose levels were less than (150) one-hundred fifty, as ordered by a medical provider. A review of an admission Record, disclosed Resident #43 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites, congestive heart failure (CHF), and hepatic encephalopathy. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 7 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of a medical provider Order Summary Report disclosed and order for Insulin aspart subcutaneous solution pen-injector at 100 unit/ml (milliliter) - inject 8 unit subcutaneously before meals for DM (diabetes mellitus). Hold if (blood sugar) <150 (less than one-hundred fifty) with a start date of [DATE]. A review of Resident #43's May, June, and [DATE] MARs (medication administration records) indicated Insulin aspart was administered on the following dates/times with BS (blood sugar) levels outside of the ordered parameter of holding the medication if BS <150: [DATE]-BS 138 at 6:00 AM [DATE]-BS 131 at 6:00 AM [DATE]-BS 87 at 6:00 AM [DATE]-BS 136 at 4:00 PM [DATE]-BS 124 at 4:00 PM [DATE]-BS 134 at 6:00 AM [DATE]-BS 144 at 4:00 PM [DATE]-BS 97 at 6:00 AM [DATE]-BS 137 at 4:00 PM [DATE]-BS 146 at 6:00 AM [DATE]-BS 148 at 11:00 AM [DATE]-BS 127 at 6:00 AM [DATE]-BS 108 at 11:00 AM [DATE]-BS 140 at 4:00 PM [DATE]-BS 137 at 6:00 AM [DATE]-BS 106 at 4:00 PM A review of Resident #43's comprehensive person-center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the medical provider of a significant change in condition in a timely manner for two (2) of 51 residents in the survey sample, Resident #95 and Resident #6.The facility's failure to recognize, act upon, and report a heart rate of 131 beats per minute to a medical provider for approximately six hours, likely caused and/or hastened the resident's death which occurred one to two hours after being sent out to the hospital with complaints of shortness of breath and chest pain.This resulted in the identification of Immediate Jeopardy for Resident #95. The survey team informed the facility on [DATE] at 3:28 PM of the Immediate Jeopardy situation regarding Resident #95. The scope and severity were originally cited at level IV isolated. On [DATE] at 11:10 AM the Immediate Jeopardy was removed and lowered to a level III isolated.The findings included: 1. For Resident #95, the facility staff failed to recognize, act upon, and report a heart rate of 131 beats per minute to a medical provider for approximately six hours. This likely caused and/or hastened the resident's death which occurred one to two hours after being sent out to the hospital with complaints of shortness of breath and chest pain. The facility policy titled, Notification of Changes with a revised date of [DATE] was reviewed. The document read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Under the heading Compliance Guidelines the document read in part, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Under Circumstances requiring notification include item #2 read, Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include a. Life threatening conditions, or b. Clinical complications. A policy titled Vital Signs with no review or revised date read in part, The purpose of this policy is to provide guidelines for the measurement and reporting of vital signs. Under item #4 the document read, Acceptable ranges for adults item b. Pulse: 60-100 beats per minute. Resident #95's admission Record indicated the facility admitted the resident on [DATE]. The admission Record included the diagnoses of atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome (also known as broken heart syndrome which is a temporary condition where the heart's main pumping chamber, the left ventricle weakens and changes shape. It closely mimics a heart attack.), presence of prosthetic heart valve and bacteremia. Resident #95's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the resident had no memory impairment and was independent in making reasonable and consistent decisions. The MDS indicated the resident was independent with eating, hygiene and upper body dressing and only required minimal assistance with other tasks of activities of daily living (ADL's). Resident #95 required partial to moderate assistance with getting out of bed and could only walk around 10 feet with partial to moderate assistance. Resident #95's baseline care plan was reviewed, and it indicated that the resident was admitted on intravenous (IV) antibiotics, diuretic and anticoagulant medications, was cognitively intact, always continent of bowel and bladder and had a discharge goal of returning home. A nursing progress note dated [DATE] at 11:40 AM read, Pt [patient] picked up by transport to go to [acute care hospital] at 1140 [11:40 AM]. Pt was tachycardic [rapid heart rate] (135), had new leg swelling, and altered mental status. This nurse informed NP [name omitted] who then evaluated pt. When EMS arrived, PT's O2 was 85%. A [DATE] provider progress note titled Post Acute Care Visit #2 by the Nurse Practitioner (NP) was reviewed and read in part, .evaluated for an acute change in status. [Resident] was found to have atrial fibrillation with a rapid ventricular rate [RVR] and was noted to be dyspneic [short of breath] during conversation. atrial fibrillation and a rapid ventricular response, confirmed by physical exam and bedside 3-lead EKG. This is contributing to clinical presentation of dyspnea and likely hemodynamic instability.The recommendation for urgent transport to the emergency department was made due to the inability to obtain rapid labs to guide resuscitation and determine the degree of strain on her heart Resident #95 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The hospital Discharge summary dated [DATE] was reviewed and revealed that Resident #95 was admitted with a diagnosis of atrial fibrillation with RVR [rapid ventricular rate] and a heart rate in the 150's. On [DATE] at 11:03 AM a nursing progress note indicated that Resident #95 had a heart rate of 131 beats/minute and a blood pressure of 98/53. Under the heading Cardiovascular the note read, Skin warm and pink with brisk capillary refill (<3 seconds). No edema present. There was no documentation indicating a medical provider was notified of the elevated heart rate or that a nurse further assessed the elevated heart rate. The next clinical record entry dated [DATE] at 6:12 PM, approximately seven hours later, was from an on-call provider who documented in part, Complaint: Shortness of breath, chest pain, not feeling well Provide Current Vital Signs: 114/64 p [pulse] 80 o2 [oxygen saturation] 77 Message: Given one nitro for chest pain. Was slightly better but was sent out to hospital. [DATE], 6:12 PM. There was no indication in the note that the facility nurse had informed the on-call provider of the resident's extensive cardiac history, their hospitalization just days prior when the resident was sent out with a heart rate of 135 or that the resident had a heart rate at 11:03 AM of 131. There was no documentation in Resident #95's clinical record to indicate if the resident remained stable during the seven hours or if they were checked on during the seven-hour period. The next entry in the clinical record was dated [DATE] at 1:01 AM and it read, RSD [resident] expired at [hospital]. TOD [time of death] 2052 [8:52 PM]. Family aware. A document titled, Change in Condition (SBAR)-CHC was dated [DATE] at 5:52 PM. Under the heading Situation it read, not feeling well, SOB (shortness of breath), chest pain. Under the heading Vital Signs the pulse from the 11:03 AM nurse note of 131 was documented as well as the rest of the 11:03 AM vital signs, indicating the nurse never obtained another set of vital signs. It is unclear where the pulse of 80 documented in the on-call provider note at 6:12 PM came from. Under the heading Cardiovascular Evaluation item #2 Chest pain/tightness was checked but item #6 Resting pulse <100 or <50 was not checked. On [DATE] at 9:39 AM, NP (nurse practitioner) #1 was interviewed via telephone. They said they were no longer seeing patients at the facility but remembered Resident #95 well. They stated, It was a Sunday if I'm not mistaken and the nurse had contacted me a few times that day about other residents but never said a word about [Resident #95]. When I got to the building on Monday and was informed about what happened I was shocked. I spoke to [Licensed Practical Nurse/LPN #2] about it. I wanted to know why with a heart rate of 130 and when [resident] had been sent out already just days prior and was in ICU [intensive care unit] and we were aware this was a serious problem for [resident], that required monitoring due to poor compensation, and I had made it clear that [resident] had to be watched closely, I just could not understand why I wasn't called. She [LPN #2] had contacted me within an hour of documenting that heart rate about someone else and never said a word. I would have had [resident] sent out right then if she had just told me. I asked her Monday morning what did you do about this heart rate and she told me it was [resident's] baseline and she didn't do anything. I told her you do know that she died, right? We had seven hours to intervene and do something, but she [LPN #2] just shrugged and walked away. I tried to talk to [the Director of Nursing/DON] about her [LPN #2] and all she said was I know, we've had the same problem with her before and we've talked to her, but some people just don't learn. I tried to bring the concern to the Administrator as well, many concerns but I never received a response other than we're working on it. This death could have been prevented. [Resident] died just an hour or two after getting to the hospital because [resident] was not sent out timely. On [DATE] at 10:57 AM LPN #2 was interviewed. When asked what they did for Resident #95 when they got the heart rate of 131 they stated, The C.N.A. [certified nursing assistant] got the vital signs and gave them to me and when I saw that pulse I immediately went back and checked [resident] out. I got 87 when I checked it and [resident] was fine, [resident] didn't have any complaints or anything, there were no other symptoms, so I didn't do anything. It wasn't until that evening when the C.N.A. was transferring [resident] to bed that [resident] complained about being short of breath and heart racing, so I assessed [resident] and the heart rate was quite quick and the o2 sat was low, so I sent [resident] out. When asked why she didn't document that she went and rechecked the heart rate that morning, she stated, It was a crazy day, and we had a lot going on. When asked where the on-call provider got the heart rate of 80 LPN #2 could not recall a pulse of 80 and was not sure where it came from. On [DATE] at 3:28 PM, the survey team notified the Administrator and Assistant Director of Nursing (ADON) of the Immediate Jeopardy situation involving Resident #95. On [DATE] at 12:35 PM, the Administrator presented the following Immediate Jeopardy Removal Plan: Resident #95 was discharged on [DATE]. An immediate in-house evaluation for all residents currently residing in the facility completed in the last 24hrs. Vital signs, including blood pressure, pulse, respirations, and temperature, were obtained for every resident and reviewed by a licensed nurse to identify any actual or potential changes in resident conditions. Any abnormal findings identified were assessed by a licensed nurse and addressed through the facility's change in condition process, to include resident assessment, physician and family notification with implementation of any physician orders or recommendations when applicable. Licensed nursing staff will be educated by the RDCS/designee on identifying, assessing, and timely reporting a change in resident condition. A post-test will be administered and scored by the RDCS/designee to validate understanding with the expectation of 100% to pass. If 100% is not achieved, we will re-educate and re-administer the test. Staff unable to receive education due to schedule will be educated prior to their next scheduled shift. Licensed nursing staff will be educated by the ADON/designee on notifying the provider timely when a resident's change in condition is noted and on documenting the provider's response and actions taken to address the change in condition. Staff unable to receive education due to schedule will be educated prior to their next scheduled shift. The interdisciplinary team (IDT) will review all resident changes in condition five (5) days per week x 8 weeks during the daily Clinical Morning Meeting to ensure timely assessment, physician and resident/responsible party notification, implementation of interventions, and accurate EMR documentation. Any identified concerns will be addressed immediately through corrective action and follow-up changes. Facility asserts completion [DATE] at 2pm The facility's removal plan was approved as presented on [DATE] at 12:50 PM and the Administrator was notified. The facility staff presented credible evidence that the removal plan had been implemented, including vital sign evaluation reviews, staff education and post-tests as outlined in the removal plan. Interviews with staff verified education as outlined in the removal plan. On [DATE] at 11:10 AM, the survey team verified the Immediate Jeopardy had been cleared and the Administrator was notified. No further information was provided to the survey team prior to the exit conference. 2. For Resident #6, the facility staff failed to notify the medical provider of a significant 28.6-pound weight gain with a medical history that included end stage renal disease with dialysis and alcoholic cirrhosis of the liver with ascites. A facility policy titled, Weight Monitoring, revised [DATE], specified The physician should be informed of a significant change in weight. An admission Record indicated the facility admitted Resident #6 on [DATE]. According to the admission Record, the resident had a medical history that included end stage renal disease with dependence on renal dialysis, alcoholic cirrhosis of liver with ascites, type 2 diabetes mellitus, portal hypertension, and congestive heart failure. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) summary score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #6's weight history revealed an admission weight of 164.4 pounds obtained on [DATE]. The resident was not weighed again until [DATE] at which time he weighed 193.0 pounds. The [DATE] weight identified significant weight gain of 28.6 pounds in five weeks. A dietary progress note dated [DATE] indicated a significant weight gain of 17.4%. A review of Resident #6's clinical record failed to reveal documentation of medical provider notification regarding the significant weight gain. On [DATE] at 5:19 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding failure to notify the medical provider of a significant weight gain. No further information regarding this concern was provided prior to the exit conference on [DATE].

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain lab testing as ordered by the medical provider for 8 of 51 sampled residents, Resident #94, Resident #2, Resident #3, Resident #5, Resident #7, Resident #8, Resident #12, and Resident #6. For Resident #94, the facility staff failed to obtain PT/INR results as ordered following the transition of Eliquis to Coumadin using a limited Lovenox bridge on four separate occasions from [DATE] through [DATE]. Lab results obtained on [DATE] and received by the lab on [DATE] resulted in a PT greater than 90 (reference range 9.60-11.33) and INR results that could not be calculated as the result greater than linearity. Resident #94 began showing signs of active bleeding on [DATE]. Additional Lab results obtained on [DATE] revealed a critically low hemoglobin of 6.7, a low hematocrit of 20.9, and PT/INR levels that were unable to be determined due to no clotting endpoint on the lab instrument. Resident #94 died on [DATE] while actively bleeding from the nose, mouth, urinary tract, and rectum.This resulted in the identification of Immediate Jeopardy for Resident #94. The survey team informed the facility on [DATE] at 6:10 PM of the Immediate Jeopardy situation regarding Resident #94.The scope and severity were originally cited at Level IV Isolated. On [DATE] at 5:30 PM, the Immediate Jeopardy was removed and lowered to a Level III Isolated. The findings included: 1. For Resident #94, the facility staff failed to obtain PT/INR results as ordered following the transition of Eliquis to Coumadin using a limited Lovenox bridge on four separate occasions from [DATE] through [DATE]. An admission Record indicated the facility admitted Resident #94 on [DATE]. According to the admission Record, the resident had a medical history that included atrial fibrillation, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and bladder-neck obstruction. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A [DATE] Change in Condition (SBAR) form indicated Resident #94's family member requested a re-evaluation of his medication to see if another medication could be substituted for Eliquis because it was very expensive. New medical provider orders were received on [DATE] to discontinue Eliquis and start Lovenox 80 mg/8ml inject one application subcutaneously every morning and bedtime for bridge therapy while transitioning to Coumadin (Warfarin), may discontinue when INR 2-3 for 24 hours and Warfarin (Coumadin) 5 mg by mouth at bedtime. On [DATE], the medical provider ordered PT/INRs every 48 hours to start on [DATE] for transition to Warfarin (Coumadin) from Eliquis. A PT/INR was obtained on [DATE] and the INR was within therapeutic range at 2.75. This result indicated that if the next INR was between 2 - 3, Lovenox would be discontinued. PT/INRs were due on [DATE], [DATE], and [DATE]; however, they were not obtained. On [DATE], the medical provider ordered a PT/INR. According to the lab report, the PT/INR blood sample was not collected until [DATE], received by the lab the following day on [DATE] at 11:14 AM and reported on [DATE] at 9:36 PM. The PT was greater than 90 (reference range 9.60-11.33) and confirmed by repeat analysis and the INR results could not be calculated as the result greater than linearity. This result indicated the resident's blood clotting time was so prolonged that the lab's analyzer's range was exceeded. A nursing progress note dated [DATE] at 5:35 AM indicated Lovenox was held to see stat result of PT/INR. A [DATE] hospice nursing progress note read in part .Resident observed lying in bed with bloody nose from nosebleed.Resident's face cleaned and gown, sheets and pillowcase changed, soiled with blood.foley cath observed with blood-tinged urine in collection bag.instructed to hold bedtime dose of 5 mg Coumadin and AM dose of Lovenox 80 mg. A [DATE] hospice nursing progress note read in part Resident observed sitting up in bed with a small stream of blood coming from left nostril. Dark bloody urine observed in foley collection bag and tubing.Writer contacted [hospice physician] and given lab results for PTT and INR over the phone, order given and completed for 10mg/1ml of Vitamin K injection.At the completion of care, bleeding had stopped.Lovenox 80 mg injection discontinued and 5 mg of Coumadin held for Saturday and Sunday doses, with repeat labs for Monday morning. A [DATE] hospice nursing progress note read in part .Pt [patient] states he feels as he is dying. Pt has frank blood coming out of both nares, mouth and foley, BP 78/42. MD ordered STAT BMP [basic metabolic panel] CBC [complete blood count] and INR. Family present and repeatedly stated pt does not want to go to the hospital.foley catheter 24 F with frank blood in bag. Unable to note if any urine present due to blood. No noted clots. A second hospice nursing visit was made on [DATE], this progress note read in part Visit due to ongoing bleeding. Upon assessment, patient laying in bed oriented to person and pale in color. Blood noted to nose, in catheter bag, and out of rectum.Consulted with [hospice physician] and order received to start TXA [Tranexamic Acid] 650 mg tablet PO [by mouth] TID [three times a day] for 5 days. This nurse picked up medication from [area hospital] lobby pharmacy and delivered to facility. Tranexamic Acid is a medication used to prevent and control excessive bleeding. The [DATE] lab results revealed a white blood cell count of 21.81 (reference 4.5-10.5), red blood cell count of 2.51 (reference 4.3-5.8), hematocrit 20.9 (reference 42-52), critically low hemoglobin of 6.7 (reference 13.0-17.3), PT/INR results were not available as there was no clot endpoint obtained on the instrument. According to the National Institutes of Health, no end point detected indicates that the analyzer was unable to detect clot formation within the test window. Resident #94's clinical record failed to include evidence that the facility medical provider or hospice were notified of the [DATE] abnormal lab results including the critically low hemoglobin and the inability to obtain PT/INR results due to no clot endpoint. The lab report indicated the Director of Nursing (DON) reviewed the results on [DATE] at 3:56 PM. This was over four and a half hours after the resident's death. Resident #94 was pronounced deceased on [DATE] at 11:20 AM in the facility. During an interview on [DATE] at 10:55 PM, Licensed Practical Nurse (LPN) #8 stated preceding his death, Resident #94 was bleeding from his nose, mouth, and foley. LPN #8 stated the bleeding was not profuse, but they had to keep wiping the blood from his nose. Nurse Practitioner (NP) #1 was interviewed on [DATE] at 11:43 AM. NP #1 stated she had spoken with Resident #94's family member and Eliquis was very expensive and they elected to switch to Coumadin using a Lovenox bridge. NP #1 stated she had trouble getting the PT/INRs completed. NP #1 stated she was present in the facility when the resident passed, and she went to his room, and his mouth and nose were completely caked with dried blood. She stated she assisted the staff in cleaning him up and it took over 20 minutes trying to get the caked blood out of his nose. The facility's contracted lab service was contacted on [DATE] at 5:41 PM, the STAT Lab Specialist confirmed Resident #94 had only three PT/INRs obtained in [DATE], on [DATE], [DATE], and [DATE]. This information was conveyed to the DON at 5:47 PM and she stated that was not what she wanted to hear but it is what it is. On [DATE] at 6:10 PM the survey team notified the Administrator, DON, and Assistant DON of the Immediate Jeopardy situation involving Resident #94. On [DATE] at 2:29 PM the Administrator presented the following Immediate Jeopardy Removal Plan: 1. Resident #94 is no longer in the facility as of [DATE]. 2. An immediate audit of all current residents who have had an order for a PT/INR Lab within the past 60 days, were reviewed Regional Director of Clinical Services to ensure completion. The audit revealed that only one current resident is being monitored with those labs. The resident was not affected by the deficient practice. 3. DON/designee will review all lab orders during morning clinical 5 days weekly. Then they will verify that the order has been entered into the lab servicing portal. Orders will be entered into the lab book to be drawn. DON/designee will verify lab completion with the next business day. 4. All Licensed nurses were educated by the Assistant Director of Nursing on the lab ordering procedure to include step by step process from time of receipt of the order, up to monitoring results and taking appropriate action done in-person or over the phone. Any nurses who did not receive the education will be educated prior to their next scheduled shift. 5. Weekly audits by the Director of Nursing/designee will be completed of all PT/INR labs to ensure compliance for 3 months. Facility asserts completion [DATE] at 1pm The facility's removal plan was approved as presented on [DATE] at 2:55 PM and the Administrator was notified at 3:21 PM. The facility staff presented credible evidence that the removal plan had been implemented, including lab book review and staff education as outlined in the removal plan. Interviews with staff verified education as outlined in the removal plan. On [DATE] at 5:30 PM, the survey team verified that the Immediate Jeopardy had been cleared. The Administrator, ADON, and Regional [NAME] Present #1 and #2 were informed that the Immediate Jeopardy was cleared as of 5:30 PM. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 2. For Resident #2, the facility staff failed to obtain a urinalysis as ordered on [DATE] and a urinalysis with culture and sensitivity as ordered on [DATE]. A facility policy titled, Laboratory Services and Reporting, revised [DATE], specified The facility must provide or obtain laboratory services to meet the needs of its residents. An admission Record indicated the facility admitted Resident #2 on [DATE]. According to the admission Record, the resident had a medical history that included vascular dementia, type 2 diabetes mellitus, chronic kidney disease, and history of urinary tract infections (UTIs). A significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #2 had a Brief Interview for Mental Status score of 1 which indicated severe cognitive impairment. Resident #2's comprehensive person-centered care plan included a focus area stating the resident had a history of recurrent UTIs with interventions including but not limited to monitor/document signs and/or symptoms of UTI. Resident #2 was seen by the medical provider on [DATE], the progress note indicated The patient presents with increased confusion and garbled speech, which is an acute change from her baseline confusion. These symptoms are typical for her when she has an underlying infection, raising suspicion for a breakthrough urinary tract infection. A urinalysis has been ordered to evaluate for a possible infectious etiology, specifically a UTI, which is the likely precipitant of her altered mental status. Resident #2 was seen again by the medical provider on [DATE], the progress note revealed The patient's altered mental status is highly suspicious for a urinary tract infection as the underlying cause. This is supported by her history of recurrent UTIs, including those with extended-spectrum beta-lactamase (ESBL) producing organisms, and her known chronic colonization with E. coli. A urinalysis has been ordered to be checked expeditiously. If the urinalysis is positive, we will await culture with speciation and sensitivities to ensure appropriate coverage, particularly for a potential ESBL infection. Treat with Macrobid and follow need for change to therapy. A review of Resident #2's clinical record failed to reveal urinalysis results following the [DATE] and [DATE] provider visits. A medical provider progress note dated [DATE] revealed increased confusion during nighttime. Due to the patient's age and clinical presentation, a urinary tract infection is being considered as a potential underlying cause for her change in mental status. A urinalysis with culture and sensitivity will be obtained to evaluate for a urinary tract infection. A urinalysis report dated [DATE] was present in the clinical record which showed 4+ bacteria, 51-100 white blood cells, 2+ nitrite and the culture was positive for E. coli. During an interview on [DATE] at 3:55 PM, the Regional Director of Clinical Services (RDCS) stated there were no reports of a urinalysis done on [DATE] or [DATE], only the current one dated [DATE]. During a meeting on [DATE] at 5:19 PM, the Administrator and RDCS were notified of the concern regarding the missing urinalysis tests for Resident #2. No further information regarding this concern was presented prior to the exit conference on [DATE]. 3. For Resident #3, the facility staff failed to obtain PT/INRs as ordered by the medical provider. A facility policy titled, Laboratory Services and Reporting, revised [DATE], specified The facility must provide or obtain laboratory services to meet the needs of its residents. An admission Record indicated the facility admitted Resident #3 on [DATE]. According to the admission Record, the resident had a medical history that included chronic obstructive pulmonary disease, history of anticoagulant use, and history of venous thrombosis and embolism. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #3 had a Brief interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. Resident #3's clinical record indicated the resident had been prescribed and taking Warfarin due to a deep vein thrombosis. Warfarin is an anticoagulant used to thin the blood. Resident #3's medical provider orders included an order dated [DATE] to obtain a PT/INR on [DATE]; however, the lab was not obtained until [DATE]. Resident #3's medical provider orders included an order dated [DATE] to obtain a PT/INR on [DATE]; however, it was never obtained. Resident #3's medical provider orders included an order dated [DATE] to obtain a PT/INR on [DATE]; however, the lab was not obtained until [DATE]. During an interview on [DATE] at 3:55 PM, the Regional Director of Clinical Services verified the PT/INR findings. He also stated previously the medical providers entered and approved their own orders which caused orders to be entered and not seen by nursing. He stated new orders are now entered into a cue for nursing staff to process. During a meeting on [DATE] at 5:19 PM, the Administrator and RDCS were notified of the concern regarding Resident #3's PT/INR results. No further information regarding this concern was presented prior to the exit conference on [DATE]. 4. For Resident #5, the facility staff failed to obtain a complete blood count (CBC) and a comprehensive metabolic panel (CMP) as ordered by the medical provider. A facility policy titled, Laboratory Services and Reporting, revised [DATE], specified The facility must provide or obtain laboratory services to meet the needs of its residents. An admission Record indicated the facility admitted Resident #5 on [DATE]. According to the admission Record, the resident had a medical history that included sepsis due to Escherichia coli, urinary tract infection (UTI), and acute kidney failure. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #5's comprehensive person-centered care plan included a focus area dated [DATE], that indicated the resident was at risk for dehydration related to recent septicemia, UTI, multidrug resistant organism, and intravenous antibiotics. Interventions directed the staff to obtain and monitor lab/diagnostic work as ordered. A nursing progress note dated [DATE] at 1:39 PM indicated Resident #5 was seen by the nurse practitioner and new orders were received for a CBC and CMP. A review of Resident #5's clinical record failed to reveal evidence that the CBC and CMP were obtained. During an interview on [DATE] at 3:55 PM, the Regional Director of Clinical Services stated he did not have results for a CBC or CMP ordered on [DATE], he only had results from an order on [DATE]. No further information was provided prior to the exit conference on [DATE]. 5. For Resident #7, the facility staff failed to obtain a urinalysis with culture and sensitivity as ordered by the medical provider. A facility policy titled, Laboratory Services and Reporting, revised [DATE], specified The facility must provide or obtain laboratory services to meet the needs of its residents. An admission Record indicated the facility admitted Resident #7 on [DATE]. According to the admission Record, the resident had a medical history that included sepsis due to other specified staphylococcus, urinary tract infection, type 2 diabetes mellitus, and Alzheimer's Disease. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE]. Revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Resident #7's comprehensive person-centered care plan included a focus area dated [DATE], that indicated the resident had an indwelling catheter, a history of BPH (benign prostatic hyperplasia), obstructive uropathy, recent urinary tract infection (UTI) with risk for further UTIs or infection. Interventions included labs as ordered. Resident #7's medical orders included an order dated [DATE] at 8:11 PM for a urinalysis with micro, reflex to urine culture. Resident #7 was seen by the Nurse Practitioner (NP) on [DATE]. The progress note revealed The patient presents with AMS [altered mental status] manifested by staff reports of increased confusion, hallucinations, and anxiety. This is most likely a delirium secondary to an infectious process, given the concurrent suspicion for a urinary tract infection. The progress note also revealed The patient has an indwelling Foley catheter and foul-smelling urine, raising high suspicion for a catheter-associated urinary tract infection (CAUTI). This is the most likely trigger for his acute delirium. A urinalysis with culture and sensitivity has been ordered to confirm the diagnosis and guide potential antimicrobial therapy. A review of Resident #7's clinical record failed to reveal results of a urinalysis obtained following the [DATE] medical provider order. During an interview on [DATE] at 3:55 PM, the Regional Director of Clinical Services (RDCS) stated they had no evidence that the urinalysis was done, they only had urinalysis results obtained on [DATE]. No further information was provided prior to the exit conference on [DATE]. 6. For Resident #8 the facility staff failed to obtain the physician ordered laboratory tests for oxcarbazepine level, felbamate level and lamotrigine level. Resident #8's clinical record listed diagnoses which included but not limited to epilepsy, unspecified, not intractable, without status epilepticus. Resident #8's most recent quarterly minimum data set with an assessment reference date of [DATE] coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section N, medications, coded the resident as receiving anticonvulsant medications. Resident #8's comprehensive care plan was reviewed and contained a plan for . has a seizure disorder with recurrent seizures. Interventions for the care plan included Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Resident #8's clinical record contained a physician's order summary which read in part, Labs: Oxcarbazepine level, felbamate level, lamotrigine level one time only for 3 days ordered on [DATE]. Surveyor could not locate the results of these tests. The physician's order summary also contained an order for lamotrigine, felbamate, and oxcarbazepine level on time only for labs for 1 day ordered on [DATE]. Surveyor could not locate the results for the felbamate level in the resident's clinical record. Surveyor requested and was provide with a facility policy entitled, Laboratory Services and Reporting which read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The concern of not obtaining physician ordered laboratory tests was discussed with the administrator and regional director of clinical services on [DATE] at 5:15 pm. No further information was provided prior to exit. 7. For Resident #12 the facility staff failed to obtain physician ordered laboratory tests. Resident #12's clinical record listed diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting non-dominant right side, moderate protein-calorie malnutrition, epilepsy, unspecified, and obstructive and reflux uropathy, unspecified. Resident #12's most recent quarterly minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #12's comprehensive care plan was reviewed and contained a plan for . has a seizure disorder. Interventions for this care plan included Obtain and monitor lab/diagnostic work as ordered . Resident #12's clinical record contained a physician's order summary which read in part, Culture-Other fluid from nephrostomy tube at connection site one time only for infection for 3 days-order date [DATE], CBC (complete blood count), BMP (basic metabolic panel), Magnesium one time a day for infectious work up for 1 day-order date [DATE], CBC-BMP-Mag one time only until [DATE]-order date [DATE] and Blood culture, CBC CMP (comprehensive metabolic panel) on time only for 1 day-order date [DATE]. Surveyor could not locate the results of the labs ordered on [DATE] and [DATE] and could not locate the BMP/Magnesium level ordered on [DATE] or the blood culture ordered on [DATE]. Surveyor requested and was provide with a facility policy entitled, Laboratory Services and Reporting which read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The concern of not obtaining physician ordered laboratory tests was discussed with the administrator and regional director of clinical services on [DATE] at 5:15 pm. No further information was provided prior to exit. 8. For Resident #6, the facility staff failed to obtain the provider ordered laboratory test ammonia level. Resident #6's diagnoses included cirrhosis of the liver with ascites and portal hypertension. Section C (cognitive patterns) of Resident #6's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] included a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment for daily decision making. Review of the comprehensive care plan identified an intervention to obtain laboratory testing as ordered or as needed. Review of the clinical record revealed provider orders dated [DATE] and [DATE] for ammonia levels. The clinical record included the results of one ammonia level collected on [DATE], with reported results of 112 (high). Documentation in the clinical record indicated the resident intermittently refused their provider ordered lactulose. During an end of the day meeting on [DATE] at 4:00 PM, the surveyor reviewed the missing ammonia level with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing. On [DATE] at 12:05 PM, the DON acknowledged that one of the two provider ordered ammonia levels had not been obtained. A facility policy titled, Laboratory Services and Reporting, revised [DATE], specified The facility must provide or obtain laboratory services to meet the needs of its residents. On [DATE] at 5:20 PM, the missing ammonia level was reviewed with the Regional Director of Clinical Services and Administrator. No additional information regarding the missed provider ordered laboratory test was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure competent staff to recognize a significant change in condition for one of 12 closed record reviews, Resident #95. The facility staff also failed to ensure nurse competencies, including skills assessments were completed for licensed nursing staff, Registered Nurse #7. The findings included: 1. For Resident #95 the facility staff failed to ensure nurses were competent to recognize and act appropriately when a significant change in resident condition occurred. Licensed Practical Nurse (LPN) #2 failed to recognize, act upon, and report a heart rate of 131 beats per minute to a medical provider for approximately six hours which likely caused and/or hastened the resident's death which occurred one to two hours after being sent out to the hospital with complaints of shortness of breath and chest pain. This constituted harm to Resident #2. The facility policy titled, Notification of Changes with a revised date of [DATE] was reviewed. The document read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Under the heading Compliance Guidelines the document read in part, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Under Circumstances requiring notification include item #2 read, Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include a. Life threatening conditions, or b. Clinical complications. A policy entitled Vital Signs with no review or revised date read in part, The purpose of this policy is to provide guidelines for the measurement and reporting of vital signs. Under item #4 the document read, Acceptable ranges for adults item b. Pulse: 60-100 beats per minute. Resident #95's admission Record indicated the facility admitted the resident on [DATE]. The admission Record included the diagnoses of atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome (also known as broken heart syndrome which is a temporary condition where the hearts main pumping chamber, the left ventricle weakens and changes shape. It closely mimics a heart attack.), presence of a prosthetic heart valve and bacteremia. Resident #95's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the resident had no memory impairment and was independent in making reasonable and consistent decisions. The MDS indicated the resident was independent with eating, hygiene and upper body dressing and only required minimal assistance with other tasks of activities of daily living (ADL's). Resident #95 required partial to moderate assistance with getting out of bed and could only walk around 10 feet with partial to moderate assistance. Resident #95's baseline care plan was reviewed, and it indicated that the resident was admitted on intravenous (IV) antibiotics, diuretic and anticoagulant medications, was cognitively intact, always continent of bowel and bladder and had a discharge goal of returning home. A nursing progress note dated [DATE] at 11:40 AM read, Pt [patient] picked up by transport to go to [acute care hospital] at 1140 [11:40 AM]. Pt was tachycardic [rapid heart rate] (135), had new leg swelling, and altered mental status. This nurse informed NP [name omitted] who then evaluated pt. When EMS arrived, PT's O2 was 85%. A [DATE] provider progress note titled Post Acute Care Visit #2 by the Nurse Practitioner (NP) was reviewed and read in part, .evaluated for an acute change in status. [Resident] was found to have atrial fibrillation with a rapid ventricular rate [RVR] and was noted to be dyspneic [short of breath] during conversation. atrial fibrillation and a rapid ventricular response, confirmed by physical exam and bedside 3-lead EKG. This is contributing to clinical presentation of dyspnea and likely hemodynamic instability.The recommendation for urgent transport to the emergency department was made due to the inability to obtain rapid labs to guide resuscitation and determine the degree of strain on her heart Resident #95 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The hospital Discharge summary dated [DATE] was reviewed and revealed that Resident #95 was admitted with a diagnosis of atrial fibrillation with RVR [rapid ventricular rate] and a heart rate in the 150's. On [DATE] at 11:03 AM a nursing progress note indicated that Resident #95 had a heart rate of 131 beats/minute and a blood pressure of 98/53. Under the heading Cardiovascular the note read, Skin warm and pink with brisk capillary refill (<3 seconds). No edema present. There was no documentation indicating a medical provider was notified of the elevated heart rate or that a nurse further assessed the elevated heart rate. The next clinical record entry dated [DATE] at 6:12 PM, approximately seven hours later, was from an on-call provider who documented in part, Complaint: Shortness of breath, chest pain, not feeling well Provide Current Vital Signs: 114/64 p [pulse] 80 o2 [oxygen saturation] 77 Message: Given one nitro for chest pain. Was slightly better but was sent out to hospital. [DATE], 6:12 PM. There was no indication in the note that the facility nurse had informed the on-call provider of the resident's extensive cardiac history, their hospitalization just days prior when the resident was sent out with a heart rate of 135 or that the resident had a heart rate at 11:03 AM of 131. There was no documentation in Resident #95's clinical record to indicate if the resident remained stable during the seven hours or if they were checked on during the seven-hour period. The next entry in the clinical record was dated [DATE] at 1:01 AM and it read, RSD [resident] expired at [hospital]. TOD [time of death] 2052 [8:52 PM]. Family aware. A document titled, Change in Condition (SBAR)-CHC was dated [DATE] at 5:52 PM. Under the heading Situation it read, not feeling well, SOB (shortness of breath), chest pain. Under the heading Vital Signs the pulse from the 11:03 AM nurse note of 131 was documented as well as the rest of the 11:03 AM vital signs, indicating the nurse never obtained another set of vital signs. It is unclear where the pulse of 80 documented in the on-call provider note at 6:12 PM came from. Under the heading Cardiovascular Evaluation item #2 Chest pain/tightness was checked but item #6 Resting pulse <100 or <50 was not checked. On [DATE] at 9:39 AM, NP (nurse practitioner) #1 was interviewed via telephone. They said they were no longer seeing patients at the facility but remembered Resident #95 well. They stated, It was a Sunday if I'm not mistaken and the nurse had contacted me a few times that day about other residents but never said a word about [Resident #95]. When I got to the building on Monday and was informed about what happened I was shocked. I spoke to [Licensed Practical Nurse/LPN #2] about it. I wanted to know why with a heart rate of 130 and when [resident] had been sent out already just days prior and was in ICU [intensive care unit] and we were aware this was a serious problem for [resident], that required monitoring due to poor compensation, and I had made it clear that [resident] had to be watched closely, I just could not understand why I wasn't called. She [LPN #2] had contacted me within an hour of documenting that heart rate about someone else and never said a word. I would have had [resident] sent out right then if she had just told me. I asked her Monday morning what did you do about this heart rate and she told me it was [resident's] baseline and she didn't do anything. I told her you do know that she died, right? We had seven hours to intervene and do something, but she [LPN #2] just shrugged and walked away. I tried to talk to [the Director of Nursing/DON] about her [LPN #2] and all she said was I know, we've had the same problem with her before and we've talked to her, but some people just don't learn. I tried to bring the concern to the Administrator as well, many concerns but I never received a response other than we're working on it. This death could have been prevented. [Resident] died just an hour or two after getting to the hospital because [resident] was not sent out timely. On [DATE] at 10:57 AM LPN #2 was interviewed. When asked what they did for Resident #95 when they got the heart rate of 131 they stated, The C.N.A. [certified nursing assistant] got the vital signs and gave them to me and when I saw that pulse I immediately went back and checked [resident] out. I got 87 when I checked it and [resident] was fine, [resident] didn't have any complaints or anything, there were no other symptoms, so I didn't do anything. It wasn't until that evening when the C.N.A. was transferring [resident] to bed that [resident] complained about being short of breath and heart racing, so I assessed [resident] and the heart rate was quite quick and the o2 sat was low, so I sent [resident] out. When asked why she didn't document that she went and rechecked the heart rate that morning, she stated, It was a crazy day, and we had a lot going on. When asked where the on-call provider got the heart rate of 80 LPN #2 could not recall a pulse of 80 and was not sure where it came from. The employee file for LPN #2 was reviewed. LPN #2 was hired less than one year ago. The file included an orientation checklist that indicated required education was provided during the orientation period. There was a copy of the Notification of Changes in LPN #2's file but there were no dates or signatures to indicate when it had been reviewed or by who. There was no evidence of any hands-on skills validation noted in the file. No further information was provided to the survey team prior to the exit conference. 2. The facility staff failed to ensure Registered Nurse (RN) #7 demonstrated skill competencies and completed required retraining after scoring below expected facility standards on the skills competency assessment. On [DATE] at 10:15 AM, the surveyor requested from Human Resources Staff #1 required training for RN #7. Human Resource Staff #1 provided the surveyor with a copy of a document titled, Section C Skills Competency Assessment For Nurse Staff this document read in part, .If your overall performance or competency is rated below the minimum competency level, you must participate in additional training and that performance or competency must be reassessed. This document was dated 02/2026, identified RN #7 as a new hire and included scores below the required expected standards in the following areas Sit to Stand Lift, Glucometer, Nebulizer Administration, CPAP and BIPAP, Tracheostomy Suctioning, Enteral Medication Pass, Life Vest, Hemovac and JP Drain, Left Ventricular Device, and Medical Systems and Processes. The bottom portion of this competency assessment contained the following evaluation check boxes: Employee is competent to perform the above tasks independently and without supervision. Employee's level of competence is below 2. Note the date to reassess competency. Both sections were left unmarked, and no completion date or evaluator sign-off was documented. On [DATE] at 1:46 PM, Human Resources Staff #1 stated they were unable to locate further evidence of the required training for RN #7. This staff further identified the educator as the former Assistant Director of Nursing, who had resigned during the survey. The Administrator was able to provide the surveyor with a copy of an Education In-service Attendance Record dated [DATE] indicating RN #7 attended training on admission order entry and discharge summary review process. No other training records were provided. The above issue was reviewed with the Regional Director of Clinical Services and the Administrator on [DATE] at 5:20 PM. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to protect the resident's right to be free from sexual abuse and physical abuse by another resident of the facility for 1 of 39 current sampled residents, Resident #69. The facility staff failed to (1) protect Resident #69 from sexual abuse by another resident (Resident #98) on 4/15/26 and (2) protect Resident #69 from physical abuse resulting from an altercation with another resident (Resident #64) on 7/04/26. The facility's investigation determined that the altercation on 7/04/26 resulted in a closed fracture of the right fourth metatarsal neck thus constituting harm to Resident #69. The fourth metatarsal bone is a long bone located in the midfoot region connecting the midfoot to the fourth toe. The findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 10/14/25, specified, The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. An admission Record indicated the facility admitted Resident #69 on 5/27/16. According to the admission Record, the resident had a medical history that included Alzheimer's Disease, post-traumatic stress disorder, generalized anxiety disorder, and major depressive disorder. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/08/26, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #69's comprehensive person-centered care plan included a focus area revised on 4/17/26, that indicated the resident had a potential for re-traumatization due to history of trauma. Resident #69 has a history of stating that she has been raped and abused and at times has sexual behaviors. Interventions directed staff to avoid situations that remind resident of the trauma. (1) A final facility synopsis of events dated 4/23/26 indicated that on 4/15/26, a staff member observed Resident #98 lying on Resident #69's bed with his penis exposed and Resident #69 was sitting in her wheelchair holding his penis. Resident #98 had a documented BIMS score of 13, which indicated he was cognitively intact. Upon interview following the observation, Resident #98 denied having his pants down and his penis exposed. Resident #69 had no recollection of the incident. The report disclosed Based upon the facility investigation, we are able to validate that this incident occurred.Resident #69 was seen by the medical provider on 4/16/26, the progress note disclosed The patient presents for evaluation of increased sexual behaviors, which is concerning in the context of her baseline impaired cognition. The patient is alert but confused and has no recollection of the event.During an interview on 7/27/26 at 11:56 AM, the facility social worker (SW) stated Resident #98 was placed on 15-minute checks following the incident and stated she thought he remained on 15-minute checks until his discharge from the facility. When asked if Resident #69 had the mental capacity to consent to sexual activity, the SW stated no. The SW stated Resident #69 had no changes in behavior following the incident. Resident #98 was discharged from the facility on 5/01/26.Resident #69 was interviewed privately in her room on 7/20/26 at 3:56 PM and asked if there had been an unclothed male resident in her bed and she placed her hand on her chest and emphatically stated no, no, no! According to Resident #69's clinical record, she had a legal guardian in place. A call was placed to Resident #69's legal guardian on 7/22/26 at 11:18 AM and a message was left requesting a return call. However, the call was not returned prior to the end of the survey. (2) Resident #69's clinical record included a nursing progress note dated 7/04/26 at 6:41 PM which read staff was alerted to two residents fighting. Staff stated that another resident was blocking the way out and pt [patient] wanted to leave the dining room, and the two were seen fighting. [Resident #69] was seen with several small scratches on the right lower arm together, bruise above the elbow joint on right arm about the size of a half dollar, bruise on the back of the right arm about the size of a half dollar, and bruise on the back of the left arm the size of a quarter. Pt had no pain and due to dysphagia could not give description.Resident #69 was seen by the medical provider on 7/07/26, the progress note disclosed Patient presents with right foot swelling and toe discoloration. Previously, the etiology was unclear, but new information reveals a recent traumatic event where a wheelchair rolled over the patient's foot. This mechanism of injury is consistent with the findings. The absence of pain is atypical but does not rule out a fracture or significant soft tissue injury, especially in the context of the patient's severe dementia which may affect her ability to perceive or report pain. An X-ray of the right foot and ankle, including the toes, has been ordered to evaluate for an occult fracture given the new history of a crush injury. This will also help further assess the etiology of the swelling and discoloration. Further treatment will be determined after the X-ray results are reviewed.Resident #69 was seen by the medical provider on 7/09/26, the progress note indicated the X-rays revealed a fracture of the right fourth metatarsal neck. Resident #69 was being referred to podiatry for further evaluation and management of the fracture and ibuprofen 600 mg three times a day was ordered prophylactically for pain and inflammation for seven days. The facility's final synopsis of events dated 7/10/26 read in part .Dietary staff reported [Resident #69] and [Resident #64] were in the dining room speaking in loud voices and notified Clinical Staff that residents were having a verbal altercation. Clinical Staff observed both residents in their wheelchairs intertwined facing each other with [Resident #64] holding onto the wheelchair of [Resident #69] and not letting go. Residents were immediately separated. Both residents were assessed at the time of the incident. [Resident #69] was observed to have small scratches on her right forearm, discoloration on her bilateral arms.On 7/07/26 [Resident #69] was noted to have swelling to her right foot and ankle.X-ray results showed a fracture involving the fourth metatarsal.Based upon the facility investigation, we are able to validate that this incident occurred.No further information was provided prior to the exit conference on 7/28/26.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide pharmacy services to meet the needs of the residents for nine of 51 residents, Residents #23, #44, #92, #8, #12, #2, #6, #33, and #90. The findings include: 1. For Resident #23, the narcotic count sheet did not accurately reflect the amount of liquid Phenobarbital on hand. The narcotic count sheet documented there were 233 ml's of Phenobarbital. During a narcotic count with Licensed Practical Nurse (LPN) #1 the liquid Phenobarbital measured more than 300 ml's. Resident #23's diagnoses included epilepsy. Section C (cognitive patterns) of Resident #23's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/05/2026 included a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The comprehensive care plan identified the focus area of seizures and included the intervention to give seizure medication as ordered. On 07/16/2026 at 2:30 PM, the surveyor conducted a controlled substance count with LPN #1. This cart contained a bottle of liquid Phenobarbital that was identified as belonging to Resident #23. The controlled narcotic count sheet documented 233 ml's remaining; however, the observation of the bottle revealed more than 300 ml's remaining. During this observation, LPN #1 stated the facility's practice required the outgoing and incoming nurses to perform and verify narcotic counts during shift change. LPN #1 stated she had assumed responsibility for the medication cart to assist with the medication pass and had not counted the narcotics. LPN #1 identified LPN #4 as having completed the narcotic count. LPN #4 stated she was aware the count was over but did not realize the discrepancy exceeded the documented amount by that much. Per the request of the surveyor the Director of Nursing (DON) verified the amount of Phenobarbital remaining in the bottle and confirmed the narcotic count sheet did not match the actual quantity on hand. Review of the facility policy titled, Controlled Substances effective date 11/30/2014 read in part, .the number of controlled substances on hand must be counted and verified at the end of each shift. The Narcotic Sign in Sheet must be completed at the end of each shift every day. The outgoing Nurse or her designee will count all controlled substances being stored at the residence while the oncoming nurse or his or her designee watches. Both staff member sign that the count and verification has been completed. In the event the count does not match the controlled substances on hand, the Executive Director will be notified immediately. During an end of the day meeting on 07/27/2026 at 5:20 PM with the Administrator and Regional Director of Clinical Services the issue with the Phenobarbital count discrepancy was reviewed. The RDCS stated they had obtained a Phenobarbital level on this resident with no issues identified. Resident #23's clinical record included Phenobarbital levels obtained on 07/17/2026 (21.2) and 07/18/2026 (19.7). The reference range was documented as 15-40. No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #44, the facility staff failed to ensure proper accountability of the Schedule II narcotic, Oxycodone. The facility staff were unable to account for 30 tablets of Oxycodone. Resident #44's diagnoses included osteoarthritis of knee and polyneuropathy. Section C (cognitive patterns) of Resident #44's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/28/2026 included a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Section J (Health Conditions) was coded to indicate the resident received a scheduled pain management regimen. The resident's comprehensive care plan identified pain as a focus area with interventions including administration of analgesics. The clinical record contained a provider order dated 12/27/2025 for Oxycodone 5 mg two times daily for pain, hold if asleep or sedated. On 07/17/2026, the provider documented Resident #44 was out of Oxycodone and the pharmacy requires a new script to fill. Resident not currently complaining of pain. Registered Nurse (RN) #1 documented the medication was being held per MD. On 07/17/2026, the facility Administrator submitted a facility synopsis of events indicating the facility staff were investigating the potential misappropriation of Resident #44's Oxycodone. A review of the Medication Administration Records (MARs) for 07/2026 revealed that on 07/18/2026 at 9:00 AM and 9:00 PM the facility nursing staff documented a 5 for the Oxycodone, 5=hold see nurse notes. Corresponding nursing notes documented the following: 07/18/2026 at 9:42 AM, ordered, waiting on delivery. 07/18/2026 at 10:22 PM: waiting on pharmacy to deliver. Review of narcotic count sheets revealed the pharmacy delivered to the facility 60 tablets of Oxycodone 5 mg for Resident #44 on 06/24/2026. Facility staff were only able to produce narcotic count sheets accounting for 30 of these tablets. The administrative staff acknowledged they were unable to locate a narcotic count sheet or any other documentation accounting for the remaining 30 tablets. In addition, only one licensed nurse the Assistant Director of Nursing (ADON) had signed for receipt of the medication, the facility policy required two licensed nurses to verify and sign for controlled substances upon delivery. The ADON had resigned during the survey and was not interviewed. A written statement from Licensed Practical Nurse (LPN) #3 documented that the pharmacy confirmed 60 tablets had been delivered on 06/24/2026, and the discrepancy was reported to the Director of Nursing (DON). Review of the facility policy titled, Acceptance of Medication and Controlled Substances effective date 01/15/2015, read in part, To ensure medications and controlled substances are properly accounted for.2 nurses will sign the medications into the facility on the pharmacy delivery slip. During an interview on 07/28/2026 at 2:10 PM, the Regional Director of Clinical Services (RDCS) stated the facility had purchased hardback narcotic record books, would discontinue use of the free-floating narcotic count sheets, and would write off the previous two months of Oxycodone charges for Resident #44. On 07/30/2026 at 10:30 AM, pharmacy personnel #9 confirmed they had sent to the facility 60 tablets of 5 mg Oxycodone on 06/24/2026 and 30 tablets on 07/23/2026. Indicating 30 tablets of Oxycodone were unaccounted for. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #92, the controlled count sheets for the narcotic medications Suboxone and Oxycodone did not match the documentation of what had been administered. This was a closed record review. Resident #92's diagnoses included end stage renal disease, diabetes, epilepsy, and osteoarthritis. Resident #92's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/01/2025 included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section J (health conditions) was coded to indicate the resident experienced pain occasionally and were on a pain medication regimen. The comprehensive care plan identified the focus area of pain. Resident #92's clinical record included an order dated 07/15/2025 for Suboxone give 1 sublingually three times a day. Review of the Suboxone narcotic count sheets for 07/2025 revealed that on 07/17/2025 nursing staff documented removal of one tablet of Suboxone at 6:00 AM, 9:00 AM, 2:00 PM, and 9:00 PM. Review of the Medication Administration Record (MAR) documented administration at 9:00 AM, 1:00 PM, and 9:00 PM only. There was no documentation to support administration of the tablet removed at 6:00 AM. Additionally, on 07/31/2025 the nursing staff documented they had removed one tablet of Suboxone at 6:00 AM from the narcotic supply; however, the surveyor was unable to locate corresponding documentation on the MAR indicating the medication had been administered. The controlled substance count records/narcotic count sheets did not reconcile with the medication administration documentation. Further review of the clinical record revealed a provider order dated 07/15/2025 for Oxycodone 5 mg, one tablet by mouth every 6 hours as needed for pain. Review of the narcotic count sheet documented removal of one tablet at 1:30 PM and 8:00 PM on 07/16/2025. However, the surveyor was unable to locate documentation on the MAR or elsewhere in the clinical record indicating the medication had been administered. The narcotic count sheet did not reconcile with the medication administration documentation. The facility policy titled, Controlled Substances effective date 11/30/2014, read in part, .The staff.must also maintain strict records of the controlled substances stored in the residence as well as the dose given to the resident. It is essential to make certain the resident requiring the controlled substance receives it as ordered by the physician.When a controlled substance is administered to a resident, it must be recorded on the resident's Medication Sheet as well as a separate Controlled Substance/Schedule II Narcotic Sheet that is created for each prescription. On 07/28/2026 at 5:20 PM, the Regional Director of Clinical Services and the Administrator were informed of the discrepancies identified between the narcotic count sheets and the MARs. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #8 the facility staff failed to ensure the medications scopolamine and glycopyrrolate were available for administration. Resident #8's clinical record listed diagnoses which included but not limited to dysphasia following unspecified cerebrovascular disease, dysphagia, oropharyngeal phase, and disturbances of salivary secretion. Resident #8's most recent quarterly minimum data set with an assessment reference date of 06/16/26 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Resident #8's comprehensive care plan was reviewed and contained a plan for . has potential for altered respiratory status/difficulty breathing r/t (related to) NPS (nothing by mouth), gastrostomy status/enteral feed, potential for excessive oral secretions. Resident #8's clinical record contained a physician's order summary which read in part, Scopolamine Transdermal Patch 72 Hour 1 MG/3 Days. Apply 1 mg transdermally one time a day every 3 day(s) for secretions and Glycopyrrolate Oral Tablet 1 MG. Give 1 mg via G-Tube every morning and at bedtime for excessive secretions. Resident #8's electronic medication administration record for the months of April 2026 and June 2026 were reviewed and contained entries as above. The entry for scopolamine was coded 9 on 04/03/26 and 06/08/26, and coded 5 on 06/17/26. Chart code 9 is equivalent to Other/See Nurse Notes. Chart code 5 is equivalent to Hold/See Nurse Notes. The entry for glycopyrrolate was coded 9 on 04/04/26. Resident #8's progress notes were reviewed and contained notes which read in part, 04/03/2026 08:33 Note Text: Scopolamine Transdermal Patch 72 Hour 1 MG/3 Days. Apply 1 mg transdermally one time a day every 3 day(s) for secretions. 1x hold per MD . (name omitted), 04/04/2026 06:16 Note Text: Glycopyrrolate Oral Tablet 1 MG. Give 1 mg via G-tube every morning and at bedtime for excessive secretions. not available, 06/08/2026 08:12 Note Text: Scopolamine Transdermal Patch 72 Hour 1 MG/3 Days. Apply 1 mg transdermally one time a day every 3 day(s) for secretions. n/a (not applicable) rx (prescription)/np (nurse practitioner) made aware, and 06/17/2026 12:29 Note Text: Scopolamine Transdermal Patch 72 Hour 1 MG/3 Days. Apply 1 mg transdermally one time a day every 3 day(s) for secretions. Surveyor spoke with physician on 07/22/26 at 12:10 pm regarding Resident #8's medications. Physician stated, It doesn't look like a provider order was put in to hold, it was just that one time. When asked if they were notified, physician stated, I don't recall being notified, maybe just in passing in the hall, told me med wasn't available and was it ok to hold. I didn't actually ever see this resident for the first time until 04/15/26. The concern of Resident #8's medications not being available for administration was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 5. For Resident #12 the facility staff failed ensure a schedule II narcotic was correctly accounted for. The facility was unable to account for 84 oxycodone 5 mg tablets. Resident #12's clinical record listed diagnoses which included but not limited to rheumatoid arthritis, unspecified, contracture of muscle, right shoulder, and hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side. Resident #12's most recent quarterly minimum data set with an assessment reference date of 06/29/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section J, health management, coded the resident as receiving scheduled pain medication. Resident #12's comprehensive care plan was reviewed and contained a plan for . is at risk for alterations in pain r/t (related to) RA (rheumatoid arthritis), CVA (cerebrovascular accident), PEG (percutaneous endoscopic gastrostomy) placement, and generalized pain, neuropathy. Resident #12's clinical record contained a physician's order summary which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 8 hours for pain. Resident #12's narcotic control sheets were for the months of June and July 2026 were reviewed on 07/27/26. The control sheets for the dates of 06/01/26-06/12/26 revealed a dispensed amount of 56 tablets and a received amount of 30 tablets. The control sheet for the dates of 06/21/26-06/26/26 revealed a dispensed amount of 12 tablets and a received amount of 12 tablets. The control sheet for the dates of 07/04/26-07/14/26 revealed a dispensed amount of 88 tablets and a received amount of 30 tablets. The control sheet for the dates of 07/18/26 revealed a dispensed amount of 8 tablets and a received amount of 8 tablets. The control sheet dated 07/21/26 revealed a dispensed amount of 30 tablets and a received amount of 30 tablets. There were no control sheets for the dates of 06/13/26-06/21/26, 06/27/26-07/04/26, or 07/15/25-07/18/26. Surveyor spoke with pharmacy technician #5 on 07/27/26 at 10:08 am regarding Resident #12's oxycodone. Pharmacy technician #5 stated the pharmacy sent 88 tablets from a prescription for 90 tablets, leaving 2 tablets out so facility could pull from emergency supply. This was divided into two cards of 30 tablets each, and one card of 28 tablets. Pharmacy technician stated the pharmacy sent 8 tablets from a 9-tablet order, leaving one out so facility could pull from emergency supply. Of these 96 tablets sent from the pharmacy, a total of 58 were unaccounted for. Surveyor spoke with pharmacy technician #6 on 07/27/26 at 4:22 pm regarding Resident #12's oxycodone. Pharmacy technician #6 stated a delivery of 56 tablets, divided by one card of 30 tablets and one card of 26 tablets, was delivered to the facility on [DATE] and a delivery on 12 tablets was delivered to the facility on [DATE]. Of these 68 tablets sent from the pharmacy, a total of 26 tablets were unaccounted for. This is a cumulative total of 84 tablets unaccounted for. Surveyor spoke with the regional director of clinical services (RDCS) and administrator on 07/28/26 at 9:12 am regarding Resident #12's missing oxycodone. RDCS stated they are aware of the missing medications and have started an investigation, which is ongoing. Administrator stated they have reported this to the police and Office of Licensure and Certification on 07/17/26. RDCS stated they have been unable to locate the medications or the control sheets. RDSC stated, We can't substantiate or unsubstantiate drug diversion since we have no medication cards. We've been at a loss, we have no cards, no control sheet, or no destruction file. Surveyor requested and was provided with a facility policy entitled Acceptance of Medication and Controlled Substances which read in part, Policy: To ensure medications and controlled substances are properly accounted for in accordance with Federal Regulations. Medications will be delivered to the facility by the pharmacy and 2 nurses will sign the medications into the facility on the pharmacy delivery slip. The concern of not correctly accounting for Resident #12's oxycodone was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 6. For Resident #2, the facility staff failed to ensure the medication Suvorexant was available for administration on two separate occasions. A facility policy titled, Medication Shortages/Unavailable Medications, revised 8/01/24, specified If a medication is unavailable during normal Pharmacy hours: A Facility nurse should call Pharmacy to determine the status of the order, which may be found on [name omitted] under the Pharmacy Connection menu. If the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain medication from the Emergency Medication Supply to administer dose. If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT delivery, if medically necessary. An admission Record indicated the facility admitted Resident #2 on 11/19/24. According to the admission Record, the resident had a medical history that included vascular dementia and insomnia. A significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/26, revealed Resident #2 had a Brief Interview for Mental Status score of 1 which indicated severe cognitive impairment. Resident #2's comprehensive person-centered care plan included a focus area indicating the resident was receiving hypnotic medication for insomnia with interventions that included but were not limited to administer medications as ordered by the physician. Resident #2's medical provider orders included an order dated 4/29/26 for Suvorexant 10 mg by mouth at bedtime for insomnia. A review of Resident #2's Medication Administration Records for April 2026 through July 2026 revealed Suvorexant was not administered on 5/11/26 or 6/1/26. A 5/11/26 10:28 PM nursing progress note documented the Suvorexant was on order from the pharmacy and not available in the Omnicell. A 6/01/26 10:42 PM nursing progress note indicated the Suvorexant was again on order. On 7/27/26 at 5:19 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding the unavailability of Suvorexant for Resident #2 No further information was provided regarding this concern prior to the exit conference on 7/28/26. 7. For Resident #6, the facility staff failed to ensure the medication sildenafil citrate was available for administration on two separate occasions. A facility policy titled, Medication Shortages/Unavailable Medications, revised 8/01/24, specified If a medication is unavailable during normal Pharmacy hours: A Facility nurse should call Pharmacy to determine the status of the order, which may be found on [name omitted] under the Pharmacy Connection menu. If the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain medication from the Emergency Medication Supply to administer dose. If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT delivery, if medically necessary. An admission Record indicated the facility admitted Resident #6 on 6/08/26. According to the admission Record, the resident had a medical history that included end stage renal disease, pulmonary hypertension, portal hypertension, and congestive heart failure. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/26, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) summary score of 12, which indicated the resident had moderate cognitive impairment. Resident #6's clinical record included an order dated 6/08/26 for sildenafil citrate 20 mg by mouth three times a day for pulmonary hypertension. A review of the resident's June and July 2026 Medication Administration Records (MARs) revealed sildenafil citrate was not administered on 6/10/26 9:00 AM and 7/09/26 9:00 AM. Corresponding nursing progress notes dated 6/10/26 10:22 AM and 7/09/26 at 11:04 AM indicated sildenafil citrate was not administered due to one-time holds-pharmacy to send. A review of the in-house emergency medication supply inventory revealed sildenafil citrate was not maintained in the in-house inventory. On 7/27/26 at 5:19 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding the unavailability of sildenafil citrate on 6/10/26 and 7/09/26 resulting in two missed doses for Resident #6. No further information was provided regarding this concern prior to the exit conference on 7/28/26. 8. For Resident #33, the facility staff failed to administer Phenylephrine as ordered by the medical provider. An admission Record indicated the facility admitted Resident #33 on 4/21/23. According to the admission Record, the resident had a medical history that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/03/26, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #33's comprehensive person-centered care plan included a focus area which indicated the resident had altered respiratory status, difficulty breathing related to respiratory failure, asthma, and allergies. Intervention instructed staff to administer medication as ordered. Resident #33's medical provider orders included an order dated 5/11/26 for Phenylephrine 10 mg by mouth every six hours for five days for congestion. A review of Resident #33's May 2026 Medication Administration Record (MAR) revealed Phenylephrine was not administered on 5/11/26 12:00 PM, 5/11/26 6:00 PM, 5/12/26 midnight, 5/12/26 6:00 AM, 5/13/26 midnight, 5/13/26 6:00 AM, 5/16/26 midnight, and 5/16/26 6:00 AM. Nursing progress notes on 5/11/26 11:25 AM, 5/12/26 12:54 AM, 5/12/26 6:28 AM, 5/13/26 6:12 AM, 5/13/26 12:31 AM, 5/16/26 1:34 AM, and 5/16/26 6:19 AM indicated the medication was not in the cart/available for administration. On 7/27/26 at 5:35 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding the unavailability of Phenylephrine. No further information was provided prior to the exit conference on 7/28/26. 9. For Resident #90 the facility staff failed to ensure a schedule II narcotic was correctly accounted for. The facility was unable to account for 60 oxycodone 5 mg tablets. Resident #90's clinical record listed diagnoses which included but not limited to chronic pain, muscle weakness. chronic pulmonary edema, limitation of activities due to disability, and cellulitis of lower right limb. Resident #90's most recent quarterly minimum data set (MDS) with an assessment reference date of 03/19/25 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident was cognitively intact. Section J, health management, coded the resident as receiving scheduled pain medication. Resident #90's comprehensive care plan was reviewed and contained a plan for . has pain r/t chronic pain, history of rib fracture and liver disease. Resident #90's clinical record contained a physician's order summary which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 6 hours for pain/discomfort give one tablet q6h [every 6 hours] with a 325 tylenol. Resident #90's electronic medication administration record (eMAR) for the month of April and May 2025 were reviewed and reconciled with the narcotic control sheet. The eMAR contained an entry which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 6 hours for pain/discomfort give one tablet q6h with a 325 Tylenol. The oxycodone was documented on the eMAR as administered per the physician's order on 4/20/25 and 4/22/25 with three doses missing on the narcotic sheet; 4/21/25 with four doses missing on the narcotic control sheet; 4/24/25, 4/25/25, 4/26/25, 4/27/25, and 4/28/25 with one dose missing. The narcotics control sheet showed that one tablet was removed on each of these days during the entries signed for and no indication of what happened to the missing medication was documented. On 4/27 and 4/28/25, the eMAR showed two doses to be given daily while the narcotic control sheet reflected three (out of four) doses given. Surveyor spoke with the director of nursing (DON) and (ADON) on 7/16/26 at 8:45 am, requested April 2025 controlled substance narcotic sheets. Surveyor spoke with DON on 07/16/2026 at 2:30 pm, the narcotic control sheet reviewed with the DON, and it was determined medications were not documented or accounted for. Surveyor spoke with pharmacy tech supervisor #7 on 07/28/26 at 5:04 pm regarding Resident #90's billing for oxycodone. Pharmacy tech supervisor #7 was able to confirm that the 120 tablets were filled on 4/11/25. The facility had called on 4/28/25 to have 30 tablets sent on 4/30/25 and another 90 tablets sent on 5/4/25. Review of the facility policy titled, Controlled Substances effective date 11/30/2014 read in part, .the number of controlled substances on hand must be counted and verified at the end of each shift. The Narcotic Sign in Sheet must be completed at the end of each shift every day. The outgoing Nurse or her designee will count all controlled substances being stored at the residence while the oncoming nurse or his or her designee watches. Both staff member sign that the count and verification has been completed. In the event the count does not match the controlled substances on hand, the Executive Director will be notified immediately. The concern of Resident #12's missing narcotics was discussed with the administrator and regional director of clinical services on 07/28/26 at 2:15 pm. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review, the facility staff failed to follow medical provider orders for (11) eleven of (51) fifty-one sampled residents, Resident #9, Resident #10, Resident #13, Resident #43, Resident #8, Resident #48, Resident #33, Resident #69, Resident #42, Resident #55, and Resident #79. Findings included: 1. For Resident #9, the facility staff failed to obtain a pulse ox reading (a quick, painless measurement of the percentage of oxygen in the blood and pulse rate) as ordered by a medical provider. A review of an admission Record, disclosed Resident #9 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, major depressive disorder, history of venous thrombosis and embolism, urinary catheter, and symbolic dysfunction. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A medical provider order dated 07/20/2026 disclosed an order for, pulse ox every shift for monitoring for 3 days with a start date of 07/20/2026 and an end date of 07/23/2026. On 07/24/2026, a review of the July 2026 Medication Administration Record (MAR) was completed and revealed that pulse ox monitoring was not completed on 07/22/2026 on evening and night shift and a pulse ox was not obtained on 07/23/2026 on any shift. The Director of Nursing and Assistant Director of Nursing were not available for interview during this time of the survey. This concern was discussed on 07/24/2026 at 1:24 PM in a meeting with the Administrator and Regional Director of Clinical Services. No further information was provided prior to exit on 07/28/2026. 2. For Resident #10, the facility staff failed to administer the medications buspirone (an anti-anxiety medication), lidocaine external patch (a topical anesthetic agent used to numb nerve endings), and oxycontin (opioid analgesics to treat pain) and the facility staff failed to perform accuchecks (a blood glucose monitoring system) as ordered by a medical provider. A review of an admission Record, disclosed Resident #10 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, acute and chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, morbid obesity with alveolar hypoventilation, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of a medical provider Order Summary Report disclosed the following ordered medications: Buspirone 15 mg (milligrams) give 1 tablet by mouth three times a day for depression. The order had a start date of 10/17/2025. Accucheck TID (three times a day) for monitoring. The order had a start date of 02/10/2026 and an end date of 07/08/2026. Lidocaine external patch, apply to Right shoulder topically one time a day for pain. The order had a start date of 04/04/2026. Oxycodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every 6 hours for pain. The order had a start date of 06/10/2026. A review of Resident #10's June 2026 MAR (Medication Administration Record) disclosed accuchecks were not performed on 06/09/2026 at 6:00 AM, 06/14/2026 at 11:00 AM, or on 06/23/2026 at 6:00 AM. A review of nursing progress notes did not disclose a reference depicting a reason the accuchecks were not performed. Further review of the June 2026 MAR disclosed the lidocaine patch was not administered on 06/14/2026. Oxycodone was not administered on 06/14/2026 at 12:00 PM, and buspirone was not administered on 06/14/2026 at 2:00 PM. A review of nursing progress notes did not disclose a reference depicting a reason the medications were not administered. A review of the July 2026 MAR disclosed oxycodone was not administered on 07/09/2026 at 6:00 PM. A review of nursing progress notes did not disclose a reference depicting a reason the medication was not administered. The Director of Nursing and Assistant Director of Nursing were not available for interview during the time of the survey. This concern was discussed at the end of day (pre-exit) meeting on 07/27/2026 at 5:19 PM, with the Administrator and Regional Director of Clinical Services. A facility policy titled, Medication Administration with a revision date of 11/07/2025, specified under the heading, Policy, Medications are administered by licensed nurses.as ordered by the physician in accordance with professional standards of practice. No further information was provided prior to exit on 07/28/2026. 3. For Resident #13, the facility staff failed to administer the medication sodium chloride for 14 (fourteen) days as ordered by a medical provider. A review of an admission Record, disclosed Resident #13 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, post-traumatic stress disorder, Alzheimer's disease, vascular dementia, and history of transient ischemic attack (TIA). The most recent significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A medical provider order dated 07/01/2026 disclosed a medication order for, sodium chloride tablet 1 GM (gram), give 2 (two) tablets by mouth three (3) times a day for hyponatremia for 14 (fourteen) days, take with meals. A review of the July 2026 MAR disclosed the medication was administered for 13 (thirteen days). The medication was administered/not administered on the following dates and times: 07/01/2026-not administered 07/02/2026-administered at 9:00 AM, 1:00 PM, and 5:00 PM 07/03/2026-administered at 9:00 AM, 1:00 PM, and 5:00 PM-resident was transferred out to the hospital 07/04/2026-hospitalized 07/05/2026-hospitalized -returned to facility-administered at 5:00 PM 07/06/2026-refused at 9:00 AM, administered at 1:00 PM and 9:00 PM 07/07/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/08/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/09/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/10/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/11/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/12/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/13/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/14/2026-administered at 9:00 AM, 1:00 PM, and 9:00 PM 07/15/2026-administered at 9:00 AM and 1:00 PM The Director of Nursing and Assistant Director of Nursing were not available for interview during the time of the survey. This concern was discussed at the end of day (pre-exit) meeting on 07/27/2026 at 5:19 PM, with the Administrator and Regional Director of Clinical Services. A facility policy titled, Medication Administration with a revision date of 11/07/2025, specified under the heading, Policy, Medications are administered by licensed nurses.as ordered by the physician in accordance with professional standards of practice. No further information was provided prior to exit on 07/28/2026. 4. For Resident #43, the facility staff failed to administer the medications Insulin aspart and hydralazine as ordered by a medical provider. A review of an admission Record, disclosed Resident #43 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus and hypertension. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 7 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of a medical provider Order Summary Report disclosed the following ordered medications: Insulin aspart subcutaneous solution pen-injector.100 unit/ml (milliliter).Inject 8 unit subcutaneously before meals for DM (diabetes mellitus).Hold if (blood sugar) <150 (less than 150). with a start date of 05/19/2026. Hydralazine.10 mg (milligrams).give 1 (one) tablet by mouth three times a day for HTN (hypertension). A review Resident #43's June 2026 MAR (Medication Administration Record) disclosed Insulin aspart subcutaneous pen-injector was blank on 06/14/2026, indicating the medication was not administered. A review of nursing progress notes did not disclose a reference depicting a reason the medication was not administered. A review of the July 2026 MAR disclosed administration of hydralazine was blank on 07/06/2026 at 2:00 PM, and on 07/18/2026 at 2:00 PM, indicating the medication was not administered. A review of nursing progress notes did not disclose references depicting a reason the medication was not administered. A review of Resident #43's comprehensive person-centered care plan included an intervention in the focus area of diabetes to administer medications as ordered. The Director of Nursing and Assistant Director of Nursing were not available for interview during the time of the survey. This concern was discussed at the end of day (pre-exit) meeting on 07/27/2026 at 5:19 PM, with the Administrator and Regional Director of Clinical Services. A facility policy titled, Medication Administration with a revision date of 11/07/2025, specified under the heading, Policy, Medications are administered by licensed nurses.as ordered by the physician in accordance with professional standards of practice. No further information was provided prior to exit on 07/28/2026. 5. For Resident #8 the facility staff failed to follow physician's orders for abdominal binder and failed to administer the medication metoprolol per the physician's order. Resident #8's clinical record listed diagnoses which included but not limited to gastrostomy status and epilepsy, unspecified, not intractable, without status epilepticus. Resident #8's most recent quarterly minimum data set with an assessment reference date of 06/16/26 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Resident #8's comprehensive care plan was reviewed and contained a plan for .requires tube feeing G-tube r/t (related to) Cerebral palsy, NPO (nothing by mouth), Seizure D/O (disorder), Gerd (gastroesophageal reflux disease) . Interventions for this care plan included abdominal binder around abdomen to protection Resident #8's clinical record contained a physician's order summary which read in part, Abdominal binder on at all times every shift for Peg tube stability and Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate). Give 50 mg via G-Tube every morning and at bedtime hold for HR (heart rate) < 60 or SBP (systolic blood pressure) < 110 mmHG (millimeters of mercury) related to Essential (Primary) Hypertension. Resident #8's electronic medication administration record for the month of June 2026 was reviewed and contained an entry as above. This entry was coded 11 06/01/26. Chart code 11 is equivalent to Held Per Parameters. Resident #8's blood pressure was documented as 119/82 and there was no pulse documented. Resident #8's clinical record was reviewed and contained progress notes which read in part, 5/27/2026 19:59 Note Text: Abdominal binder on at all times every shift for Peg tube stability. no binder in place, 06/01/2026 05:28 Note Text: Metoprolol Tartrate Oral Tablet 50 MG. Give 50 mg via G-Tube every morning and at bedtime for hold for HR < 60 or SBP < 110 mmHG related to Essential (Primary) Hypertension, 06/14/2026 06:33 Note text: check for skin breakdown under abdominal binder every 2 hours for skin integrity. observe for skin breakdown, redness, swelling, or discoloration and is skin w/d (warm/dry) to touch. no abdomen binder in place, and 06/17/2026 01:36 Note Text: check for skin breakdown under abdominal binder every 2 hours for skin integrity observe for skin breakdown, redness, swelling, or discoloration and is skin w/d to touch. no abdominal binder in place. The concern of not following the physician's order for administration of metoprolol and abdominal binder was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 6. For Resident #48 the facility staff failed to follow the physician's order for weights related to an as needed medication. Resident #48's clinical record listed diagnoses which included but not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure and hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Resident #48's most recent quarterly minimum data set with an assessment reference date of 07/03/26 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #48's comprehensive care plan was reviewed and contained a plan for The resident is on diuretic therapy r/t (related to) hypertension, chf (congestive heart failure). Interventions for this care plan included administer diuretic medications as order by physician. Monitor for side effects and effectiveness. Resident #48's clinical record contained a physician's order summary which read in part, Furosemide Oral Tablet 20 MG (Furosemide). Give 1 tablet by mouth every 24 hours as needed for weight gain of > 3 lbs in 48 hours OR > 5 lbs in 1 week related to CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE (I50.42). Resident #48's electronic medication administration record for the month of July 2026 was reviewed and contained an entry as above. There were no weights recorded in relation to this order. Resident #48's weight record was reviewed and there were no weights documented after 05/20/26. The concern of not following the physician's order for weights related to an as needed medication was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 7. For Resident #33, the facility staff failed to follow a medical provider order for the administration of Aldactone (Spironolactone). Aldactone (Spironolactone) is a diuretic medication used to treat high blood pressure and heart failure. An admission Record indicated the facility admitted Resident #33 on 4/21/23. According to the admission Record, the resident had a medical history that included hypertensive heart and chronic kidney disease with heart failure. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/03/26, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #33's comprehensive person-centered care plan included a focus area which indicated the resident had altered cardiovascular status related to congestive heart failure, and hypertension. Interventions instructed staff to administer medication as ordered. Resident #33's medical provider orders included an order dated 6/16/26 for Aldactone (Spironolactone) 50 mg by mouth one time a day for heart failure. A review of Resident #33's July 2026 Medication Administration Record (MAR) revealed Aldactone (Spironolactone) was not administered on 7/12/26 at 9:00 AM. A corresponding nursing progress note dated 7/12/26 at 9:59 AM indicated Aldactone was not administered and staff were waiting on delivery from the pharmacy. A review of the facility in-house medication supply inventory, Omnicell, indicated Spironolactone 25 mg tablets were available for resident use. On 7/27/26 at 5:35 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding Resident #33's Aldactone (Spironolactone). No further information was provided prior to the exit conference on 7/28/26. 8. For Resident #69, the facility staff failed to follow a medical provider order for a urology consult. An admission Record indicated the facility admitted Resident #69 on 5/27/16. According to the admission Record, the resident had a medical history that included Alzheimer's Disease with early onset. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/08/26, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #69's comprehensive person-centered care plan included a focus area revised 2/17/25 which indicated the resident was incontinent with risk for urinary tract infection (UTI). Interventions included urology consult as ordered or needed initiated on 3/13/26. Resident #69's medical provider orders included an order dated 1/30/26 for a urology consult. Resident #69 was seen by the medical provider on 1/30/26. The progress note revealed history of nephrolithiasis [kidney stones] who presents with bleeding and pain concerning for a recurrent kidney stone. Her presentation is similar to a prior stone event. A larger stone was known to be present on imaging last year. Her baseline dementia limits her ability to provide a detailed history. Currently, she is not in acute distress and denies pain, which may suggest she has already passed a stone. The progress note also indicated We will consult Urology for further evaluation and management of possible kidney stone. Resident #69's clinical record did not include any evidence that the resident was evaluated by urology following the medical provider's order on 1/30/26. On 7/24/26 at 1:24 PM during a meeting with the Administrator and Regional Director of Clinical Services, evidence of a urology consult for Resident #69 was requested. During an interview on 7/27/26 at 12:05 PM, the facility social worker stated she would follow up with medical records to see if Resident #69 had been out to a urology appointment. The social worker did not return with any additional information. No further information was provided prior to the exit conference on 7/28/26. 9. Resident #42, facility staff failed to obtain/monitor a pulse ox (oxygen saturation) as ordered by medical provider. An admission Record indicated the facility admitted Resident #42 on 06/23/2026. According to the admission Record, the resident had a medical history including diagnoses that were not limited to, type 2 diabetes mellitus without complications, dysphagia, oropharyngeal phase, and other symbolic dysfunctions and other lack of coordination. The most recent admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/2026, assigned Resident #42 a Brief Interview for Mental Status (BIMS) summary score 10 of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. For Resident #42, a medical provider order entry dated 06/19/2026 stated, Pulse ox every shift for monitoring. (AM shift (day), PM shift (night) to obtain an oxygen saturation (O2 sat) reading to monitor residents circulating oxygen level.) A review of the vitals record disclosed that oxygen saturation levels were not obtained on the following dates/shifts: 07/01/2026 – PM shift 07/04/2026 – AM or PM shift 07/05/2026 – AM or PM shift 07/06/2026 – PM shift 07/07/2026 – PM shift 07/08/2026 – PM shift 07/11/2026 – PM shift 07/12/2026 – PM shift 07/13/2026 – PM shift 07/14/2026 – PM shift Resident #42 had a medical provider order dated 6/19/2026 that stated, Assess resident for pain every shift: Non-pharmacological interventions: 1=relaxation, 2=light touch, 3=imagery, 4=exercise, 5=music 6=N/A, 7=other see progress note. Document corresponding code and pain level in supplemental documentation. A review of the vitals record revealed that pain levels were not documented on the following dates: 07/03/2026 07/06/2026 07/07/2026 07/11/2026 07/12/2026 07/13/2026 07/16/2026 These concerns were discussed on 07/21/2026 at 4:04 PM during the end of day meeting with the Administrator, [NAME] President of Operations, and Regional Director of Clinical Services. On 07/22/2026 at 3:03 PM Licensed Practical Nurse #1 (LPN#1) was interviewed and stated, Vitals are typically checked by the aides, and it is the responsibility of the primary nurse to follow-up and make sure they are obtained as well as any shift orders. 07/22/2026 at 3:15 PM, the Interim Director of Nursing (IDON), stated It is the responsibility of the nursing management to check the re-cap summaries each day and follow-up to make sure that the weights, vitals and other required orders are being followed and documented. As you can see, we have clearly had a problem with that. A Facility policy titled, Pain Management stated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This policy read in part, Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). No further information was provided during exit survey on 07/28/2026. 10. For Resident #55, facility staff failed to monitor efficacy of pain management interventions. An admission Record indicated the facility admitted Resident #55 on 07/02/2026. According to the admission Record, the resident had a medical history including but not limited to, Colles' fracture of right radius, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus without complications, and unspecified dementia. The most recent admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2026, assigned Resident #55 a Brief Interview for Mental Status (BIMS) summary score of 6 of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Resident #55's medical provider orders revealed an order dated 07/02/2026 for multi-shift pain assessments and outcome tracking. The order stated to assess the resident for pain every shift utilizing nonpharmacological intervention (NPI) codes: 1=relaxation, 2=light touch, 3=imagery, 4=exercise, 5=music, 6=N/A (not applicable), 7=other, see progress note and to document the corresponding code and pain level in the supplemental documentation every shift for monitoring. A second medical provider order dated 07/02/2026, stated to monitor the outcome of the intervention every shift using corresponding codes: I-Improved, U-unchanged, W-worsened (call MD) every shift for monitoring. Put in corresponding code from above. A review of Resident #55's July 2026 Medication Administration Record (MAR) indicated one medication intervention for pain, oxycodone oral tablet 5mg (milligrams). Give 0.5mg (one half tablet) by mouth every 6 hrs. (hours) as needed for pain. (Standard pain scale is 0 through 10, 0 being no pain and 10 expressing the worst.) A review of Resident #55's Treatment Administration Record (TAR) disclosed on 07/04/2026, a day shift nurse documented pain level of 5 with a non-pharmaceutical intervention (NPI) level as 6 N/A (not applicable). No pain medication was documented as administered. The outcome of the intervention was documented as unchanged. No progress note was discovered to indicate the intervention had been effective, or a re-evaluation of the resident's pain level was completed. On 07/10/2026, the MAR reflected the resident received oxycodone on day shift and was coded as effective for pain re-evaluation. The TAR indicated a night shift nurse documented pain level as 4 with NPI level as 1 for relaxation and the outcome of the intervention was documented as unchanged. Oxycodone was not administered and no progress note was discovered to indicate the intervention had been effective, or a reevaluation of the resident's pain level was completed. On 07/11/2026 and 07/12/2026, the TAR documentation was identical for both the day shift and the night shift across both days. Nurses consistently documented a pain level of 4 with a NPI code of 1 for relaxation and the outcome of the interventions as unchanged. Oxycodone was not administered and no progress notes were discovered to indicate the intervention had been effective, or a re-evaluation of the resident's pain level was completed for the consecutive shifts. On 07/13/2026 a day shift nurse documented the resident's pain as a level 6. The NPI was coded as 1 and an outcome of unchanged. Oxycodone was not administered and no progress notes were discovered to indicate the interventions had been effective, or a re-evaluation of the resident's pain level was completed for either shift. 07/14/2026, the MAR indicated the resident received oxycodone on day shift and E was documented as effective for pain re-evaluation. During the night shift, the resident's pain was documented as level 7. A nurse documented a NPI code of 1 and an outcome of unchanged. Oxycodone was not administered and no progress note was discovered to indicate the intervention had been effective, or a re-evaluation of the resident's pain level was completed for the shift. On 07/15/2026 at 9:15 AM, an interview was conducted with Licensed Practical Nurse #1, (LPN#1) the unit manager. LPN #1 recalled that she knew the non-pharmaceutical interventions had been working for Resident #55 and that the resident reported relief. LPN #1 stated that she probably should have made a note about when the methods were or were not effective. She further disclosed that Resident #55 did not have pain medication available at the time of admission and had to wait for the pharmacy to deliver it, noting that standing orders like acetaminophen are entered by a nurse if a resident were to need it. LPN #1 was unable to provide any further information related to the unavailable documentation noting the efficacy of interventions. 07/15/2026 at 3:15 PM, interview was conducted with Resident #55 and the resident stated that staff bring pain medication if asked, that it is a pill, and that they are taking good care of them. On 07/15/2026 at 3:45 PM, this concern was discussed with the Director of Nursing and Assistant Director of Nursing. A facility policy titled Documentation in Medical Record with a revision date of 11/07/2025 specified, Each resident's medical record shall contain 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. Under the heading, Policy Explanation and Compliance Guidelines Item 4. Principles of documentation include but are not limited to. a. Documentation shall be factual, objective and resident centered.ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. No further information was provided prior to exit on 07/28/2026. 11. For Resident #79, the facility nursing staff failed to obtain provider ordered blood pressures prior to administering the hypertensive medication Hydralazine and failed to administer a provider ordered PPD (tuberculosis skin test) on 0712/2026. Section C (cognitive patterns) of Resident#79's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/15/2026 included a Brief Interview for Mental Status (BIMS) score of 8, indicating Resident #79 was moderately impaired in cognitive skills for daily decision making. The comprehensive care plan identified the area of hypertension. Interventions included obtain vital signs as ordered. Review of the clinical record revealed the following provider orders: 07/09/2026: Hydralazine 25 mg, administer one tablet by mouth twice daily for hypertension, hold for systolic BP less than 130. 07/09/2026: PPD Step1 one time a day every 12 months starting on the 12 th for annual PPD. Review of the 07/2026 Medication Administration Records (MARs) revealed that on 07/17/2026, nu[TRUNCATED]

Based on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide ADL (activities of daily living) care for 7 of 51 sampled residents, Resident #8, Resident #12, Resident #71, Resident #3, Resident #10, Resident #13, and Resident #89. The findings included: 1.For Resident #8 the facility staff failed to provide evidence of showers and/or bed baths. Resident #8's clinical record listed diagnoses which included but not limited to cerebral palsy, unspecified, unspecified intellectual disabilities, abnormal posture, and epilepsy, unspecified. Resident #8's most recent quarterly minimum data set with an assessment reference date of 06/16/26 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Section GG, functional abilities, coded the resident as dependent in the area of shower/bathe self. Resident #8's comprehensive care plan was reviewed and contained a care plan for . has an ADL self-care performance deficit r/t (related to) requires total care, Non ambulatory ID (intellectual disabilities), CP (cerebral palsy) Seizure D/o (disorder), contracture UE/LE (upper extremity/lower extremity). Interventions for this care plan included Showers/bathing per schedule. Resident #8's clinical record was reviewed and contained ADL shower sheets for the months of May, June, and July 2026. These shower records indicate that resident's shower days are Monday and Thursday. For the month of May 2026, the shower sheets were coded NA on 05/04/26, 09,09 on 05/07/26, 09,09 on 05/11/26, blank on 05/14/26, 09,09 on 05/18/26, blank on 05/21/26, 09,09 on 05/25/26 and 09,09 on 05/28/26. Code 09,09 is equivalent to Not applicable-Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. This indicated that the resident did not receive any showers for the month of May 2026. There was no documentation of resident receiving bed baths for the month of May. The ADL shower sheet for the month of June 2026 was coded 01,01 on 06/01/26, 09,09 on 06/04/26, blank on 06/08/26 and 06/11/26, 09,09 on 06/15/26, blank on 06/18/26, 01,01 on 06/22/26, 01,01 on 06/25/26 and blank on 06/29/26. Code 01,01 is equivalent to dependent. This shower sheet indicates that the resident received three showers in the month of June, with no documentation of resident receiving any bed baths for the month. The ADL shower sheet for the month of July 2026 was blank on 07/02/26, 07/06/26, 07/09/26, 07/13/26, coded 01,01 on 07/16/26 and 07/20/26, blank on 07/23/26 and 07/27/26. This sheet indicates that the resident has received 2 showers for the month of July, with no documentation of any bed baths for the month. Surveyor requested and was provided with a facility policy entitled, Activities of Daily Living which read in part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The concern of the facility not having evidence of Resident #8 receiving showers and/or bed baths was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 2. For Resident #12 the facility staff failed to provide evidence of showers and/or bed baths. Resident #12's clinical record listed diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side and contracture of muscle, right shoulder. Resident #12's most recent quarterly minimum data set with an assessment reference date of 06/29/26 assigned the resident brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section GG, functional abilities, coded the resident as needing partial/moderate assistance with shower/bath self. Resident #12's comprehensive care plan was reviewed and contained a plan for . has a self-care/mobility performance deficit r/t (related to) Sepsis, CVA (cerebrovascular accident) with residual hemiparesis to R (right) non dominant side, COPD (chronic obstructive pulmonary disease), Respiratory failure, epilepsy, PCM, Dysphagia and aphasia, RA (rheumatoid arthritis), Right shoulder contracture. Interventions for this care plan included Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated and Bathing/Showering: The resident requires up to substantial assistance via 1-2 staff as needed. Resident #12's clinical record was reviewed, and no ADL shower sheets could be located. There was no documentation related to showers and/or bed baths. Surveyor requested and was provided with a facility policy entitled, Activities of Daily Living which read in part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The concern of the facility not having evidence of Resident #12 receiving showers and/or bed baths was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 3. For Resident #71 the facility staff failed to provide evidence of showers and/or bed baths. Resident #71's clinical record listed diagnoses which included but not limited to cerebral palsy and hemiplegia, unspecified affecting right non-dominant side. Resident #71's most recent annual minimum data set with an assessment reference date of 06/10/26 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section GG, functional abilities, coded the resident as dependent for shower/bathe self. Resident #71's comprehensive care plan was reviewed and contained a plan for . has an ADL (activities of daily living) self-care performance deficit r/t (related to) weakness, impaired mobility, L (left) hemi with contractures, CP (cerebral palsy)/Brain injury at 2 years old, ID/MR (intellectual disability/mental retardation). Interventions for this care plan include Stretcher showers per shower schedule and PRN (as needed) and Assist with ADL's as needed. Surveyor observed Resident #71 on 07/22/26 at 9:35 am. Resident's fingernails on left hand observed to be long and jagged, toenails observed to be long and curled upward. Resident #71's clinical record was reviewed and contained ADL shower sheets for the months of May, June and July 2026, which indicated the resident's shower days are Monday and Thursday. The shower sheet for May was coded NA on 05/04/26, 09,09 on 05/07/26, 09,09 on 05/11/26, blank on 05/14/25, 09,09 on 05/18/26, blank on 05/21/26, 09,09 on 05/25/26, and 09,09 on 05/28/26. Code 09,09 is equivalent to Not applicable-Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. This indicates that the resident did not receive any showers for the month of May 2026, and there is no documented evidence of bed baths. Resident #71's ADL shower sheets for the month of June were coded 09,09 on 06/01/26, 01,01 on 06/04/26, blank on 06/08/26 and 06/11/26, 01,01 on 06/15/26, blank on 06/18/26, 01,01 on 06/22/26 and 06/25/25 and blank on 06/29/26. Code 01,01 is equivalent to dependent. This indicates that the resident received 4 showers in June 2026. There was no documented evidence of bed baths in the clinical record. Resident #71's ADL shower sheets for the month of July were blank on 07/02/26, 07/06/26, 07/09/26, 07/13/26, coded 01,01 on 07/16/26 and 07/20/26, and blank on 07/23/26 and 07/27/26. This indicates that the resident has received 2 showers for the month of July. There was no documented evidence of bed baths in the clinical record. Surveyor requested and was provided with a facility policy entitled, Activities of Daily Living which read in part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The concern of the facility not having evidence of Resident #71 receiving showers and/or bed baths was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 4. For Resident #3, the facility staff failed to ensure the resident was provided with a shower and/or full bath at least twice per week. A facility policy titled, Activities of Daily Living (ADLs) with a revision date of 11/07/2025 specified under the heading, Policy Care and services will be provided for the following activities of daily living, Item #1, Bathing. A review of an admission Record, disclosed Resident #3 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, morbid obesity, weakness, and abnormalities of gait/mobility. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 8 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. Section GG (Functional Abilities) Item GG0130 E. was coded as (02) indicating the resident required substantial/maximal assistance with showering/bathing self. A review of the comprehensive person-centered care plan specified Resident #3 had an ADL self-care performance deficit related to right tibia fracture and obesity. An intervention associated with the focus specified to provide a sponge bath when a full bath or shower could not be tolerated. A review of Resident #3's Shower/Bathing Task Record disclosed the resident's scheduled shower days were Monday and Thursday. A thirty-day look-back of the shower record disclosed, No Data Found, indicating that no showers/baths were provided/documented for the resident in the past 30 days. The Director of Nursing and Assistant Director of Nursing were not available for interview during the time of the survey. This concern was discussed at the end of day (pre-exit) meeting on 07/27/2026 at 5:19 PM, with the Administrator and Regional Director of Clinical Services. No further information was provided prior to exit on 07/28/2026. 5. For Resident #10, the facility staff failed to ensure the resident was provided with a shower and/or full bath at least twice a week. A facility policy titled, Activities of Daily Living (ADLs) with a revision date of 11/07/2025 specified under the heading, Policy Care and services will be provided for the following activities of daily living, Item #1, Bathing. A review of an admission Record, disclosed Resident #10 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, acute and chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, morbid obesity with alveolar hypoventilation, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Section GG (Functional Abilities) Item GG0130 E. was coded as (03) indicating the resident required partial/moderate assistance with shower/bathing self. On 07/20/2026 at 3:32 PM, Resident #10 was observed/interviewed and stated the staff work short on the weekends and she does not always get her showers/baths. A review of the comprehensive person-centered care plan specified Resident #10 had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, pain, and wounds. Interventions associated with the focus specified the resident required partial/limited assistance with bed baths and/or tub/showers (washing and drying hair and body 3x (three times) per week and PRN (as needed) and to provide the resident a sponge bath when a full bath/shower could not be tolerated. A review of Resident #10's clinical record revealed the resident's scheduled shower days were Wednesday and Saturday. A review of a Shower/Bathing Task Record thirty-day look-back disclosed the resident received a shower/bath on 07/04/2026. There were no entries from 07/05/2026 through 07/10/2026. 07/11/2026 was coded as 09, 09 indicating not applicable. From 07/12/2026 through 07/14/2026, there were no entries. 07/18/2026 was coded as NA, NA (not applicable.) From 07/19/2026 through 07/21/2026 there were no entries. On 07/22/2026 the record disclosed the resident received a shower/bath. The Director of Nursing and Assistant Director of Nursing were not available for interview during the time of the survey. This concern was discussed at the end of day (pre-exit) meeting on 07/27/2026 at 5:19 PM, with the Administrator and Regional Director of Clinical Services. No further information was provided prior to exit on 07/28/2026. 6. For Resident #13, the facility staff failed to ensure the resident was provided with a shower and/or full bath at least twice a week. A facility policy titled, Activities of Daily Living (ADLs) with a revision date of 11/07/2025 specified under the heading, Policy Care and services will be provided for the following activities of daily living, Item #1, Bathing. A review of an admission Record, disclosed Resident #13 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included, but were not limited to, post-traumatic stress disorder, Alzheimer's disease, vascular dementia, and history of transient ischemic attack (TIA). The most recent significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. Section F (Preferences for Customary Routine and Activities) Item F0400 was coded as (2) Somewhat important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Section GG (Functional Abilities) Item GG0130 E. was coded as (04) indicating the resident needed supervision or touching assistance for showers/bathing self. A review of the comprehensive person-centered care plan specified Resident #13 had an ADL self-care performance deficit related to dementia and limited mobility. An intervention associated with the focus specified the resident required assistance to provide a bath/shower. A review of Resident #13's Shower/Bathing Task Record thirty-day look-back, disclosed the resident received a shower on 07/01/2026. Further review indicated the resident was out of the facility from 07/03/2026 through 07/05/2026. A review of the shower/bathing record disclosed no showers/baths were provided/documented from 07/06/2026 through 07/13/2026. The shower/bathing records did not identify the resident's shower days schedule. The Director of Nursing and Assistant Director of Nursing were not available for interview during the time of the survey. This concern was discussed at the end of day (pre-exit) meeting on 07/27/2026 at 5:19 PM, with the Administrator and Regional Director of Clinical Services. No further information was provided prior to exit on 07/28/2026. 7. Resident #89's admission Record revealed the facility admitted the resident on 11/25/24 with diagnoses that included acute and chronic cholecystitis post-surgery, metabolic encephalopathy, need for assistance with personal care, other abnormalities of gait and mobility, and dementia. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/3/25 assigned the resident a brief interview for mental status (BIMS) score of 7 indicating severe cognitive impairment. Resident #89 was coded as being frequently incontinent of bowel and bladder. The resident was also coded as having two falls since admission. Resident #89's care plan included a focus area that read, (Resident name omitted) has bladder incontinence r/t (related to) impaired mobility. Interventions included, Clean peri-area with each incontinent episode. A Weekly Skin Integrity Review with an effective date of 12/3/24 indicated the resident had no skin issues. A weekly Skin Integrity Review with an effective date of 12/10/24 revealed resident #89 had MASD (moisture associated dermatitis) to peri area. On 12/17/24 the Weekly Skin Integrity Review revealed Peri area red/inflamed orders for treatment in place. On 12/24/24 the Weekly Skin Integrity Review revealed that the redness to the peri area continued and stated there was a treatment in place. On 12/31/24 the Weekly Skin Integrity Review stated, MASD-healing well, treatment order in place. The Documentation Survey Report, which is where the care that the Certified Nursing Assistants (C.N.A.'s) provide is documented, was reviewed for December 2024. The document included a section for ADL-Personal Hygiene to be documented on page 2 of 20. There were blanks for the night shift on 12/1/24, 12/4/24, 12/13/24, 12/14/24, 12/27/24, 12/28/24, 12/29/24 and 12/31/24. On 7/21/26 at 1:20 PM Registered Nurse (RN) #1 was interviewed. They stated they were the Unit Manager for Unit 2. They did not recall much about Resident #89. When asked what the holes in the documentation meant to them they stated, It means somebody didn't document. When asked if there was another way to confirm that the resident got the care they needed they stated, I mean we can pull the schedule but that will just show who was here. On 7/21/26 at 1:40 PM C.N.A. #4 was interviewed. They did not remember Resident #89. When asked what the holes in the documentation meant they stated, It means somebody didn't document. When asked if there was another way to confirm the resident was provided the needed care with no documentation for several shifts they stated, Not that I'm aware of. On 7/21/26 at 4:34 PM the survey team met with the Administrator, the Regional [NAME] President of Operations and the Regional Director of Clinical Services. This concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen. Findings included:On 07/20/2026 at 12:01 PM, an initial tour/observation of the facility kitchen was conducted with the Dietary Manager (DM). On 07/20/2026 at 12:04 PM during the initial tour of the facility kitchen, Dietary Cook/Aide #1 (DCA#1) was observed preparing food on the tray line with visible hair uncontained and extending past the hairnet boundaries to the shoulders all the way around her head. DCA#1 stated she was hot and sweaty and the hair must have fallen out. DCA#1 left the food prep area and adjusted the hair net, placing all the uncontained hair strands into the hairnet. An observation of a juice machine was conducted and boxes of apple, orange, and lemonade juices were observed on the shelf below the machine with hoses running from the boxes up to the juice machine unit above. The three (3) hoses were noted with a moderate amount of black substances inside the tubes and the orange juice had juice laying in the middle of the tube approximately 4-5 inches long. The outside of the tubes were noted to be sticky. When asked how often the hoses are cleaned, the DM stated he didn't know how to clean them and stated the juice boxes were empty. The DM stated they were waiting for juice to be delivered and agreed the hoses were dirty and stated they are cleaned once a week. The walk-in refrigerator was observed with the following findings: Two (2) pieces of watermelon were observed wrapped in plastic wrap with no label or date. One (1) box of zucchini was observed with no date of receipt noted on the box and the zucchini were observed to be soft, spongy, and squishy to touch with signs of decomposition and browning on the skins in several spots. One (1) box containing three (3) heads of raw cabbage was observed with a receipt date of 07/01/2026. The box contained loose, dislocated, wilted leaves and a moderate amount of brown spots were observed on the three (3) heads of cabbage. The DM agreed the cabbage should have been discarded. Two (2) bags of prepared salad mix were observed on the second shelf with a received date of 07/08/2026 marked on each bag. The salad mixes were noted to have brown lettuce throughout the packages. A large covered square container of American Cheese Slices was observed with a sticker on the lid that read, Opened 6/16/26.Discard 7/16/26. The DM stated he was told that cheese does not go bad and to just change the sticker. The DM stated he would discard all the items from the walk-in refrigerator. These concerns were discussed at the end of day meeting on 07/21/2026 at 4:04 PM with the Administrator, [NAME] President of Operations, and Regional Director of Clinical Services. Requested, but did not receive a facility policy on food labeling and storage. No further information was provided prior to exit on 07/28/2026.

Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to protect residents from misappropriation of medications for 4 of 51 residents, Resident #12, Resident #44, Resident #90, and Resident #91. The findings included:1.For Resident #12 the facility staff failed to protect the resident from misappropriation of the Schedule II narcotic pain medication, oxycodone. Resident #12's clinical record listed diagnoses which included but not limited to rheumatoid arthritis, unspecified, contracture of muscle, right shoulder, and hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side. Resident #12's most recent quarterly Minimum Data Set with an Assessment Reference Date of 06/29/26 assigned the resident a Brief Interview for Mental Status score of 3 out of 15 in section C, cognitive patterns. This indicated that the resident was severely cognitively impaired. Section J, health management, coded the resident as receiving scheduled pain medication. Resident #12's comprehensive care plan was reviewed and contained a plan for . is at risk for alterations in pain r/t (related to) RA (rheumatoid arthritis), CVA (cerebrovascular accident), PEG (percutaneous endoscopic gastrostomy) placement, and generalized pain, neuropathy. Resident #12's clinical record contained a physician's order summary which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 8 hours for pain. Resident #12's narcotic control sheets for the months of June and July 2026 were reviewed on 07/27/26. The control sheets for the dates of 06/01/26-06/12/26 revealed a dispensed amount of 56 tablets and a received amount of 30 tablets. The control sheet for the dates of 06/21/26-06/26/26 revealed a dispensed amount of 12 tablets and a received amount of 12 tablets. The control sheet for the dates of 07/04/26-07/14/26 revealed a dispensed amount of 88 tablets and a received amount of 30 tablets. The control sheet for the dates of 07/18/26 revealed a dispensed amount of 8 tablets and a received amount of 8 tablets. The control sheet dated 07/21/26 revealed a dispensed amount of 30 tablets and a received amount of 30 tablets. There were no control sheets for the dates of 06/13/26-06/21/26, 06/27/26-07/04/26, or 07/15/25-07/18/26. Surveyor spoke with pharmacy technician #5 on 07/27/26 at 10:08 am regarding Resident #12's oxycodone. Pharmacy technician #5 stated the pharmacy sent 88 tablets from a prescription for 90 tablets on 06/24/26, leaving 2 tablets out so facility could pull from emergency supply. This was divided into two cards of 30 tablets each, and one card of 28 tablets. Pharmacy technician #5 stated the pharmacy sent 8 tablets from a 9-tablet order on 07/17/26, leaving one out so facility could pull from emergency supply. Of these 96 tablets sent from the pharmacy, a total of 58 were unaccounted for. Surveyor spoke with pharmacy technician #6 on 07/27/26 at 4:22 pm regarding Resident #12's oxycodone. Pharmacy technician #6 stated a delivery of 56 tablets, divided by one card of 30 tablets and one card of 26 tablets, was delivered to the facility on [DATE] and a delivery on 12 tablets was delivered to the facility on [DATE]. Of these 68 tablets sent from the pharmacy, a total of 26 tablets were unaccounted for. This is a cumulative total of 84 tablets unaccounted for. Surveyor spoke with the regional director of clinical services (RDCS) and administrator on 07/28/26 at 9:12 am regarding Resident #12's missing oxycodone. RDCS stated they are aware of the missing medications and have started an investigation, which is ongoing. Administrator stated they have reported this to the police and Office of Licensure and Certification on 07/17/26. RDCS stated they have been unable to locate the medications or the control sheets. RDSC stated, We can't substantiate or unsubstantiate drug diversion since we have no medication cards. We've been at a loss, we have no cards, no control sheet, or no destruction file. Surveyor requested and was provided with the final facility synopsis of events dated 07/24/26 which read in part, This letter is to serve as our final report for an FRI (facility reported incident) submitted to your office on 07/17/26, it was reported that there was a potential of misappropriation of Oxycodone HCL ordered for . (omitted); . (Resident #12) . (Resident #12) is ordered 5 mg Oxycodone HCL every 8 hours for pain. On 6/24/2026 new script was sent to the pharmacy to reorder the medication. The medication was received in the facility and receipt of medication was signed in by . (assistant director of nursing). It was reported to this writer on 7/17/2026, that earlier in the week the medication needed to be re-ordered for both residents and a new script needed to be obtained .At the time the investigation is ongoing, there is inconclusive evidence of any misappropriation. Should we learn more information that would lead us to a different conclusion, we will contact your office at that time . This was signed by the administrator. Surveyor requested and was provided with a facility policy entitled Acceptance of Medication and Controlled Substances which read in part, Policy: To ensure medications and controlled substances are properly accounted for in accordance with Federal Regulations. Medications will be delivered to the facility by the pharmacy and 2 nurses will sign the medications into the facility on the pharmacy delivery slip. Surveyor was also provided with a facility policy entitled Abuse, Neglect, and Exploitation which read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Misappropriation of Resident Property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Surveyor spoke with RDCS on 07/28/26 at 2:12 pm regarding Resident #12's oxycodone. RDCS stated the facility will absolutely reimburse residents for missing narcotics. RDCS stated they talked with business office manager and will write off last two months of narcotics. The concern of Resident #12's missing narcotics was discussed with the administrator and RDCS on 07/28/26 at 2:15 pm. No further information was provided prior to exit. 2. For Resident #44, the facility staff failed to protect the resident from the misappropriation of the Schedule II narcotic medication Oxycodone. The facility staff were unable to account for 30 tablets of Oxycodone 5 mg. Resident #44's diagnoses included osteoarthritis of knee and polyneuropathy. Section C (cognitive patterns) of Resident #44's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/28/2026 included a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Section J (Health Conditions) was coded to indicate the resident received a scheduled pain management regimen. The resident's comprehensive care plan identified pain as a focus area with interventions including administration of analgesics. Resident #44's clinical record included a provider order for Oxycodone oral tablet 5 mg two times a day for pain, hold if asleep or sedated. The order date was documented as 12/27/2025. A review of the Medication Administration Records (MARs) for 07/2026 revealed that on 07/17/2026 at 9:00 AM, 07/18/2026 at 9:00 AM and 07/18/2026 at 9:00 PM the facility nursing staff documented a 5 for the Oxycodone, 5=Hold/See Nurse Notes. Corresponding progress notes documented the following: 07/17/2026, the provider documented Resident #44 was out of Oxycodone and the pharmacy requires a new script to fill. Resident not currently complaining of pain. 07/17/2026 at 2:38 PM, Registered Nurse (RN) #1 documented the medication being held per MD. 07/18/2026 at 9:42 AM, ordered, waiting on delivery. 07/18/2026 at 10:22 PM, waiting on pharmacy to deliver. On 07/17/2026, the facility Administrator submitted a facility synopsis of events indicating they were investigating the potential of misappropriation of the narcotic medication Oxycodone for this resident. On 07/28/2026 at 11:20 AM, Resident #44 stated he was taking pain medication for his knees, hips, and ribs from an old injury. Stated there may have been a couple of times when he did not receive his pain medication but reported no current concerns. On 07/28/2026, the Administrator provided the surveyor with a copy of a narcotic count sheet indicating that on 06/24/2026 the pharmacy had sent to the facility 60 tablets of Oxycodone 5 mg for Resident #44, the facility staff could only produce narcotic count sheets/documentation accounting for 30 tablets of Oxycodone. Administrative staff acknowledged they were unable to locate additional narcotic count sheets or otherwise account for the remaining 30 tablets. Only one licensed staff had signed for this medication the Assistant Director of Nursing (ADON). The Administrator also provided the surveyor with a copy of a written statement documented by Licensed Practical Nurse (LPN) #3 I called the rx [pharmacy] to order Oxy [Oxycodone] for [Resident #44]. RX informed me that 60 had been sent on 6/24. I reported this to the DON [Director of Nursing]. The facility staff provided the survey team with a copies of the following polices: Abuse, Neglect and Exploitation with a revision date of 10/14/2025, that read in part, .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Acceptance of Medication and Controlled Substances effective date 01/15/2015, this policy read in part, To ensure medications and controlled substances are properly accounted for.2 nurses will sign the medications into the facility on the pharmacy delivery slip. During an interview on 07/28/2026 at 2:10 PM, the Regional Director of Clinical Services (RDCS) stated the facility had purchased hardback narcotic record books, would discontinue use of the free-floating narcotic count sheets, and would write off the previous two months of Oxycodone charges for Resident #44. On 07/30/2026 at 10:30 AM, pharmacy personnel #9 confirmed they had sent to the facility 60 tablets of 5 mg Oxycodone on 06/24/2026 and 30 tablets on 07/23/2026. Indicating 30 tablets of Oxycodone were unaccounted for. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #90 the facility staff failed to protect the resident from misappropriation of the medication oxycodone. The resident was discharged on 8/1/25. Resident #90's clinical record listed diagnoses which included but not limited to; chronic pain, muscle weakness. chronic pulmonary edema, limitation of activities due to disability, and cellulitis of lower right limb. Resident #90's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/19/25 assigned the resident a Brief Interview for Mental Status (BIMS) score of 15 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Section J, health management, coded the resident as receiving scheduled pain medication. Resident #90's comprehensive care plan was reviewed and contained a plan for . has pain r/t [related to ] chronic pain, history of rib fracture and liver disease. Resident #90's clinical record contained a physician's order summary which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 6 hours for pain/discomfort give one tablet q6h [every 6 hours] with a 325 Tylenol. Surveyor spoke with Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 7/16/26 at 8:45 am and requested the April 2025 controlled substance narcotic sheets. It was reported they would need to go to the shed to access the older documents. May 2025 sheets had been provided but not all of April 2025 provided. Surveyor spoke with DON on 07/16/2026 at 2:30 pm and asked to discuss the controlled substance narcotic sheet dated 4/22/25 to 4/29/25. Only the front page of the sheet had been provided and the DON stated she did not have the sheet herself. She was unable to explain how a copy was provided to the surveyor when she did not have a copy. Review of the electronic medical administration record (eMAR) for Resident #90 showed that the oxycodone was documented on the eMAR, as administered per the physician's order, on 4/20/25 and 4/22/25 with three doses missing on the narcotic sheet; 4/21/25 with four doses missing on the narcotic control sheet; 4/24/25, 4/25/25, 4/26/25, 4/27/25, and 4/28/25 with one dose missing. The narcotics control sheet showed that one tablet was removed on each of these days during the entries signed for and no indication of what happened to the missing medication was documented. On 4/27 and 4/28/25, the eMAR showed two doses to be given daily while the narcotic control sheet reflected three (out of four) doses given. When the sheet was reviewed with the DON, it was confirmed medications were not documented or accounted for. Surveyor spoke with pharmacy tech supervisor #7 on 07/28/26 at 5:04pm regarding Resident #90's billing for oxycodone. Pharmacy tech supervisor #7 explained that the company had a new system but was able to confirm that the medication was billed to Resident #90's insurance for 120 tablets filled on 4/11/25. The facility had called on 4/28/25 to have 30 tablets sent on 4/30/25 and another 90 tablets sent on 5/4/25, both transactions to billed to the facility to offset the charges on 4/11/25. During the end of day meeting with the Administrator, the DON and the ADON, it was reported that there was a staff nurse identified as the alleged perpetrator who terminated employment during the process of their facility-based investigation regarding the missing controlled substances with both Resident #90 and Resident #91. The staff nurse had not signed any of the controlled medications within their narcotics binder and refused a drug screen. Other staff nurses that would have access to the same hall med cart were drug screened during that time. A report had been filed with state agency, ombudsman and law enforcement. A review of the Facility Synopsis of Events dated 4/28/25, and the addendum dated 5/9/25, revealed, on 04/27/25, the facility discovered a bottle of liquid Hydromorphone 24ml missing and control signature log missing for Resident #91 and 60 Oxycodone 5mg missing with control signature sheets for Resident #90. Multiple staff members were identified and interviewed regarding the missing medication based on their assignments with the medication cart and dates in question. A police report filed with investigation, Adult Protective Services (APS) report filed, and Ombudsman contacted. Staff in question were drug screened, with all results being negative and were suspended during the investigation. All employees received education for 5 Rights of Medications, misappropriation of resident property, and the protocol for receiving medications from pharmacy. All employees were originally cleared but new information came to light, and a further investigation revealed evidence of further missing medications. The new evidence was investigated, along with narcotics sheets and medical documentation. The nurse in question refused to submit a drug screen and was terminated. The facility could not definitively prove that the nurse was responsible for the original missing medications reported on 4/28/25 but did believe her to be responsible. The DON reported an ongoing review of measures taken to ensure the residents remain free from narcotic diversion. DON reports creating a method of checks and balances she would oversee including; making sure yellow sheets are placed in box, doing a review of each cart to make sure all medications in and continuing to provide education to the staff. The DON stated that Resident #90 never went without his medication had not been charged for the medication. Surveyor requested and was provided with a facility policy titled Acceptance of Medication and Controlled Substances which read in part, Policy: To ensure medications and controlled substances are properly accounted for in accordance with Federal Regulations. Medications will be delivered to the facility by the pharmacy, and 2 nurses will sign the medications into the facility on the pharmacy delivery slip. Surveyor was also provided with a facility policy titled Abuse, Neglect, and Exploitation which read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Misappropriation of Resident Property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The concern of Resident #90's missing narcotics was discussed with the Administrator and Regional Director of Clinical Services on 07/28/26 at 2:15 pm. No further information was provided prior to exit. 4. For Resident #91, the facility staff failed to protect the resident from misappropriation of a Schedule II narcotic medication, liquid hydromorphone that was prescribed for the resident. The facility and pharmacy determined the liquid medication had been replaced with what appeared to be water. Resident #91 was admitted to the facility on [DATE] with a diagnosis list which indicated diagnoses, included but not limited to, unspecified atrial fibrillation, acute myocardial infarction, unspecified, acute on chronic systolic (congestive) heart failure, hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic neuropathy, unspecified. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/2025 assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 7 out of 15, indicating resident had moderate cognitive impairment. A medical provider order with a start date of 04/21/2026 specified hydromorphone HCL (belongs to the class of medications called opioid (narcotic) analgesics. It is a strong mu-opioid receptor agonist used to manage moderate to severe pain) oral liquid 1mg/ml (milligram/milliliter). Give 1ml by mouth every 4 hours for pain. A review of Resident #91's April 2025 Medication Administration Record (MAR) revealed two doses of liquid hydromorphone as not being administered on 04/23/2025 at 0400 (4:00 AM) and 0800 (8:00 AM). The medication was discontinued on 04/23/2025 at 10:38 AM at the time of the resident's death. On 07/15/2026 at 10:50 AM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) regarding a medication discrepancy. The DON stated that on the evening of 04/27/2025, a staff nurse reported a narcotic discrepancy during the shift-change count. The DON and ADON subsequently conducted a comprehensive audit of all facility narcotics. During this audit, Resident #91's liquid hydromorphone was observed to have an abnormal color and consistency. The DON verified with the facility pharmacist that the medication appeared to have been replaced with water. According to the DON, the facility implemented corrective actions following the incident. All employees received mandatory education on the Five Rights of Medication Administration, misappropriation of resident property, and pharmacy delivery protocols. Additionally, the DON stated that the facility initiated a new protocol establishing checks and balances for receiving pharmacy deliveries. A facility synopsis of events file for the incident was received and reviewed. A Timeline report was provided by the facility Administrator and reviewed. The facility synopsis of events included the dates and times for the facility's investigation, including interviews with staff and residents and when notifications had been made to Law Enforcement, Adult Protective Services and the local state Ombudsman. The report summarized that the facility performed drug screening on facility nurses and one staff nurse resigned and one refused the mandatory drug screen and was terminated. A facility policy titled, Inventory of Controlled Medications with a revision date of 08/01/18, read in part, Procedure 1. The community should maintain separate individual controlled medication records on all Schedule II medications and any drug with a potential for abuse or diversion in the form of a declining inventory, using the Controlled Substances Declining Inventory Record should contain.2.8 Signature of person observing, assisting with or administering the drug. A facility policy titled, Controlled Substances, that read in part, Procedure: 2. When a controlled substance is administered to a resident, it must be recorded on the resident's Medication Sheet as well as a separate Controlled Substance/Schedule II Narcotic Sheet that is created for each prescription. 3. In addition to the Medication Sheet and the Schedule II Narcotic Sheet, the number of controlled substances on hand must be counted and verified at the end of each shift. The Narcotic Sign In Sheet must be completed at the end of each shift every day. The outgoing Nurse or her designee* will count all controlled substances being stored at the residence while the oncoming nurse or his or her designee watches. Both staff members sign that the count and verification have been completed. A facility policy titled Abuse, Neglect, and Exploitation which read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Misappropriation of Resident Property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. No further information was provided prior to exit on 07/28/2026.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 3 of 51 sampled residents, Resident #94, Resident #2, and Resident #12.The findings included: 1. For Resident #94, the facility staff failed to revise the comprehensive person-centered care plan (CP) when hospice services were initiated. A facility policy titled, Comprehensive Care Plans revised 11/14/25 specified The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. An admission Record indicated the facility admitted Resident #94 to the facility on 1/23/26. According to the admission Record, the resident had a medical history that included sepsis due to Serratia, urinary tract infection (UTI), type 2 diabetes mellitus, and chronic obstructive pulmonary disease. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/26, revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. Resident #94's medical provider orders included an order dated 4/20/26 for Hospice to evaluate and treat. A hospice nursing admission note dated 4/21/26 indicated Resident #94 was admitted with a primary diagnosis of chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia. A review of Resident #94's CP failed to reveal a care plan focus regarding end of life, hospice services and care coordination. During a meeting on 7/27/26 at 5:19 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding Resident #94's CP. No further information was provided prior to the exit conference on 7/28/26. 2. For Resident #2, the facility staff failed to review and revise the comprehensive person-centered care plan when restorative services for ambulation were discontinued. A facility policy titled, Comprehensive Care Plans revised 11/14/25 specified The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. An admission Record indicated the facility admitted Resident #2 on 11/19/24. According to the admission Record, the resident had a medical history that included vascular dementia and type 2 diabetes mellitus with diabetic polyneuropathy. A significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/26, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. Resident #2's comprehensive person-centered care plan included a focus area initiated 4/20/26, that indicated the resident was to ambulate with rolling walker and minimum assist up to 50 feet six days a week with the restorative program. A review of Resident #2's clinical record failed to reveal evidence of the resident participating in the restorative program and receiving assistance to ambulate six days a week. During an interview on 7/24/26 at 12:08 PM, Restorative Certified Nursing Assistant #1 stated Resident #2 was no longer on the restorative program caseload and service was discontinued about a month ago. On 7/27/26 at 5:19 PM, the Administrator and Regional Director of Clinical Services were notified of the concern regarding Resident #2's restorative care plan remaining active despite services being discontinued. No further information regarding this concern was presented prior to the exit conference on 7/28/26. 3. For Resident #12 the facility staff failed to revise the care plan to include the use of a prophylactic antibiotic. Resident #12's clinical record listed diagnoses which included but not limited to obstructive and reflux uropathy, unspecified. Resident #12's most recent quarterly minimum data set with an assessment reference date of 06/29/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #12's comprehensive care plan was reviewed and contained a plan for . has incontinence at times, she has obstructive uropathy with a Hx (history of) nephrostomy tubes with recurrent dysfunction recent removal. Resident #12's clinical record was reviewed and contained a physician's order summary which read in part, Fosfomycin Tromethamine Oral Pack 3 GM (Fosfomycin Tromethamine). Give 1 packet by mouth one time a day every Tue for UTI (urinary tract infection) treatment and PPx (prophylaxis). Surveyor could find where this treatment had been added to the care plan. Surveyor requested and was provided with a facility policy entitled, Care Plan Revisions Upon Status Change which read in part, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The concern of not revising the resident's care plan was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:20 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, the facility staff failed to meet professional standards of practice for the documentation of medication administration for 2 of 51 residents, Resident #12 and Resident #90. The findings included:1.For Resident #12 the facility staff documented the narcotic medication oxycodone as being administered, when no oxycodone was documented as removed from the narcotic supply. Resident #12's clinical record listed diagnoses which included but not limited to rheumatoid arthritis, unspecified, contracture of muscle, right shoulder, and hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side. Resident #12's most recent quarterly minimum data set with an assessment reference date of 06/29/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section J, health management, coded the resident as receiving scheduled pain medication. Resident #12's comprehensive care plan was reviewed and contained a plan for . is at risk for alterations in pain r/t (related to) RA (rheumatoid arthritis), CVA (cerebrovascular accident), PEG (percutaneous endoscopic gastrostomy) placement, and generalized pain, neuropathy. Resident #12's clinical record contained a physician's order summary which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 8 hours for pain. Resident #12's electronic medication administration record (eMAR) for the month of June 2026 was reviewed and reconciled with the narcotic control sheet. The eMAR contained an entry which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 8 hours for pain. The oxycodone was documented on the eMAR as administered per the physician's order on 06/01/26, 06/02/26, and 06/03/26, but the narcotics control sheet only documented one tablet removed on each of these days. The oxycodone was documented on the eMAR as administered per the physician's order on 06/22/26 and 06/23/26, but the narcotics control sheet documented no tablets removed on 06/22/26 and two tablets removed on 06/23/26. Surveyor requested and was provided with a facility titled, Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 10. Ensure that the six rights of medication are followed: f. Right documentation. 20. Sign MAR (medication administration record) after administered .21. If medication is a controlled substance, sign narcotic book. The concern of not following professional standards for documenting medications for Resident #12 was discussed with the administrator and regional director of clinical services on 07/27/26 at 5:15 pm. No further information was provided prior to exit. 2. For Resident #90, the controlled count sheets for the narcotic medication Oxycodone did not match the documentation of what had been administered. The facility reported missing 60 Oxycodone (out of 120) for Resident #90 during an facility wide audit of controlled medications. Resident #90's clinical record listed diagnoses which included but not limited to chronic pain, muscle weakness. chronic pulmonary edema, limitation of activities due to disability, and cellulitis of lower right limb. Resident #90's most recent quarterly minimum data set (MDS) with an assessment reference date of 03/19/25 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Section J, health management, coded the resident as receiving scheduled pain medication. Resident #90's comprehensive care plan was reviewed and contained a plan for . has pain r/t chronic pain, history of rib fracture and liver disease. Resident #90's electronic medication administration record (eMAR) for the month of April and May 2025 were reviewed and reconciled with the narcotic control sheet. The eMAR contained an entry which read in part, oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every 6 hours for pain/discomfort give one tablet q6h [every 6 hours] with a 325 Tylenol. The oxycodone was documented on the eMAR as administered per the physician's order on 4/20/25 and 4/22/25 with three doses missing on the narcotic sheet; 4/21/25 with four doses missing on the narcotic control sheet; 4/24/25, 4/25/25, 4/26/25, 4/27/25, and 4/28/25 with one dose missing. The narcotics control sheet showed that one tablet was removed on each of these days during the entries signed for and no indication of what happened to the missing medication was documented. On 4/27 and 4/28/25, the eMAR showed two doses to be given daily while the narcotic control sheet reflected three (out of four) doses given. Surveyor spoke with Licensed Practical Nurse (LPN) #3 on 7/16/25 at 10:40 pm who reports having education on controlled substances, the 5 rights of medication administration, abuse, neglect and exploitation and misappropriation of property. She reports that when a controlled substance is administered to a resident the documentation must be filled out according to policy with two nurses to verify counts, charting each medication administration including pain levels and communication with the provider. Surveyor requested and was provided with a facility policy titled, Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 10. Ensure that the six rights of medication are followed: f. Right documentation. 20. Sign MAR (medication administration record) after administered .21. If medication is a controlled substance, sign narcotic book. The concern of Resident #12's missing narcotics was discussed with the administrator and regional director of clinical services on 07/28/26 at 2:15 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review and facility policy review, the facility staff failed to provide or obtain radiology services to meet the needs of its residents for 1 of 7 residents in the survey sample, Resident #5. This failure resulted in a delay in treatment for a left hip fracture sustained after a fall thus constituting harm.The findings included:A facility policy entitled, Radiology and other Diagnostic Services and Reporting, dated 11/07/2025, read in part, The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law. 1. The facility must provide or obtain radiology and other diagnostic service to meet the needs of its residents. Under item 4. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.The admission Record for Resident #5 indicated the facility admitted the resident on 01/07/2023. According to the admission Record Resident #5 had a medical history that included diagnoses of dementia with psychotic disturbance, lack of coordination, muscle weakness, abnormalities of gait and mobility and osteoporosis.The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/29/2026 assigned Resident #5 a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS also indicated that the resident experienced frequent pain that limited day-to-day activities as high as a 10 on a 0-10 pain scale during the lookback period. The MDS revealed Resident #5 had not had any recent falls.A document in the clinical record for Resident #5 entitled, Change in Condition (SBAR) dated 06/23/2025 was reviewed. The document indicated that resident had a witnessed fall and complained of left hip pain that was worse with movement and rated 4 out of 10 on a 0-10 pain scale. The document indicated that the medical provider was notified and ordered a left hip x-ray and the resident was assisted up into a wheelchair and medicated with a PRN (as needed) medication. A Post Fall Documentation form dated 06/24/2025 at 3:21 PM documented a pain score of 0 but under section 7a. Describe injuries the document read, c/o (complained of) hip pain this nurse in to ask about pain level and fall today. Rsd (resident) doesn't remember. No c/o pain.On 06/25/2025 at 11:21 a nurse progress note read, Rsd c/o left hip pain this shift with ADLs (activities of daily living). Rsd unable to stretch left leg out w/o c/o pain. This nurse asked (name omitted) NP (nurse practitioner) to evaluate rsd. Rsd had a x-ray ordered on Monday and this nurse called to get an update on if it was completed or not because there was no results in system. (Name of x-ray vendor omitted) stated it was ordered to come today but they did not have a time. NP given order to send rsd out r/t (related to) left hip pain. (Name of guardian omitted) is made aware of situation.A note on 06/25/2025 at 2:46 PM read, Orthopedic surgeon called facility for RP information to give consent for surgery. Rsd admitted to (name of hospital omitted) for left hip fx (fracture).On 05/05/2026 at 4:35 PM Licensed Practical Nurse (LPN) #1 was interviewed. LPN #1 stated she witnessed the fall, (Resident #5) was trying to get out of the bed and was refusing help (resident) was agitated. I think (resident) refused everything, didn't want to go to see the doctor or anything, It's in my notes. Informed LPN #1 there were no progress notes from her on 06/23/2025, It's in risk management then. He refused everything I notified the doctor of everything. We got (resident) back up to the wheelchair. LPN #1 stated she could not remember who helped get the resident up. When asked if the resident complained of pain she stated yes, that's why we ordered the x-ray. When asked if she assessed range of motion she stated, Yes, I assessed (resident) for all of that. It should be in my note.On 05/06/2026 at 5:46 AM LPN #2 was interviewed via telephone. LPN #2 confirmed that she sent Resident #5 out to the hospital on [DATE]. LPN #2 stated, (resident) is not someone who complains so I knew it was a problem and something needed to be done when the aide told me (resident) had 10 out of 10 pain. They had told me in report he had fallen and when I went in the room to see about the pain (resident) told me (resident) had fallen. I went to look for the x-ray report and couldn't find where it had been done so I called them and they said it was scheduled to be done that day, but they were too busy to come. I called the NP and she ordered to send him out and it wasn't long before the hospital called and said the hip was broken.On 05/06/2026 at 10:10 AM the Director of Nursing (DON) was interviewed regarding the facility's fall process. When asked if falls, including resident assessments should be documented in progress notes, she stated, it's in risk management. When reminded the survey team does not have access to risk management; incident reports are not part of the clinical record she stated, there is a link in risk management that pulls the information to the notes. Requested she provide the notes including the physical assessment for Resident #5 for the 06/23/2025 fall with fracture. When asked if she would expect to see follow up documentation on the resident's pain on 06/23/2025 and 05/24/2025 she stated, He wasn't having pain until the 25th. Informed her that is not true, the resident had pain after the fall on the 23rd rated 4 out of 10 on a 1-10 pain scale as documented on the Change in Condition form, which was why an x-ray was ordered and Tylenol was administered per the medication administration record (MAR). When asked what the expectation for a time frame is when a resident falls, complains of pain and a hip x-ray is ordered, she stated, I would expect it to be done the same day and if not I would expect to call the doctor and follow orders to hopefully send them out for the x-ray.On 05/06/2026 at 11:20 AM the DON stated she had no explanation for the failure to obtain the x-ray and was unable to produce evidence that staff followed up on the x-ray on 06/24/2025. She also stated she was unable to produce evidence that a physical assessment was done post fall.On 05/06/2026 at 4:20 PM the Account Manager for the mobile x-ray company was interviewed. When asked what the timeframe should be from when an x-ray is ordered until it is done she stated, There is no official timeframe or expectation unless it is ordered stat (requiring immediacy), but it shouldn't take three days for a resident who fell and was having pain.On 05/07/2026 at 4:16 PM the Medical Director at the time of the fall was interviewed. When asked what the expected timeframe for a hip x-ray when a resident falls and complains of hip pain he stated, I'm not sure what the normal process is exactly but two or three days is definitely too long. (Resident) should have been sent out sooner and I am not sure why that didn't happen.On 05/07/2026 at 5:13 PM the survey team met with the Administrator, DON and Assistant Director of Nursing. This concern was discussed with them at that time.No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility policy review, the facility staff failed to provide pain management to residents who require such services that are consistent with professional standards of practice for 1 of 7 residents in the survey sample, Resident #2. The findings included:The policy entitled Pain Management with a revised date of 09/24/2025 was reviewed and read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Under the heading Recognition the document read, 1. In order to help a resident maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated b. Evaluate the resident for pain and the cause(s) of pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain.) c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the residents goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait (e.g. limping), skin color, vital signs (increased heart rate, respirations, and/or blood pressure) perspiration. B. Loss of function or inability to perform activities of daily living (ADL's) (e.g. rubbing a specific location of the body or guarding a limb or other body parts) c. Fidgeting, increased or recurring restlessness. d. Facial expressions e. behaviors such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in physical and/or social activities. f. Difficulty eating or loss of appetite. g. Weight loss h. Difficulty sleeping i. Negative vocalizations j. Decline in activity level. k. Skin conditions. Under the heading Pain Assessment read, 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g. nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: a. History of pain and it's treatment (including nonpharmacological, pharmacological and alternative medicine and whether or not each treatment has been effective); b. History of addiction, past and/or ongoing and related treatment for opioid use disorder; c. Asking the patient to rate the intensity of pain using a numerical scale, a verbal or visual descriptor that is appropriate an preferred by the patient. d. Reviewing the residents current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputations, oral health conditions, post cva (stroke), venous and arterial ulcers and multiple sclerosis.) e. Identifying key characteristics of the pain: I. Duration of the pain II. Frequency III. Location IV. Timing V. Pattern VI. Radiation of pain. f. Obtaining descriptors of the pain (e.g.) stabbing, aching, pressure, spasms). g. Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain. h. Impact on pain on quality of life (sleeping, functioning, appetite and mood.) i. Current prescribed pain medications, dosages and frequency including medication for OUD (opioid use disorder). j. The resident's goals for pain management and his/her satisfaction with the current level of pain control. k. Physical and psychosocial issues that may be causing or exacerbating the pain. l. Additional symptoms associated with pain (e.g. nausea, anxiety).The admission Record for Resident #2 revealed the facility admitted the resident on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression and anxiety.The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/23/2025 assigned the resident a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Resident #2 was coded as having little interest or pleasure in doing things 2-6 days in the look back period and feeling down, depressed, or hopeless 2-6 days in the 2 week look back period. Resident #2 was coded as having frequent pain that interfered with sleep, ability to participate in therapy and that limited day-to-day activities. Pain was coded as being as high as 9 on a 0-10 pain scale over the prior five days.The medical provider notes were reviewed for the entirety of Resident #2's stay at the facility. The History and Physical note dated 04/18/2025 read in part, It is noted with the discharge summary that (resident) displayed some narcotic seeking behavior. (Resident) was found concealing a pill bottle containing home dose Percocet and gabapentin medications. The medications were confiscated and pain medicine was held. (Resident) became agitated and altered and was tachycardic, displaying signs of opioid withdrawal. The PDMP (prescription drug monitoring program) was reviewed, and it appears (resident was taking far too much opioid analgesia. (Resident) was started on a pain regimen that was half of prior to admission dosing, which resulted in improvement of her overall symptoms. The daily SPN/Skilled notes were reviewed. Every daily skilled note for Resident #2 throughout the duration of the stay stated the resident had no chest pain, no edema, and no swallowing problems and GI (gastrointestinal) complaints are none. Many of the notes documented pain levels as high as 10/10 but did not include a location of the pain, pain characteristics, or nonpharmacologic interventions offered.According to the Medication Administration Record (MAR) for April 2025, resident had an order that read, Acetaminophen 500 mg give two tablets by mouth every 6 hours as needed for pain. This order was not signed as given on 04/19/2026 and was only administered one time on 04/18/2025 for complaint of generalized pain during the resident's stay at the facility.According to the daily skilled notes and MAR, Resident #2 complained of a pain level of 7 or higher on fifteen out of their seventeen day stay at the facility.A Physical Therapy note dated 04/20/2025 read in part, Pt refused for more ex. (exercise) Pt refused for bed mobility. Pt c/o chest wall pain along with pain in stomach, ribs, back and pt's BP is also low, nurse informed. Pt educated on use of call bell for assistance. There was no nurses note to indicate the resident was assessed for chest pain or low blood pressure. The only note was a SPN/Skilled Note that indicated the blood pressure was 140/60, pain level was 9 but there was no location given for the pain and the note specifically said, no chest pain.The Treatment Administration Record (TAR) was reviewed and included an order that read, Assess resident for pain every shift: Nonpharmacological interventions: 1=relaxation, 2=light touch, 3=imagery, 4=exercises, 5=music, 6=N/A, 7=other see progress notes. Document corresponding code and pain level in supplemental documentation. The pain levels on the TAR did not consistently match the pain levels on the MAR or in the skilled notes. On 04/20/2025 for the evening and night shift the pain scale and nonpharmacological intervention was blank on the TAR, but resident had complained of 9 out 10 pain on the evening shift and 6 out 10 on the night shift according to the MAR.A provider progress note dated 04/21/2025 read in part, (Resident) reports chest pain, gas pain, and acid reflux. Describes chest pain as burning sensation in the epigastric area. Worse after eating and drinking. Pain relieved with Tums. Denies SOB (shortness of breath), N/V (nausea and vomiting), syncope and headaches. The progress note indicated Nitrostat as needed for chest pain.Resident #2's medical provider orders included an order for nitroglycerin sublingual tablet 0.4 mg give one tablet sublingually every 5 minutes as needed for angina (chest pain) take one tab every 5 minutes for up to 15 minutes do not take more than 3 tabs in 15 minutes. This order was not administered to Resident #2 at any point during their stay according to the MAR. SPN/Skilled Notes dated 04/25/2025, 04/26/2025, 04/27/2025, 04/30/2025, and 5/01/25 each revealed a documented pain level of 10 out of 10 with no evidence that the high pain levels were assessed or reported to the medical provider.A nurse progress note dated 05/01/2025 at 6:00 PM and signed by the Assistant Director of Nursing (ADON) read in part, Patients condition was discussed at length in care plan meeting today with RP (name of responsible party omitted). Discussed.pain control for low back pain.MD aware of concerns, new orders as follows.Aspercreme Lidocaine Patch 4% apply to lower back topically one time a day for pain and remove per schedule.On 05/07/2026 the ADON was interviewed. When asked about resident #2's c/o chest pain the ADON stated, (resident) didn't have chest pain, (resident) had low back pain, and always said (resident) was in pain but the scheduled pain medication was effective. In the hospital records it talks about her abusing pain medication and going through withdrawals When asked about daily physical assessment and pain assessment the ADON stated, Those are documented in the skilled notes, and the pain assessment is also on the MAR. When asked if they had noticed that the skilled notes in many cases seemed to be copied and pasted including vital signs, they agreed that there were many similarities at times.On 05/07/2025 the Director of Nursing (DON) was interviewed regarding Resident #2's high pain levels, c/o chest pain and lack of daily pain assessments. The DON provided the MAR to show that the resident was asked about pain each shift and a pain level documented. When asked what the expectation for documenting location and pain characteristics she stated, I think they do that for the most part. When asked about standard of practice the DON stated, I think our policy covers that. On 05/07/2025 at 5:15 PM the survey team met with the Administrator, DON and ADON. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to maintain acceptable levels of nutritional status resulting in a significant 16-pound weight loss for 1 of 7 residents in the survey sample, Resident #2. The findings included: The admission Record for Resident #2 revealed the facility admitted the resident on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression and anxiety.The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/23/2025 assigned the resident a brief interview for mental status (BIMS) score of 08 indicating moderate cognitive impairment.The hospital discharge summary was reviewed. Resident #2's weight was documented as 115 lbs. during the discharge exam.The Documentation Survey Report where activities of daily living (ADL's) such as eating, toileting and bathing were documented for Resident #2 was reviewed. For eating, there was no documentation to support resident #2 was provided lunch on 04/18/2025, breakfast or lunch on 04/19/2025, breakfast or lunch on 04/20/2025, breakfast or lunch on 04/23/2025, breakfast or lunch on 04/24/2025, breakfast or lunch on 04/28/2025, breakfast or lunch on 04/29/2025, breakfast or lunch on 05/02/2025. According to the Documentation Survey Report Resident #2 ate 0-25% breakfast on 04/18/2025, 0-25% breakfast, lunch and supper on 05/03/2025 and 0-25% breakfast and lunch on 05/04/2025. Resident #2 was documented as eating only 26-50% for supper on 04/19/2025 and for all three meals on 05/01/2025.A provider progress note dated 04/21/2025 read in part, (Resident) reports chest pain, gas pain, and acid reflux. Describes chest pain as burning sensation in the epigastric area. Worse after eating and drinking. Pain relieved with Tums. Denies SOB (shortness of breath), N/V (nausea and vomiting), syncope and headaches. The note did not address poor intake or nutritional status.Daily weights began on 04/21/2025 and were recorded on the Treatment Administration Record (TAR). 04/21/2025 117.5 lbs., 04/22/2025 118.1 lbs. 04/23/2025 112.2 lbs. 04/24/2025 blank, 04/25/2025 111.8 lbs., blanks for 04/27/2025-04/29/2025 and on 04/30/2025 99 lbs. 05/01/2025 99.2 lbs., 05/02/2025 99 lbs., 05/03/2025 99.1 lbs.The SPN/Skilled Notes were reviewed. On 04/27/2025 the nurse documented, lethargic, flat affect, little energy/tired poor appetite. On 04/30/2025 flat affect poor appetite sluggish. There was no evidence that any alternatives were offered or the medical provider was notified.A Weight Note dated 04/28/2025 entered by the Registered Dietician read, Resd (resident) reviewed for weight loss of 5.2# x 9 days. Wt (weight) on admission 117# (04/17/2025). Regular, Mech (mechanical) soft, thin liquid diet order. 2000 ml (milliliters) fluid restriction. Resd appetite and PO (by mouth) intake is poor. Family bringing in some foods. Resd reports poor appetite. Family states ubw (usual body weight) of 140# prior to hospitalization. Resd dislikes mech soft textures. Currently receiving ST (speech therapy) for dx (diagnosis) dysphagia (swallowing difficulty). PU (pressure ulcer) stage I to sacrum. MVI (multivitamin) with minerals in place for skin integrity. Prostat protein liquid increased ordered 3x daily for wound healing. Continue wts as ordered. Will recommend Magic Cup once daily between meals for wt stabilization.A nurse progress note dated 04/28/2025 read, Patient's weight loss was discussed with son and (physician's name omitted), loss of 6.3 lbs. (pounds) in one week- orders from (physician's name omitted); increase protein supplement from 1x (one time) a day to 3x (three times) r/t (related to) nutritional needs, ST to evaluate for swallowing issues. Medication to stimulate appetite was discussed but not found to be warranted at this time. Son was in agreement with this plan.The Speech Therapy (ST) evaluation and notes were reviewed. On 04/30/2025 ST documented in part, Patient remains at nutritional risk due to consistently low po intake and reported weight loss. Continued education and reinforcement of strategies remain essential to promote safe swallowing and adequate nutrition. Under the heading Summary of daily skilled services the note read in part, SLP (speech language pathologist) collaborated with physician about current status as pt (patient) is not eating. MD will write an order for ENT referral.A nurse progress note dated 05/01/2025 at 6:00 PM and signed by the Assistant Director of Nursing (ADON) read, Patients condition was discussed at length in care plan meeting today with RP (name of responsible party omitted). Discussed ENT (ears, nose, throat) vs GI regarding swallowing issues, pain control for low back pain, hydration status r/t low intake. MD aware of concerns, new orders as follows: BMP- Aspercreme Lidocaine Patch 4% apply to lower back topically one time a day for pain and remove per schedule referral to ENT r/t swallowing issues/fear of swallowing.An SLP Progress Report signed on 05/02/2025 read in part under Patient Progress, Patient continues to demonstrate variable cognitive performance with noted daily fluctuations, impacting progress toward cognitive-linguistic goals. Patient and staff report ongoing challenges with oral intake and weight loss. Earlier this week patient was unable to effectively masticate or swallow oral trials. Collaborative care has been implemented with nursing, dietician and physician actively involved. ENT referral has been made for further evaluation. The SPN/Skilled notes and nurse progress notes were reviewed again. The nurses caring for resident #2 on a daily basis documented swallowing problems are not noted daily in the skilled notes. There was no documentation by the medical providers that addressed weight loss or poor intake provided to the survey team.On 05/07/2026 the ADON interviewed. When asked about the RD recommendation for a magic cup due to weight loss the ADON stated, That was discussed with (provider name omitted) and he elected to just increase the Prostat (liquid protein) instead. When asked if the provider was aware of the weight loss, ADON stated, He was.There was no documentation by a provider addressing the weight loss or poor appetite provided to the survey team.The survey team met with the Administrator, DON and ADON on 05/07/2026 and this concern was discussed. Resident #2 was on two diuretics for congestive heart failure but the documentation by the RD and the Speech Therapist indicate the resident experienced a true weight loss rather than changes in fluid volume.

Based on staff interview, clinical record review and facility policy review, the facility staff failed to provide care and services to meet professional standards of quality for 1 of 7 resident's in the survey sample, Resident #2. The findings included:The policy entitled Pain Management with a revised date of 09/24/2025 was reviewed and read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Under the heading Recognition the document read, 1. In order to help a resident maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated b. Evaluate the resident for pain and the cause(s) of pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain.) c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the residents goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait (e.g. limping), skin color, vital signs (increased heart rate, respirations, and/or blood pressure) perspiration. B. Loss of function or inability to perform activities of daily living (ADL's) (e.g. rubbing a specific location of the body or guarding a limb or other body parts) c. Fidgeting, increased or recurring restlessness. d. Facial expressions e. behaviors such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in physical and/or social activities. f. Difficulty eating or loss of appetite. g. Weight loss h. Difficulty sleeping i. Negative vocalizations j. Decline in activity level. k. Skin conditions. Under the heading Pain Assessment read, 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g. nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: a. History of pain and it's treatment (including nonpharmacological, pharmacological and alternative medicine and whether or not each treatment has been effective); b. History of addiction, past and/or ongoing and related treatment for opioid use disorder; c. Asking the patient to rate the intensity of pain using a numerical scale, a verbal or visual descriptor that is appropriate an preferred by the patient. d. Reviewing the residents current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputations, oral health conditions, post cva (stroke), venous and arterial ulcers and multiple sclerosis.) e. Identifying key characteristics of the pain: I. Duration of the pain II. Frequency III. Location IV. Timing V. Pattern VI. Radiation of pain. f. Obtaining descriptors of the pain (e.g.) stabbing, aching, pressure, spasms). g. Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain. h. Impact on pain on quality of life (sleeping, functioning, appetite and mood.) i. Current prescribed pain medications, dosages and frequency including medication for OUD (opioid use disorder). j. The resident's goals for pain management and his/her satisfaction with the current level of pain control. k. Physical and psychosocial issues that may be causing or exacerbating the pain. l. Additional symptoms associated with pain (e.g. nausea, anxiety).The admission Record for Resident #2 revealed the facility admitted the resident on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression and anxiety.The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/23/2025 assigned the resident a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. Resident #2 was coded as having little interest or pleasure in doing things 2-6 days in the look back period and feeling down, depressed, or hopeless 2-6 days in the 2 week look back period. Resident #2 was coded as being independent prior to illness with self-care, indoor mobility and functional cognition but upon admission, required substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, bed mobility and transfers from bed to chair. The resident was coded as being incontinent of bowel and bladder. Resident #2 was coded as having frequent pain that interfered with sleep, ability to participate in therapy and that limited day-to-day activities. Pain was coded as being as high as 9 on a 0-10 pain scale over the prior five days. Resident #2 was coded as having shortness of breath with exertion, when at rest and when lying flat. The comprehensive care plan was not completed prior to Resident #2's discharge on [DATE].The hospital discharge summary was reviewed. Resident #2's weight was documented as 115 lbs. during the discharge exam. Under Recommended Follow-Up Appointments the document read, Follow up with cardiology for consideration of nonischemic stress testing.The Documentation Survey Report where activities of daily living (ADL's) such as eating, toileting and bathing were documented for Resident #2 was reviewed. For eating, there was no documentation to support Resident #2 was provided lunch on 04/18/2025, breakfast or lunch on 04/19/2025, breakfast or lunch on 04/20/2025, breakfast or lunch on 04/23/2025, breakfast or lunch on 04/24/2025, breakfast or lunch on 04/28/2025, breakfast or lunch on 04/29/2025, breakfast or lunch on 05/02/2025. According to the Documentation Survey Report Resident #2 ate 0-25% for breakfast on 04/18/2025, 0-25% breakfast, lunch and supper on 05/03/2025 and 0-25% breakfast and lunch on 05/04/2025. Resident #2 was documented as eating only 26-50% for supper on 04/19/2025 and for all three meals on 05/01/2025.The medical provider notes were reviewed for the entirety of Resident #2's stay at the facility. The History and Physical note dated 04/18/2025 read in part, It is noted with the discharge summary that (resident) displayed some narcotic seeking behavior. (Resident) was found concealing a pill bottle containing home dose Percocet and gabapentin medications. The medications were confiscated and pain medicine was held. (Resident) became agitated and altered and was tachycardic, displaying signs of opioid withdrawal. The PDMP (prescription drug monitoring program) was reviewed, and it appears (resident was taking far too much opioid analgesia. (Resident) was started on a pain regimen that was half of prior to admission dosing, which resulted in improvement of her overall symptoms. Under the Assessment and Plan portion of the document the provider documented a plan for the diagnosis of acute on chronic heart failure that read: Plan: Continue losartan 25 mg daily and diuresis with Lasix 20 mg on Monday, Wednesday and Friday. Obtain BNP (B-type Natriuretic Peptide which is a hormone produced by the heart when it is under stress that is used to monitor and assess severity of heart failure) to assess patient's current heart failure status. Continue metoprolol succinate 25 mg daily for blood pressure control. Administer Aldactone 25 mg for diuresis. Obtain CBC (complete blood count), CMP (comprehensive metabolic panel) and magnesium levels to assess for any electrolyte dysfunction associated with diuresis. Replete electrolytes as indicated.The BNP was not located in the medical record.The daily SPN/Skilled notes were reviewed. Every daily skilled note for Resident #2 throughout the duration of the stay stated the resident had no chest pain, no edema, and no swallowing problems and GI (gastrointestinal) complaints are none. Many of the notes documented pain levels as high as 10/10 but did not include a location of the pain, pain characteristics, or nonpharmacologic interventions offered.On 04/19/2025 at 12:57 PM the note read in part, Pain level: 7- 04/19/2025 09:44 AM Pain Scale: Numerical Rsd (resident) voiced c/o (complaints of) pain this shift. PRN (as needed) analgesics given and effective. According to the Medication Administration Record (MAR) for April 2025, resident had an order that read, Acetaminophen 500 mg give two tablets by mouth every 6 hours as needed for pain. This order was not signed as given on 04/19/2026 and was only administered one time on 04/18/2025 for complaint of generalized pain during the resident's stay at the facility. Resident #2 also had an order that read, nitroglycerin sublingual tablet 0.4 mg give one tablet sublingually every 5 minutes as needed for angina (chest pain) take one tab every 5 minutes for up to 15 minutes do not take more than 3 tabs in 15 minutes. This order was not administered to Resident #2 at any point during their stay according to the MAR.According to the daily skilled notes and MAR, Resident #2 complained of a pain level of 7 or higher on fifteen out of their seventeen day stay at the facility.The Treatment Administration Record (TAR) was reviewed and included an order that read, Assess resident for pain every shift: Nonpharmacological interventions: 1=relaxation, 2=light touch, 3=imagery, 4=exercises, 5=music, 6=N/A, 7=other see progress notes. Document corresponding code and pain level in supplemental documentation. The pain levels on the TAR did not consistently match the pain levels on the MAR or in the skilled notes.A Physical Therapy note dated 04/20/2025 read in part, Pt refused for more ex. (exercise) Pt refused for bed mobility. Pt c/o chest wall pain along with pain in stomach, ribs, back and pt's BP is also low, nurse informed. Pt educated on use of call bell for assistance. There was no nurses note to indicate the resident was assessed for chest pain or low blood pressure. The only note was a SPN/Skilled Note that indicated the blood pressure was 140/60, pain level was 9 but there was no location given for the pain and the note specifically said, no chest pain.On 04/20/2025 for the evening and night shift the pain scale and nonpharmacological intervention was blank on the TAR, but resident had complained of 9 out 10 pain on the evening shift and 6 out 10 on the night shift according to the MAR. The only nonpharmacological interventions documented as being performed was relaxation, light touch and imagery.A provider progress note dated 04/21/2025 read in part, (Resident) reports chest pain, gas pain, and acid reflux. Describes chest pain as burning sensation in the epigastric area. Worse after eating and drinking. Pain relieved with Tums. Denies SOB (shortness of breath), N/V (nausea and vomiting), syncope and headaches. Under the heading Assessment and Plan for the diagnosis of congestive heart failure the provider documented Plan: Continue Lasix 20 mg every Monday, Wednesday and Friday. Continue metoprolol succinate 25 mg daily. Continue spironolactone 25 mg daily. Start losartan 25 mg daily. Continue Nitrostat as needed for chest pain. Monitor for signs and symptoms of heart failure exacerbation. Follow up with cardiology for stress test. There was no evidence that a cardiology appointment/consultation was initiated by the facility. For the diagnosis hyperthyroidism the provider documented, patient has a history of hyperthyroidism and is on Synthroid 50 mg daily. Plan: continue Synthroid 50 mg daily. Obtain a TSH level to monitor thyroid function. There were no results for a TSH level in the medical record.A SPN/Skilled note dated 04/25/2025 read in part, BP 96/55 Pain level:10 Level of consciousness noted as oriented to person oriented to place lethargic. Skin is warm and dry. Swallowing problems are not noted. Mood status is flat affect tired/has little energy sluggish. GI (gastrointestinal) complaints are none. The last sentence read, Call light and fluids in reach. Patient is non-compliant with fluid restriction and refuses daily weight and states I am not getting up I am too tired. There was no evidence the low blood pressure, high pain level and lethargy were assessed or reported to the medical provider.A Physical Therapy Treatment Encounter Note dated 04/25/2025 read in part, Pt described nausea and vomiting earlier today and Pt refused further activity 2/2 (secondary to) visiting with family and upset stomach. The nurse documented GI complaints are none for the same day.A SPN/Skilled note dated 04/26/2025 read in part, BP 96/55 Pain level 10 level of consciousness noted as oriented to person oriented to place lethargic. Skin is warm dry. Swallowing problems are not noted tolerates pills whole. Mood status is flat affect sluggish. GI complaints are none. There was no evidence to support these symptoms were further assessed or reported to the provider.A SPN/skilled note dated 04/27/2025 read in part, Pain level 10 Level of consciousness noted as oriented to person oriented to place lethargic. Skin warm dry. Swallowing problems are not noted tolerates pills whole. Mood status is flat affect tired/has little energy poor appetite. GI complaints are none. No evidence in the record of further assessment or notification of provider.A Weight Note dated 04/28/2025 entered by the Registered Dietician read, Resd (resident) reviewed for weight loss of 5.2# (pounds) x 9 days. Wt (weight) on admission 117# (04/17/2025). Regular, Mech (mechanical) soft, thin liquid diet order. 2000 ml (milliliters) fluid restriction. Resd appetite and PO (by mouth) intake is poor. Family bringing in some foods. Resident reports poor appetite. Family states ubw (usual body weight) of 140# prior to hospitalization. Resd dislikes mech soft textures. Currently receiving ST for dx (diagnosis) dysphagia (swallowing difficulty). PU (pressure ulcer) stage I to sacrum. MVI (multivitamin) with minerals in place for skin integrity. Prostat protein liquid increased ordered 3x daily for wound healing. Continue wts as ordered. Will recommend Magic Cup once daily between meals for wt stabilization.On 04/28/2025 and 04/29/2025 SPN/skilled note documented a blood pressure of 94/60 each day with no assessment or intervention documented.A nurse progress note dated 04/28/2025 read, Patient's weight loss was discussed with son and (physician's name omitted), loss of 6.3 lbs. (pounds) in one week- orders from (physician's name omitted); increase protein supplement from 1x (one time) a day to 3x (three times) r/t (related to) nutritional needs, ST to evaluate for swallowing issues. Medication to stimulate appetite was discussed but not found to be warranted at this time. Son was in agreement with this plan.A nurse progress note dated 04/29/2025 at 8:34 PM read, Dicyclomine HCL (anticholinergic/antispasmodic used to treat irritable bowel syndrome) 10 mg give one capsule by mouth every 8 hours as needed for pain for 14 days. Rsd (resident) c/o (complained of) stomach pain. Two non-pharmacological interventions ineffective. Administered med per order. A later note indicated the medication was effective.On 04/30/2025 the SPN/skilled note read in part, Pain level 10 Level of consciousness noted as oriented to person oriented to place. Skin warm dry. Swallowing problems are not noted tolerates pills whole. Mood state is flat affect poor appetite sluggish. GI complaints are none.The Speech Therapy (ST) evaluation and notes were reviewed. On 04/30/2025 ST documented in part, Patient remains at nutritional risk due to consistently low po intake and reported weight loss. Continued education and reinforcement of strategies remain essential to promote safe swallowing and adequate nutrition. Under the heading Summary of daily skilled services the note read in part, SLP (speech language pathologist) collaborated with physician about current status as pt (patient) is not eating. MD will write an order for ENT referral. An SLP Progress Report signed on 05/02/2025 read in part under Patient Progress, Patient continues to demonstrate variable cognitive performance with noted daily fluctuations, impacting progress toward cognitive-linguistic goals. Patient and staff report ongoing challenges with oral intake and weight loss. Earlier this week patient was unable to effectively masticate or swallow oral trials. Collaborative care has been implemented with nursing, dietician and physician actively involved. ENT referral has been made for further evaluation. The SPN/Skilled notes and nurse progress notes were reviewed again. The nurses caring for resident #2 on a daily basis documented swallowing problems are not noted daily in the skilled notes. There was no documentation by the medical providers that addressed weight loss or poor intake provided to the survey team.On 05/01/2025, Pain level 10 level of consciousness noted as oriented to person oriented to place lethargic. Skin warm dry. Swallowing problems are not noted. Mood status is tired/has little energy poor appetite sluggish. GI complaints are none.A nurse progress note dated 05/01/2025 at 6:00 PM and signed by the Assistant Director of Nursing (ADON) read, Patients condition was discussed at length in care plan meeting today with RP (name of responsible party omitted). Discussed ENT (ears, nose, throat) vs GI regarding swallowing issues, pain control for low back pain, hydration status r/t low intake. MD aware of concerns, new orders as follows: BMP- Aspercreme Lidocaine Patch 4% apply to lower back topically one time a day for pain and remove per schedule referral to ENT r/t swallowing issues/fear of swallowing.On 05/03/2025 BP 94/58 Pain level 4. No evidence the low blood pressure was further assessed or reported to the provider. A nurse progress note dated 05/04/2025 at 3:48 PM read, CNA (certified nursing assistant) notified this nurse that rsd had vomited and had diarrhea, that she cleaned (resident) up and that rsd didn't look well. Upon assessment rsd noted unresponsive, eyes/pupils fixated and scant amount of foam in corner of L side of mouth. No response from sternal rub. No palpable pulse noted. This nurse started chest compressions immediately. MD notified and NO (new order) given to send rsd to ER emergently. 911 notified per MD.Resident #2 was sent emergently to the hospital on [DATE] where she passed away a week later.On 05/07/2026 the ADON was asked to provide all labs. ADON provided the CBC, CMP, magnesium level ordered 4/18/25 and the BMP ordered 5/2/2025 and stated that was all the labs that were done. When asked about resident #2's c/o chest pain the ADON stated, She didn't have chest pain, she had low back pain, and she always said she was in pain but the scheduled pain medication was effective. In her hospital records it talks about her abusing pain medication and going through withdrawals When asked about daily physical assessment and pain assessment the ADON stated, Those are documented in the skilled notes, and the pain assessment is also on the MAR. When asked if they had noticed that the skilled notes in many cases seemed to be copied and pasted including vital signs they agreed that there were many similarities at times. When asked about the RD recommendation for a magic cup due to weight loss the ADON stated, That was discussed with (provider name omitted) and he elected to just increase the Prostat (liquid protein) instead. When asked if the provider was aware of the weight loss, ADON stated, He was.On 05/07/2025 the Director of Nursing (DON) was interviewed regarding resident #2's high pain levels, c/o chest pain and lack of daily pain assessments. The DON provided the MAR to show that the resident was asked about pain each shift and a pain level documented. When asked what the expectation for documenting location and pain characteristics she stated, I think they do that for the most part. When asked about standard of practice the DON stated, I think our policy covers that. When asked about basic nursing assessment the DON stated, They do those in their skilled notes. When asked about changes in vital signs such as low blood pressure or notes that read resident is lethargic if they would expect further assessment of the resident to determine if a change in condition is occurring they stated, I think we do that, it's in the notes.On 05/07/2026 at 2:40 PM the former facility Nurse Practitioner was interviewed. When asked about resident #2's chest pain she stated, (Resident) said it was epigastric and was worse after eating so we prescribed another medication for GERD (gastroesophageal reflux disease) which made sense at the time. When asked about appetite and weight loss she did recall poor appetite.On 05/07/2026 at 4:16 PM the former medical director and provider for resident #2 was interviewed. When asked about weight loss they stated, I don't recall that. I'm sure if the staff made a note that they notified me then I was aware. I don't recall anything about the RD or a magic cup. I'm not sure why I wouldn't have approved that, but I can't say for sure. Regarding pain, the provider stated the resident had a well-documented history of drug seeking and he was aware of the ongoing complaints of pain but felt the pain was being controlled by the medication prescribed. (Resident) was never going to say there was no pain. Did not recall being notified of low blood pressure or lethargy. On 05/07/2026 at 5:13 PM the survey team met with the DON, ADON and Administrator. These concerns were reviewed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to follow medical provider orders for one of seven residents in the survey sample, Resident #2.The findings included:For Resident #2 the facility staff failed to follow hold orders for the administration of Toprol XL (metoprolol). An admission Record revealed the facility admitted Resident #2 on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, hypertension, coronary artery disease with a history of myocardial infarction and moderate protein-calorie malnutrition. The admission minimum data set (MDS) with an assessment reference date (ARD) of 04/23/2025 assigned the resident a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment.'The Medication Administration Record (MAR) for May 2025 revealed an order that read, Toprol XL oral tablet extended release 24-hour 25 mg (Metoprolol Succinate) give one tablet by mouth one time a day for htn (hypertension) hold if HR (heart rate) <60 SBP (systolic blood pressure) <100 or DBP (diastolic blood pressure) <60. On 05/03/2025 Resident #2's blood pressure was documented as 94/58. Toprol XL was documented as given by the nurse despite both the systolic and diastolic blood pressure being outside parameters. According to Davis's Drug Guide.com Toprol XL is a medication used to treat hypertension and heart failure. The medication functions by reducing the heart rate and the blood pressure and should be held for a systolic blood pressure less than 100 or diastolic blood pressure less than 60. On 05/07/2026 at 5:13 PM the survey team met with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The ADON reviewed the MAR and agreed that the medication was documented as given outside parameters. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to obtain medical provider ordered laboratory tests for one of seven residents in the survey sample, resident #2.The findings included:For Resident #2 the facility failed to obtain a BNP (B-type natriuretic peptide test) and a TSH (thyroid stimulating hormone) level ordered by the medical provider.An admission Record revealed the facility admitted Resident #2 on 04/17/2025. According to the admission Record Resident #2 had a medical history that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, hypertension, coronary artery disease with a history of myocardial infarction and moderate protein-calorie malnutrition.The admission minimum data set (MDS) with an assessment reference date (ARD) of 04/23/2025 assigned the resident a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment.A History and Physical note dated 4/18/2025 and electronically signed by the facility Medical Director at the time, included an order that read, Plan: Continue losartan 25 mg daily and diuresis with Lasix 20 mg on Monday, Wednesday and Friday. Obtain BNP to assess patient's current heart failure status. Continue metoprolol succinate 25 mg daily for blood pressure control. Administer Aldactone 25 mg for diuresis. Obtain CBC (complete blood count), CMP (comprehensive metabolic panel) and magnesium levels to assess for any electrolyte dysfunction associated with diuresis. Replete electrolytes as indicated.A provider progress note dated 04/21/2025 read in part, .patient has a history of hyperthyroidism and is on Synthroid 50 mg daily. Plan: continue Synthroid 50 mg daily. Obtain a TSH level to monitor thyroid function . On 5/7/2026 at 3:20 PM the Assistant Director of Nursing (ADON) provided all lab results for Resident #2. They were unable to produce the BNP or the TSH. The ADON stated, I even called the lab.On 05/07/2026 at 4:16 PM the provider who ordered the tests was interviewed via telephone. When asked about the labs ordered he stated, I obviously don't remember orders that long ago but if the other labs were ordered and were done, I suspect the BNP should have been as well.On 05/07/2026 at 5:13 PM this concern was discussed with the Administrator, Director of Nursing and the ADON. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain medical records in accordance with accepted professional standards and practices for 1 of 8 residents in the survey sample, Resident #8 (R#8). The findings included:On 5/5/26 at 1:59 pm, during a record review for Resident #4 (R#4), a wound progress note titled, patient visit record dated 3/17/2026 and a hospice consent dated 3/16/26 for Resident #8 (R#8) were observed uploaded in the chart of R#4. On 5/5/2026 at 3:10 pm an interview was conducted with the Medical Records Coordinator. She stated her procedure is to upload the records as soon as she receives them if possible, limiting who all uploads' records as to keep mistakes at a minimum. If a wrong record is uploaded into the wrong chart by staff the records are deleted immediately. She reports taking pride in her work and was upset when she was advised on the records for R#8 being uploaded into R#4's electronic record. It was noted that R#8 has a similar last name to R#4. On 5/6/2027, the facility staff provided the survey team with a copy of their policy titled, HIPPA Security Measures. This policy read in part, .It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that are in electronic format. On 05/07/2026 at 5:13 PM the survey team met with the DON (Director of Nursing), ADON (Assistant Director of Nursing) and Administrator. These concerns were reviewed at that time. No further information was provided to the survey team prior to the exit conference.

Based on interviews, clinical record review, and facility document review, the facility staff failed to appropriately respond to a decline/change in condition (lethargy, oriented to person only, clammy skin, Cheyne-Stokes labored irregular breathing) for one 1 of nine 9 sampled residents (Resident #9), resulting in death. The scope and severity was originally cited at Immediate Jeopardy, Level IV isolated, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The Administrator, Director of Nursing (DON), and Quality Assurance (QA) Nurse were notified on [DATE] at 1:45 p.m. that the survey team had identified Immediate Jeopardy in the area of Quality of Care. Upon verification of the removal plan, the Immediate Jeopardy was cleared on [DATE] at 2:45 p.m. The findings include: The facility staff failed to appropriately provide emergency care and timely transportation services, which aligned with the Resident #9's documented preferences, following a sudden decline in condition that subsequently resulted in the resident's death. Resident #9's decline was first documented on [DATE] at 9:25 am. Resident #9 died approximately 4 hours later, at 1:30 pm. Resident #9's clinical documentation included a DNR (Do Not Resuscitate order). Resident #9's clinical documentation did not contain information to indicate that the resident had requested additional limits for care other than the DNR order. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], was signed as completed on [DATE]. Resident #9 was assessed as being able to be understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact cognition. Resident #9's diagnosis included Coronary Artery Disease, Hypertension, and Paroxysmal Atrial Fibrillation (intermittent irregular heartbeat). A nurse's progress note dated [DATE] at 9:25 a.m., documented that Resident #9 experienced a decline in condition. Resident #9 was documented as having increased somnolence (drowsiness), and refusing his medications. Resident #9's nurse documented that she notified the nurse practitioner (NP) of this change in condition. A nurse's progress note dated [DATE] at 9:33 a.m., documented Resident #9 as being lethargic, oriented to person, clammy skin, and having swallowing problems of loss of liquids or solids from mouth when eating or drinking. No documentation was found to indicate the resident's blood sugar level had been checked. A nurse's progress note dated [DATE] at 11:45 a.m., documented interventions and additional changes in Resident #9's condition. This note indicated that the nurse practitioner (NP) administered two doses of Narcan (an opioid antagonist used to treat a known or potential opioid overdose) to Resident #9. The Narcan did not result in an improvement in the resident's condition; the nurse informed the NP that the resident refused his morning opioid medications. Resident #9 was documented as having labored, irregular breathing (Cheyne-Stokes respirations). This note indicated oxygen was applied for comfort by the NP; the amount of oxygen and the device used to deliver the oxygen was not documented. (During an interview, Licensed Practical Nurse (LPN) #2 reported that the NP applied a nasal cannula with, she thought, two (2) liters of oxygen.) Resident #9's son was notified of the change in condition. Resident #9's son requested to speak with the nurse practitioner and the Director of Nursing. On [DATE] at 2:27 p.m., the Director of Nursing (DON) provided the surveyor with an unsigned, draft copy of a nurse practitioner progress note for Resident #9 with a date of service of [DATE]. This draft copy included the following information: Altered level of consciousness: Patient was found unresponsive to voice command and tactile stimuli, including sternum rub . Physical examination revealed no JVD distention (bulging neck veins), clear lungs, and non-labored respirations. Despite administration of two doses of Narcan nasal spray, there was no change in the patient's level of consciousness. Plan: Given the patient's DNR status, aggressive interventions were not pursued. The patient's son was informed of the situation, and he declined hospitalization. The patient will continue to be monitored closely for any changes in consciousness or overall condition. DNR supported by son. On [DATE] at 3:20 p.m., the DON provided the surveyor with a copy of the nurse practitioner signed progress note for Resident #9 with a date of service of [DATE]; this note was signed on [DATE] (27 days after the Resident #9's death), at 2:42 p.m. This signed progress note included the following wording difference related to the nurse practitioners plan when compared to the aforementioned unsigned, draft version: The patient's son was informed of the situation, and he declined hospitalization and confirmed the DNR. On [DATE] at approximately 4:00 p.m., the nurse practitioner, who cared for Resident #9 on the day he died, reported they had talked with the residents' family, and the family was okay with the resident not being sent to the hospital. On [DATE] via a telephone interview, the nurse practitioner reported, early in Resident #9's stay at the facility, the resident had said he was ready to die but the nurse practitioner did not recall him making additional statements about not wanting to go to the hospital or limiting care/treatment. Resident #9's son was interviewed via telephone on [DATE] at 3:35 p.m. Resident #9's son was the only name (other than the resident's) listed under the contact section of Resident 9's clinical record. Resident #9's son reported he was called at 12:15 p.m., on the day his father died, by a nurse asking about a choice of mortuary due to his father was dying. Resident #9 stated he asked to speak with the attending physician. Resident #9's son stated the nurse practitioner called him back at 12:20 p.m. Resident #9's son reported the nurse practitioner discussed the resident's DNR and wanted to keep the resident at the facility. Resident #9's son said he did not agree to keep his father at the facility. Resident #9's son stated he heard the nurse practitioner tell someone to get the resident ready to send to the hospital. Resident #9's son reported he hung up with the nurse practitioner then called the facility back approximately 2 minutes later to confirm his request for Resident #9 to be sent to the hospital. Licensed Practical Nurse (LPN) #2 confirmed she had initially telephoned Resident #9's son on [DATE]. LPN #2 stated the son requested to speak to someone else. LPN #2 reported they heard the nurse practitioner speaking to Resident #9's son via the telephone. LPN #2 stated the nurse practitioner informed Resident #9's son that the resident wasn't doing well and stated the family should come in. LPN #2 stated they heard the nurse practitioner tell Resident #9's son the resident could be sent to the hospital. LPN #2 stated their understanding was Resident #9's son was okay with the resident remaining at the facility. LPN #2 stated she was not informed to prepare the resident for transport to the hospital by the nurse practitioner. LPN #2 reported Resident #9's son called the facility back after his telephone conversation with the NP. LPN #2 reported the son requested Resident #9 to be sent to the hospital. LPN #2 stated they notified the Medical Director of the son requesting to send Resident #9 to the hospital prior to LPN #2 and the Medical Director entering the room to assess Resident #9. The following nurse's note, dated [DATE] at 12:25 p.m., was documented by LPN #2: This nurse and (physician name omitted) entered room for new assessment of patient. (Physician name omitted) auscultated and assessed patient head to toe. Patient with continued [NAME] stoke breathing observed and cold to touch. Patient does not arouse to verbal stimuli at this time. Unable to obtain vital signs at this time. (Physician name omitted) called and left voicemail for son (Resident #9's son's name omitted). There is no Medical Director documentation of this interaction with Resident #9. During an interview on [DATE] at 11:55 a.m., the Medical Director reported that he had been notified by someone that Resident #9 had stated to a nurse that he was ready to die and did not want aggressive interventions. The Medical Director reported he attempted to contact Resident #9's son but was unsuccessful. The Medical Director stated he consulted with the Director of Nursing (DON) and another physician related to Resident #9's alleged request for no aggressive treatment. The Medical Director reported they were in the process of sending Resident #9 to the hospital when the resident died. A Medical Director progress note for Resident #9, with a service date of [DATE], was neither found by nor provided to the surveyor. The physician was unable to provide documentation to indicate the resident had made specific requests related to limiting treatment. Resident #9's chart only contained the DNR order. No documentation was found by or provided to the survey team to indicate the resident had requested to not be sent to the hospital. Resident #9's clinical record included a nursing progress note entered on [DATE] at 1:31 p.m., this note documented the facility staff pronouncing Resident #9 as being dead with the time of death being 1:30 p.m. No evidence was found that facility staff had made any effort to transport Resident #9 to the hospital, as Resident #9's son had requested. A review was conducted of the Change in Condition policy, with a revision date of [DATE]. An excerpt read: - The Center [sic] to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. - The nurse [sic] to notify the attending physician and Resident Representative when there is a(n): . Significant change in the patient/resident's physical, mental, or psychosocial status . - In the event of an emergency situation, 911 [sic] to be called and the attending physician and the Resident Representative [sic] to be notified as soon as possible. - Document notification in the medical record. On [DATE] at 12:40 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Quality Assurance (QA) Nurse. During this meeting, the surveyor discussed the failure of the facility staff to ensure that Resident #9 received timely medical care and/or emergency transport to a local hospital/emergency department in response to a decline/change in the resident's condition. After Immediate Jeopardy was called, the facility submitted the following IJ Removal Plan: All current residents will be assessed by a licensed nurse for a potential change in condition which may indicate the need for transport to an Emergency Department or hospital for a higher level of care. If a resident is identified, the physician/practitioner and the resident's representative will be notified and orders for care will be immediately implemented. The facility will educate all licensed nurses on care restrictions designated by a DNR (Do Not Resuscitate order) and the required staff action to ensure that resident preferences for emergency or end of life care or those indicated by their designated responsible party are honored and correctly documented in the resident's medical record. Education will begin [DATE] evening shift and additional staff will be educated prior to providing care at their assigned shifts. Newly hired licensed nurses and medical staff will be educated on DNR and Advance Directives during orientation. The facility will educate the medical staff [physician and nurse practitioners] including on-call providers on the care restrictions designated by a DNR and the required staff action to ensure that all residents' preferences for emergency or end of life care, or those indicated by their designated responsible party are honored and correctly documented. Education will begin [DATE] evening shift and additional staff will be educated prior to providing care at their assigned shifts. Current residents with written Advance Directives will be reviewed and orders will be validated and/or obtained to match the resident's preferences. The facility policy on Advance Directive has been reviewed and approved by the Medical Director. Date of Compliance: [DATE] 12:00 PM On the afternoon of [DATE], the survey team reviewed the documentation of the facility staff' audits of all current residents. These audits were looking for (a) a change in condition which required interventions and (b) an audit of current residents' advanced directive wishes to ensure accurate corresponding clinical documentation. No concerns were identified with these audits. The survey team reviewed the facility's training material related to addressing residents' change in conditions while correctly implementing the residents' documented advanced directives and/or DNR's. The survey team reviewed the documentation of the staff members who had already completed this training. The survey team interviewed the facility's licensed nurses working on the afternoon of [DATE]. All the licensed nurses that were interviewed had evidence of receiving the aforementioned training. All the licensed nurses were able to appropriately explain what a DNR order requires and doesn't require when providing care for residents. (LPN #2 was interviewed via telephone. LPN #2 provided appropriate answers related to how a DNR order would and would not influence addressing residents' changes in condition.) The survey team interviewed the facility's current medical providers related to the advanced directives verses DNR orders. The medical providers were able to explain what the DNR order requires and the limitations of the DNR orders when addressing residents' changes in condition. Upon verification of the removal plan, the Immediate Jeopardy was cleared on [DATE] at 2:45 p.m.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation the facility staff failed to ensure that for 1 of 23 residents the environment was free of accident hazards in regards to a fall (Resident #276). The findings included: The facility staff failed to place a fall mat beside Resident #276 bed. On 02/09/2020, Resident #276 fell from the bed, hit their head, and was sent to a local hospital where they received 3 stitches. The resident's (CCP) comprehensive care plan included the intervention fall mats beside of bed date of initiation 01/22/2020. This was a closed record review. Resident #276's (EHR) electronic health record included the diagnoses, Alzheimer's disease, dementia, and hypertension. Section C (cognitive patterns) of the residents annual (MDS) minimum data set assessment with an (ARD) assessment reference date of 02/03/2020 had been coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. Section E (behavior) was coded to indicate the resident did not have any behaviors, Section G (functional status) was coded 4/3 (totally dependent on two persons) for bed mobility, transfers, toilet use, and personal hygiene. The resident was coded as using a wheelchair for mobility and as having an impairment on both sides of the upper and lower extremities in range of motion. Section J (health conditions) was coded with a 1 indicting the resident had a fall since admission with a non-major injury. Section P (restraints) was coded to indicate the resident did not use any restraints but did have a wander/elopement alarm in place. The residents fall risk evaluation completed 11/06/2019 had a documented score of 15 (no risk). The fall risk evaluation completed on 01/31/2020 included a documented score of 30 (low risk). The residents CCP with a revision date of 10/31/2019 included the focus area at risk for falls related to Alzheimer's dementia, confusion, unaware of safety needs, vision/hearing problems, requires assistance with activities of daily living (ADL's) and incontinence. Recent fall. Interventions included, but were not limited to, fall mats beside of bed (01/22/2020), anticipate and meet the resident's needs (11/28/2018), be sure the residents call light is within reach and encourage the resident to use it for assistance as needed (11/28/2018). The EHR included physicians orders to indicate the resident had 2 1/4 side rails to bed. These side rails were discontinued on 01/12/2020. On 04/07/2021 at 7:55 a.m., the DON stated that the fall the resident sustained on 02/09/2020 was the residents first fall from the bed since they had been admitted . Side rail evaluation completed 01/12/2020-Indicated the side rails were not used for bed mobility, transfers, or did not assist the resident in avoiding rolling out of bed and did not assist the resident in providing a sense of security. This document was coded (yes) for the questions Could the use of bed rails create an accident hazard or barrier for this resident, would the use of bed rails act as a physical restraint for this resident, impeding movement or limiting their daily activities, and would the use of bed rails have negative psychosocial outcomes for this resident such as feelings of isolation, increased agitation or anxiety, or alter resident's self-esteem. Recommendations: Side rails Not indicated. This form had been signed by (LPN) licensed practical nurse #4. Side rail evaluation completed 01/31/2020-Why is the use of a bed rail(s) being considered-family requested. This document was coded to indicate side rail(s) would assist the resident in bed mobility, transfers, avoid rolling out of the bed and providing a sense of security. Recommendations: Side rails recommended to help with positioning. This document had been signed by the (DON) director of nursing on 02/13/2020. On 04/07/2021 at 12:26 p.m., the DON stated the side rails were discontinued on 01/12/2020 and the side rail evaluation for 01/31/2020 contained incorrect documentation. The resident was not using side rails/bed rails at the time of the fall. Resident #276's EHR included the following progress note documented on 02/09/2020 at 6:11 a.m. by (licensed practical nurse) LPN #1. 4:40 Am (CNA) certified nursing assistant reported to this nurse that resident was on floor at time when got to room resident was lying on side beside her bed which was in low position at time with blood noted under head was not moved at time (11 (sic) dialed. Hospice aware at time and daughter aware at time. (EMS) emergency medical services attended her at time. left on stretcher accompanied by EMT staff at time. (VS) vital signs 98.2-99-18 (B/P) blood pressure 170/83 (02) oxygen sat 92%. On 04/07/2021 at 9:30 a.m., the surveyor left a message for LPN #1 to call the surveyor. No return call was received prior to the exit conference. Per the DON, the CNA that was working at the time of the incident was no longer employed at the facility. The EHR included a physicians order dated 02/09/2020 to send to (ER) emergency room eval. head wound. At 10:37 p.m. on 02/09/2020, LPN #2 documented . (Rsd) resident (LOA) leave of absence at (ED) emergency department for laceration to head. Will return. On 02/09/2020, Resident #276 was treated in the ED at a local hospital and returned the facility. The facility provided the surveyor with ED notes that included the following documentation. Additional Patient, Scene, and Transport Information-patient arrives by EMS due to fall, staff found patient, unknown downtime, hit head, quarter size indentation on forehead. bruising under right eye. mild bleeding from nose. hospice care, (hx) history dementia. ED Notes, ED Triage Notes, ED Provider Notes- .Dried blood over patients face and left hand ED Course Sunday February 9, 2020 6:21 a.m. Spoke to daughter, the patients power of attorney. She would not like to obtain a CT head or C-spine for the patient given her (DNR/DNI) Do not Resuscitate/Do not intubate status. Discharge Instructions-Today you are seen in emergency department after a fall. There is a large laceration to your forehead that was repaired with 3 sutures. Please have the sutures removed in 10 to 14 days. Please keep the area clean and dry .No CT scan of your head was done per the request of your daughter . On 02/10/2020 at 2:27 a.m., LPN #1 documented Resting, Staples in place to forehead. Resident alert when spoken to. Assisted as needed with (ADLS) activities of daily living, mat at bedside low bed in place. No (C/O,s) complaints of when checked. Call light in reach at all times. The facility provided the surveyor with a copy of an EMPLOYEE CORRECTIVE ACTION FORM in regards to CNA #1, date of infraction was documented as 02/09/2020. Description of violation-Associate failed to put the fall mat back down for resident in _____ (room). Witness statement from LPN #1 read in part, on 2/9/20 440 am CNA ___ called me to room stated resident had fallen + had bleeding from head @ time ____ (room and resident name) We immediately called Supervisor _____ to unit to assist. I immediately dialed 911 at time. I did not move resident due (lg) large amt clotted blood under head with top head near bed____ stand. VS were obtained .fall mat was not on left side of bed at time of fall. The FRI (facility reported incident) revealed that the facility had completed an investigation on this fall and a five point POC (plan of correction) has been implemented. The surveyor asked the administration staff if a POC had been completed. The DON provided the surveyor with a form titled, Ad Hoc Quality Assurance & Performance Improvement Meeting dated 02/11/2020. Reason for Ad Hoc Meeting Fall (Resident #276). Opportunity for Improvement-Failure to Implement Fall Intervention at bedside Data-Fall with Laceration Analysis (Root Cause Analysis)-Fall mat was not at bed side per c/p (care plan). Plan-Review all falls from previous 60 days to ensure that resident fall intervention are appropriate, in place, C/P and reflected on kardex. Provide 1:1 re-education with nursing assistant. Re-education all nursing staff related to ensure all inventions (sic) are in place prior to leaving resident. There was no date of compliance on this form. The executive director, director of clinical services, medical director, and 2 others had signed the bottom of this form on 02/11/2020. There was documentation on this form to indicate the next meeting would be held on 02/13/2020. This form did not clearly identify the title of the person responsible for implementing the POC. On 04/07/2021 at 1:52 p.m., the DON acknowledged there was no date of compliance on the POC form and stated their education was completed by 02/13/2020 and audits completed by 02/14/2020. The DON stated so the date of compliance was 02/14/2020. The facility provided the surveyor with copies of 3 in-service log sign-up sheets completed by the (ADON) assistant director of nursing. Specific for Resident in room ______. Four signature sheets all dated 02/10/2020. Fall Mats & Bed Alarms. Six signature sheets dated 02/11/2020 and 02/12/2020. Abuse education. Five signature sheets dated 02/13/2020. Various staff were asked to identify their signature on the signature sheets/in-service logs provided to the surveyor. The DON and LPN #5 were unable to locate their signatures on the sheets specific for the resident or for the fall mats and bed alarm education. On 04/08/2021 at 1:54 p.m., the DON reviewed the signature sheets and stated she had been in-serviced by 02/14/2020. When asked if the expectation of whomever was in the in-service would have signed the in-service sheets the DON replied, yes. On 04/08/2021 at 2:18 p.m., during a meeting the (RNC) regional nurse consultant, ADON, and administrator. The RNC verbalized to the surveyor that not everyone signed every sheet of the in-service forms and the in-service on abuse was not part of their POC. The ADON stated all the in-services were completed together even though the dates did not reflect that. The RNC added that the Ad Hoc form was just minutes but it is what is considered our POC. On 04/08/2021 at 2:43 p.m., LPN #5 stated they attended the in-services and that there were so many sheets going around. LPN #5 stated they did the follow up audits after the fact and the training was about falls mats and alarms. LPN #5 stated it has been so far back and identified their signature on the in-service signature sheet on abuse. This was the in-service (education) that the RNC stated was not part of their POC. No further information regarding this issue was provided to the survey team prior to the exit conference on 04/08/2021. The surveyor did a complete walkthrough of the facility on 04/07/2021 at approximately 7:00 a.m. and no problems with bed rails or floor mats were identified. Floor mats were observed to be in use. No similar complaints were received while on site. This is a complaint deficiency.

Resident # 102 had current orders for [MEDICATION NAME] HCI Tablet 10 mg (milligram) Give 12 tablet by mouth one time a day for pain, which was initiated by the physician on 11/29/18. Resident # 102 also had orders for [MEDICATION NAME] HCI tablet 5 mg Give 2 tablet by mouth every 6 hours as needed for pain related to low back pain, which was initiated by the physician on 12/6/18. On 2/12/19 at 1:00 pm, the surveyor reviewed the (MONTH) 2019 Medication Administration Record [REDACTED]. According to the Chart Codes/Follow Up Codes 9 = Other/ See Nurses Notes. Upon review of the progress notes for Resident # 102, the surveyor observed a Medication Administration Note for Resident # 102 documented on 2/11/19 at 10:16 am. The medication administration note was documented as, [MEDICATION NAME] HCI Tablet 10 mg give 12 tablet by mouth one time a day for pain notified pharmacy and md about order. On 2/12/19 at 3:13 pm, the surveyor interviewed LPN # 2 (licensed practical nurse) via telephone. LPN # 2 confirmed that she was responsible for administering medications to Resident # 102 on 2/11/19. The surveyor asked LPN # 2 why Resident # 102 did not receive the physician ordered [MEDICATION NAME] at 9:00 am on the morning of 2/11/19. LPN # 2 stated, He didn't have it there. LPN # 2 stated that the facility called the pharmacy that morning and the facility was charged and paid for the [MEDICATION NAME] and the pharmacy delivered the [MEDICATION NAME] to the facility. The surveyor asked LPN # 2 what time Resident # 102 received the [MEDICATION NAME] on 2/11/19. LPN # 2 stated, He didn't get it until 11 something. The surveyor asked LPN # 2 if Resident # 102 reported pain while he did not have the physician ordered [MEDICATION NAME]. LPN # 2 stated, He said that he was hurting but I gave him two [MEDICATION NAME]. He was very upset and said he was going to call the ombudsman. On 12/13/19 at 12:00 pm, a Resident interview was conducted with Resident # 102 in the presence of 3 surveyors. Resident # 102 stated that on Monday 2/11/19, he was waiting for the nurse to give him his medicine. Resident # 102 stated that he usually received his medication first because he was the first room on the hall. Resident # 102 stated that he noticed that the nurse kept skipping his room and he was in pain. Resident # 102 stated that he finally got up and walked down the hall and asked the medication nurse for his medication. Resident # 102 stated that the medication nurse informed him that they were out of his medication. Resident # 102 stated that he could not believe that the facility let him run out of his [MEDICATION NAME] again. Resident # 102 stated that he spoke with the unit manager RN # 1 (registered nurse). Resident # 102 stated that RN # 1 informed him that the pharmacy did not send his medication. Resident # 102 stated that he then told RN # 1 that he heard the facility staff nurses state that there was no prescription for his [MEDICATION NAME] and that a prescription had to be written that Monday morning (2/11/19). Resident # 102 stated that RN # 1 stated that she would look into the situation, later returned, and told him that he was correct and that the prescription for [MEDICATION NAME] had been obtained that morning. Resident # 102 stated, They should not let me run out of my [MEDICATION NAME]. The surveyor asked Resident # 102 if the facility staff provided him with anything for pain in place of the [MEDICATION NAME]. Resident # 102 stated that the facility staff gave him his prn (as needed) [MEDICATION NAME] 10 mg. The surveyor asked Resident # 102 if the [MEDICATION NAME] 10 mg helped to relieve his pain during the time that the facility did not have the [MEDICATION NAME]. Resident # 102 stated, No, I take 12 tablets of [MEDICATION NAME] at one time. The surveyor asked Resident # 102 to rate his pain during the time he went without his [MEDICATION NAME] on a scale of 0 to 10 with zero being no pain and 10 being the worst pain he could imagine. Resident # 102 rated his pain at a level of 9 out of 10. The surveyor asked Resident # 102 what level of pain is usually tolerable for him. Resident # 102 reported that a pain level of 5 out of 10 was tolerable for him. Resident # 102 stated, Last time this happened was New Year's and I went into full blown withdrawal. I had to wait for two days to get it back. I was vomiting and going to the bathroom on myself. I felt like I was going to die. On 2/13/19 at 1:00 pm, the surveyor reviewed the progress notes for Resident # 102. The surveyor observed the following progress notes. A progress note documented on 1/1/19 at 9:21 am was documented as, [MEDICATION NAME] in drawer is only 4 tablets. Refill was not sent from pharmacy. Called pharmacy spoke with (pharmacy employee's name withheld) and she told me medication would be on next run. Also called(NAME)line and was told medication had already been put in to be sent on next run. 3-11 nurse notified that I spoke with pharmacy regarding medication. Resident received 4 pills in the cart awaiting delivery for full dose. Resident aware. A progress note documented on 1/1/19 at 6:24 pm, was documented as, Called pharmacy to deliver [MEDICATION NAME]. Pt. (patient) only received 40 mg dose today. Behaviors cursing staff and general moodiness, refusing evening meds. Pharm (pharmacy) was called would not send out until they receive new script. On call DR (doctor) (Physician's name withheld) was called and she wrote a one day script for 1/2/19. Pharmacy was called back and will send out on 1/2/19. A progress note documented on 1/2/19 at 10:36 am was documented as [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg Give 1 tablet by mouth every 6 hours as needed for nausea given for nausea vomiting. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg give 1 tablet by mouth every 6 hours as needed for nausea patient stated the [MEDICATION NAME] prn administration was ineffective. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME] HCI tablet 5 mg give 2 tablets by mouth every 6 hours as needed for pain related to low back pain [MEDICATION NAME] 5 mg every 6 hours prn 10/10 back pain. A progress note documented on 1/2/19 at 12:34 pm was documented as. This nurse spoke with (Pharmacy employee's name withheld) from (pharmacy name withheld), manager, about [MEDICATION NAME] not arriving in a timely manner. (Pharmacy employee's name withheld) verified medication was ordered on 12/31 online however due to the holiday it could not be filled. Then the next day nurse again called pharmacy again and requested the medication. Pt. received 40 mg which is what we had on hand. The pharmacy explained that they needed new script due to it being a holiday and needing to get med from a different pharmacy because it is controlled. Script was obtained and faxed med was not here 1/2/19 in the morning nurse again called pharmacy requested it stat in which (Pharmacy employee's name withheld) at (pharmacy's name withheld) stated it would be sent. 12 pm and medication was still not here. Nurse called back again spoke to (pharmacy employee's name withheld) in which she stated (pharmacy employee's name withheld) never put in as stat order. Order was not in as stat per (Pharmacy employee's name withheld), manager. This nurse assessed pt around 10 am. Pt appears pale, diaphoretic, states he is nauseated in which nurse gave 4 mg [MEDICATION NAME]. States he had been having diarrhea and urinating on himself all night. Vitals stable. Pt stable. This nurse informed him of plan to contact pharmacy and discuss how we will avoid this again and get medication in stat. Education provided to staff that meds will need to be reordered when the 4th card of meds is started and to order meds several days in advance of a holiday. Per (Pharmacy employee's name withheld) this nurse could keep track of med by reordering every week on wed (Wednesday), then the following week on fri (Friday) and then mon (Monday) on the third week to make sure it falls in line with insurance. Next script due jan (January) 21st. Stat medication is on it's way per (Pharmacy employee's name withheld). Will continue to monitor. Pt updated on plan of care. The surveyor observed that there was no documentation of physician notification of change of condition for Resident # 102. On 2/13/19 at 1:50 pm, the surveyor reviewed the Pain Level Summary in the clinical record for Resident # 102. The surveyor observed the following times that Resident # 102 reported pain levels of 10 during the time the [MEDICATION NAME] was not available for distribution in the facility. 1/1/19 at 6:44 pm, Resident # 102 reported a pain level of 10 1/1/19 at 7:42 pm, Resident # 102 reported a pain level of 10 1/1/19 at 8:35 pm, Resident # 102 reported a pain level of 10 1/2/19 at 4:30 am, Resident # 102 reported a pain level of 10 1/2/19 at 11:12 am, Resident # 102 reported a pain level of 10 1/2/19 at 2:00 pm, Resident # 102 reported a pain level of 10 1/2/19 at 2:21 pm, Resident # 102 reported a pain level of 10 On 2/13/19 at 3:08 pm, the surveyor interviewed the unit manager RN # 1. The surveyor asked RN # 1 if she was aware of any incidents where Resident # 102 did not have his physician ordered [MEDICATION NAME] in the facility for administration. RN # 1 stated that she was aware of the incident but could not recall the exact date. The surveyor asked RN # 1 if there was an incident that occurred on New Year's Day when Resident # 102 did not have his [MEDICATION NAME] available in the facility for administration. RN # 1 stated, Yes. RN # 1 stated that when she did come into the facility she went in to assess Resident # 102 and he was in full blown withdrawals. RN # 1 stated that Resident # 102 was shaking, diaphoretic, and was having diarrhea. The surveyor asked RN # 1 if there were any other incidents where Resident # 102's [MEDICATION NAME] was not available for administration. RN # 1 informed the surveyor that there was almost an incident on 2/11/19. RN # 1 stated that Resident # 102 got upset and came and spoke to her. RN # 1 stated that she called the physician and the pharmacy and got the medication into the facility. The surveyor then reviewed the progress note for Resident # 102 that was documented on 1/2/19 at 12:34 pm, with RN #1. The surveyor asked RN # 1 if she was the nurse that had documented the progress note in the clinical record for Resident # 102. RN # 1 stated that she had written the progress note on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 if she had informed the physician of the change of condition in Resident # 102 as documented in the progress note on 1/2/19 at 12:34 pm. RN # 1 stated that she did notify the nurse practitioner. RN # 1 reviewed the progress note along with the surveyor and agreed that she did not document physician notification of change in Resident # 102's status on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 who she made aware of the change in Resident # 102's condition on 1/2/19. RN # 1 stated that she made (Nurse practitioner's name withheld) aware. On 2/13/19 at 2:14 pm, the surveyor interviewed (Pharmacist name withheld) via telephone. The surveyor asked the pharmacist if a prescription for [MEDICATION NAME] had been received for Resident # 102. The pharmacist stated that a prescription had been received and on 1/2/19 at 2:09 pm 120 tablets of [MEDICATION NAME] was delivered to the facility for Resident # 102. The surveyor asked the pharmacist if there was an issue with the [MEDICATION NAME] prescription for Resident # 102 that would prevent the pharmacy from delivering the [MEDICATION NAME] to the facility to be available for administration. The pharmacist stated that a new prescription was needed because Resident # 102's insurance rejected the refill order. The pharmacist informed the surveyor that 60 tablets of [MEDICATION NAME] was delivered to the facility at 11:22 am on 2/11/19. On 2/13/19 at 3:30 pm, the surveyor spoke with (Nurse Practitioner's name withheld) via telephone in the presence of RN #1 and 2 other surveyors. The surveyor asked (Nurse Practitioner's name withheld) if he had been made aware of a change in Resident # 102's condition on 1/2/19. (Nurse practitioner's name withheld) stated, No. RN # 1 then interjected and stated, (Nurse practitioner's name withheld), I called you on that day to make you aware of the change with Resident # 102. (Nurse practitioner's name withheld) stated, You probably did. I must have forgotten. The surveyor asked (Nurse Practitioner's name withheld) if he would expect the nurses to make him aware when Resident's experience a change in condition. The nurse practitioner stated, Yes. The surveyor asked the nurse practitioner what he would have done for Resident # 102 if he had been made aware of his change of condition on 1/2/19. The nurse practitioner stated, Probably give him some [MEDICATION NAME]. The surveyor asked the nurse practitioner if that is all that he would have ordered for Resident # 102 The nurse practitioner stated, Yes. The facility policy on Notification of Change in Condition contained documentation that included but was not limited to, . Procedure The nurse to notify the attending physician and Resident Representative when there is a (n): Significant change in the patient/resident's physical, mental, or psychosocial status. The facility policy on Medication Shortages/Unavailable Medications contained documentation that included but was not limited to, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of this Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order to reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery;, 3.2.2 Use of an emergency (back-up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. 5. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. On 2/13/19 at 7:00 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 2/13/19. This is a complaint deficiency.

Citation Text for Tag 0755, Regulation FF11 Brouse, Debra Chappell, Shonea Based on clinical record review, Resident interview, staff interview, facility document review, and during the course of a complaint investigation, the facility staff failed to provide pharmaceutical services to meet the needs of 1 of 12 Residents in the survey sample, Resident # 102. The findings included The facility staff failed to ensure that the physician ordered [MEDICATION NAME] was in the facility and available for administration, which resulted in incomplete and late dose administrations. This caused Resident # 102 to report a pain scale of 9/10 and 10/10, and experience withdrawal symptoms because of not having the [MEDICATION NAME] in the facility. Resident # 102 was a [AGE] year-old-male who was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 102 was reviewed on 2/12/19 at 12:42 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 12/4/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 102 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 102 was cognitively intact. The plan of care for Resident # 102 was reviewed and revised on 2/17/18. The facility staff documented a focus area for Resident # 102 as, Resident # 102 has alterations in pain R/T (related to) [MEDICAL CONDITION] C5-C7, [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease), wounds, [MEDICAL CONDITIONS], [MEDICATION NAME] [DIAGNOSES REDACTED], chronic pai[DIAGNOSES REDACTED], low back pain, muscle spasms. Interventions included but were not limited to, Medications per MD orders, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Resident # 102 had current orders for [MEDICATION NAME] HCI Tablet 10 mg (milligram) Give 12 tablet by mouth one time a day for pain, which was initiated by the physician on 11/29/18. Resident # 102 also had orders for [MEDICATION NAME] HCI tablet 5 mg Give 2 tablet by mouth every 6 hours as needed for pain related to low back pain, which was initiated by the physician on 12/6/18. On 2/12/19 at 1:00 pm, the surveyor reviewed the (MONTH) 2019 Medication Administration Record [REDACTED]. According to the Chart Codes/Follow Up Codes 9 = Other/ See Nurses Notes. Upon review of the progress notes for Resident # 102, the surveyor observed a Medication Administration Note for Resident # 102 documented on 2/11/19 at 10:16 am. The medication administration note was documented as, [MEDICATION NAME] HCI Tablet 10 mg give 12 tablet by mouth one time a day for pain notified pharmacy and md about order. On 2/12/19 at 3:13 pm, the surveyor interviewed LPN # 2 (licensed practical nurse) via telephone. LPN # 2 confirmed that she was responsible for administering medications to Resident # 102 on 2/11/19. The surveyor asked LPN # 2 why Resident # 102 did not receive the physician ordered [MEDICATION NAME] at 9:00 am on the morning of 2/11/19. LPN # 2 stated, He didn't have it there. LPN # 2 stated that the facility called the pharmacy that morning and the facility was charged and paid for the [MEDICATION NAME] and the pharmacy delivered the [MEDICATION NAME] to the facility. The surveyor asked LPN # 2 what time Resident # 102 received the [MEDICATION NAME] on 2/11/19. LPN # 2 stated, He didn't get it until 11 something. The surveyor asked LPN # 2 if Resident # 102 reported pain while he did not have the physician ordered [MEDICATION NAME]. LPN # 2 stated, He said that he was hurting but I gave him two [MEDICATION NAME]. He was very upset and said he was going to call the ombudsman. On 12/13/19 at 12:00 pm, a Resident interview was conducted with Resident # 102 in the presence of 3 surveyors. Resident # 102 stated that on Monday 2/11/19, he was waiting for the nurse to give him his medicine. Resident # 102 stated that he usually received his medication first because he was the first room on the hall. Resident # 102 stated that he noticed that the nurse kept skipping his room and he was in pain. Resident # 102 stated that he finally got up and walked down the hall and asked the medication nurse for his medication. Resident # 102 stated that the medication nurse informed him that they were out of his medication. Resident # 102 stated that he could not believe that the facility let him run out of his [MEDICATION NAME] again. Resident # 102 stated that he spoke with the unit manager RN # 1 (registered nurse). Resident # 102 stated that RN # 1 informed him that the pharmacy did not send his medication. Resident # 102 stated that he then told RN # 1 that he heard the facility staff nurses state that there was no prescription for his [MEDICATION NAME] and that a prescription had to be written that Monday morning (2/11/19). Resident # 102 stated that RN # 1 stated that she would look into the situation, later returned, and told him that he was correct and that the prescription for [MEDICATION NAME] had been obtained that morning. Resident # 102 stated, They should not let me run out of my [MEDICATION NAME]. The surveyor asked Resident # 102 if the facility staff provided him with anything for pain in place of the [MEDICATION NAME]. Resident # 102 stated that the facility staff gave him his prn (as needed) [MEDICATION NAME] 10 mg. The surveyor asked Resident # 102 if the [MEDICATION NAME] 10 mg helped to relieve his pain during the time that the facility did not have the [MEDICATION NAME]. Resident # 102 stated, No, I take 12 tablets of [MEDICATION NAME] at one time. The surveyor asked Resident # 102 to rate his pain during the time he went without his [MEDICATION NAME] on a scale of 0 to 10 with zero being no pain and 10 being the worst pain he could imagine. Resident # 102 rated his pain at a level of 9 out of 10. The surveyor asked Resident # 102 what level of pain is usually tolerable for him. Resident # 102 reported that a pain level of 5 out of 10 was tolerable for him. Resident # 102 stated, Last time this happened was New Year's and I went into full blown withdrawal. I had to wait for two days to get it back. I was vomiting and going to the bathroom on myself. I felt like I was going to die. On 2/13/19 at 1:00 pm, the surveyor reviewed the progress notes for Resident # 102. The surveyor observed the following progress notes. A progress note documented on 1/1/19 at 9:21 am was documented as, [MEDICATION NAME] in drawer is only 4 tablets. Refill was not sent from pharmacy. Called pharmacy spoke with (pharmacy employee's name withheld) and she told me medication would be on next run. Also called Richmond line and was told medication had already been put in to be sent on next run. 3-11 nurse notified that I spoke with pharmacy regarding medication. Resident received 4 pills in the cart awaiting delivery for full dose. Resident aware. A progress note documented on 1/1/19 at 6:24 pm, was documented as, Called pharmacy to deliver [MEDICATION NAME]. Pt. (patient) only received 40 mg dose today. Behaviors cursing staff and general moodiness, refusing evening meds. Pharm (pharmacy) was called would not send out until they receive new script. On call DR (doctor) (Physician's name withheld) was called and she wrote a one day script for 1/2/19. Pharmacy was called back and will send out on 1/2/19. A progress note documented on 1/2/19 at 10:36 am was documented as [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg Give 1 tablet by mouth every 6 hours as needed for nausea given for nausea vomiting. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg give 1 tablet by mouth every 6 hours as needed for nausea patient stated the [MEDICATION NAME] prn administration was ineffective. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME] HCI tablet 5 mg give 2 tablets by mouth every 6 hours as needed for pain related to low back pain [MEDICATION NAME] 5 mg every 6 hours prn 10/10 back pain. A progress note documented on 1/2/19 at 12:34 pm was documented as. This nurse spoke with (Pharmacy employee's name withheld) from (pharmacy name withheld), manager, about [MEDICATION NAME] not arriving in a timely manner. (Pharmacy employee's name withheld) verified medication was ordered on 12/31 online however due to the holiday it could not be filled. Then the next day nurse again called pharmacy again and requested the medication. Pt. received 40 mg which is what we had on hand. The pharmacy explained that they needed new script due to it being a holiday and needing to get med from a different pharmacy because it is controlled. Script was obtained and faxed med was not here 1/2/19 in the morning nurse again called pharmacy requested it stat in which (Pharmacy employee's name withheld) at (pharmacy's name withheld) stated it would be sent. 12 pm and medication was still not here. Nurse called back again spoke to (pharmacy employee's name withheld) in which she stated (pharmacy employee's name withheld) never put in as stat order. Order was not in as stat per (Pharmacy employee's name withheld), manager. This nurse assessed pt around 10 am. Pt appears pale, diaphoretic, states he is nauseated in which nurse gave 4 mg [MEDICATION NAME]. States he had been having diarrhea and urinating on himself all night. Vitals stable. Pt stable. This nurse informed him of plan to contact pharmacy and discuss how we will avoid this again and get medication in stat. Education provided to staff that meds will need to be reordered when the 4th card of meds is started and to order meds several days in advance of a holiday. Per (Pharmacy employee's name withheld) this nurse could keep track of med by reordering every week on wed (Wednesday), then the following week on fri (Friday) and then mon (Monday) on the third week to make sure it falls in line with insurance. Next script due jan (January) 21st. Stat medication is on it's way per (Pharmacy employee's name withheld). Will continue to monitor. Pt updated on plan of care. The surveyor observed that there was no documentation of physician notification of change of condition for Resident # 102. On 2/13/19 at 1:50 pm, the surveyor reviewed the Pain Level Summary in the clinical record for Resident # 102. The surveyor observed the following times that Resident # 102 reported pain levels of 10 during the time the [MEDICATION NAME] was not available for distribution in the facility. 1/1/19 at 6:44 pm, Resident # 102 reported a pain level of 10 1/1/19 at 7:42 pm, Resident # 102 reported a pain level of 10 1/1/19 at 8:35 pm, Resident # 102 reported a pain level of 10 1/2/19 at 4:30 am, Resident # 102 reported a pain level of 10 1/2/19 at 11:12 am, Resident # 102 reported a pain level of 10 1/2/19 at 2:00 pm, Resident # 102 reported a pain level of 10 1/2/19 at 2:21 pm, Resident # 102 reported a pain level of 10 On 2/13/19 at 3:08 pm, the surveyor interviewed the unit manager RN # 1. The surveyor asked RN # 1 if she was aware of any incidents where Resident # 102 did not have his physician ordered [MEDICATION NAME] in the facility for administration. RN # 1 stated that she was aware of the incident but could not recall the exact date. The surveyor asked RN # 1 if there was an incident that occurred on New Year's Day when Resident # 102 did not have his [MEDICATION NAME] available in the facility for administration. RN # 1 stated, Yes. RN # 1 stated that when she did come into the facility she went in to assess Resident # 102 and he was in full blown withdrawals. RN # 1 stated that Resident # 102 was shaking, diaphoretic, and was having diarrhea. The surveyor asked RN # 1 if there were any other incidents where Resident # 102's [MEDICATION NAME] was not available for administration. RN # 1 informed the surveyor that there was almost an incident on 2/11/19. RN # 1 stated that Resident # 102 got upset and came and spoke to her. RN # 1 stated that she called the physician and the pharmacy and got the medication into the facility. The surveyor then reviewed the progress note for Resident # 102 that was documented on 1/2/19 at 12:34 pm, with RN #1. The surveyor asked RN # 1 if she was the nurse that had documented the progress note in the clinical record for Resident # 102. RN # 1 stated that she had written the progress note on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 if she had informed the physician of the change of condition in Resident # 102 as documented in the progress note on 1/2/19 at 12:34 pm. RN # 1 stated that she did notify the nurse practitioner. RN # 1 reviewed the progress note along with the surveyor and agreed that she did not document physician notification of change in Resident # 102's status on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 who she made aware of the change in Resident # 102's condition on 1/2/19. RN # 1 stated that she made (Nurse practitioner's name withheld) aware. On 2/13/19 at 2:14 pm, the surveyor interviewed (Pharmacist name withheld) via telephone. The surveyor asked the pharmacist if a prescription for [MEDICATION NAME] had been received for Resident # 102. The pharmacist stated that a prescription had been received and on 1/2/19 at 2:09 pm 120 tablets of [MEDICATION NAME] was delivered to the facility for Resident # 102. The surveyor asked the pharmacist if there was an issue with the [MEDICATION NAME] prescription for Resident # 102 that would prevent the pharmacy from delivering the [MEDICATION NAME] to the facility to be available for administration. The pharmacist stated that a new prescription was needed because Resident # 102's insurance rejected the refill order. The pharmacist informed the surveyor that 60 tablets of [MEDICATION NAME] was delivered to the facility at 11:22 am on 2/11/19. On 2/13/19 at 3:30 pm, the surveyor spoke with (Nurse Practitioner's name withheld) via telephone in the presence of RN #1 and 2 other surveyors. The surveyor asked (Nurse Practitioner's name withheld) if he had been made aware of a change in Resident # 102's condition on 1/2/19. (Nurse practitioner's name withheld) stated, No. RN # 1 then interjected and stated, (Nurse practitioner's name withheld), I called you on that day to make you aware of the change with Resident # 102. (Nurse practitioner's name withheld) stated, You probably did. I must have forgotten. The surveyor asked (Nurse Practitioner's name withheld) if he would expect the nurses to make him aware when Resident's experience a change in condition. The nurse practitioner stated, Yes. The surveyor asked the nurse practitioner what he would have done for Resident # 102 if he had been made aware of his change of condition on 1/2/19. The nurse practitioner stated, Probably give him some [MEDICATION NAME]. The surveyor asked the nurse practitioner if that is all that he would have ordered for Resident # 102 The nurse practitioner stated, Yes. The facility policy on Notification of Change in Condition contained documentation that included but was not limited to, . Procedure The nurse to notify the attending physician and Resident Representative when there is a (n): Significant change in the patient/resident's physical, mental, or psychosocial status. The facility policy on Medication Shortages/Unavailable Medications contained documentation that included but was not limited to, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of this Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order to reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery;, 3.2.2 Use of an emergency (back-up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. 5. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. On 2/13/19 at 7:00 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 2/13/19. This is a complaint deficiency.

Based on staff interview, resident interview, clinical record review, and facility document review, the facility failed to ensure resident rights and dignity were met for 1 of 23 Residents in the survey sample, Resident #5. The findings included: The facility staff failed to ensure the safety and dignity of Resident #5 was maintained. Another resident's family member cornered Resident # 5 in his room, verbally threatened and belittled him and caused him to urinate on himself. Resident # 5 was a [AGE] year-old-male who was admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 5 was reviewed on 12/13/18 at 10:41 am. The most recent MDS (minimum data set) assessment for Resident # 5 was a quarterly assessment with an ARD (assessment reference date) of 9/3/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 5 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 15 was cognitively intact. The plan of care for Resident # 5 was reviewed and revised on 11/9/18. The facility staff documented a focus area for Resident # 5 as, Resident # 5 is independent on staff for activities, cognitive stimulation, social interaction r/t (related to) anxiety, depression, [MEDICAL CONDITIONS] limited mobility, [MEDICAL CONDITION], pain, participating in activities of choice, self acts in room such as TV (television), computer, phone, sitting on porch, parties, bingo, music, socializes with staff and residents. Resident # 5 goes by cab on community outings. Interventions included but were not limited to; Report resident c/o (complaint of) pain, discomfort, breathing difficulties or any other c/o that interferes with the resident's ability to participate in activities to the nurse prn (as needed). The surveyor reviewed the entire plan of care for Resident # 5 and did not see an update that Resident # 5 made statements that are untrue. On 12/13/18 at 7:55 am, the surveyor was in Resident # 5's room conducting a Resident interview. During the interview Resident # 5 reported to the surveyor that on 12/8/18, the alleged perpetrator (his former roommate's sister) Got in my face, yelled at me and blocked the bathroom and wouldn't let me use the bathroom. Resident # 5 stated that he was going back to his room to get hot chocolate for a group of Residents that he was socializing with and to use the bathroom because he is on a bladder-retraining program. Resident # 5 stated that when he got to his room, the alleged perpetrator asked him What's going on with you and (Resident's name withheld)? Resident # 5 stated that he told the alleged perpetrator nothing was going on and that he did not know what she was talking about. Resident # 5 then stated that the alleged perpetrator got in his face and began to yell at him stating that Resident # 5's former roommate told the alleged perpetrator that Resident # 5 had been treating him differently and that Resident # 5 was going to tell her what was going on. Resident # 5 stated that he told the alleged perpetrator that he needed to use the bathroom. Resident # 5 stated that the alleged perpetrator stood in front of the bathroom door and told him he was not going to use the bathroom until she was done with him. Resident # 5 stated that he told the alleged perpetrator, This is our room and you are a guest here. You need to get out of here. Resident # 5 stated that the alleged perpetrator continued to block the door to the bathroom. Resident # 5 stated that he began to urinate on himself. Resident # 5 stated, I felt awful, I cried. Resident # 5 stated that the alleged perpetrator finally allowed him to go into the bathroom after he had urinated on himself and stated to him, I am going to be right here when you get out because you are going to tell me what's going on with you and (Resident's name withheld). Resident # 5 stated that the alleged perpetrator continued to yell at him through the door while he was in the bathroom. Resident # 5 stated that he called the police. Resident # 5 stated that the police came and She threw a fit. Resident # 5 stated that the police made her leave that evening but it would be up to them (the facility) if they bar her from the facility. Resident # 5 stated that later that same evening other family members of his former roommate came in and intimidated him. Resident # 5 stated that his former roommate's family members sat on the other side of the room saying mean things to him and stated, If something happens to (Resident's name withheld) their asses is mine. Resident # 5 stated, They made me feel like I was a piece of crap. Resident # 5 stated the next day They came back in here like it was nothing. Resident # 5 stated that the day after the incident that the alleged perpetrator approached him as he was sitting at a square table in the hallway outside of their room and jerked the table away from me. Resident # 5 stated that he asked a staff member why the alleged perpetrator was allowed to come back into the facility after what she did to him. Resident # 5 stated that he was told she has a right to visit her family member. Resident # 5 stated that he spoke with the facility executive director on Monday and the facility executive director told Resident # 5 they would move him to a different room. Resident # 5 stated that the facility executive director stated to him, we got it all handled. Resident # 5 stated that he replied, It handles the room but it doesn't handle what she did to me. Resident # 5 stated that the facility executive director stated to him, You let me handle that. I got 2 days to investigate that. Resident # 5 then stated to the surveyor, It does not make any sense how she treated me. It made me feel like I was worthless, and they let her come back in here like it was nothing after the law put her out. I thought with me being a patient here I would be protected more. The surveyor observed at this time that Resident # 5 became tearful. Resident # 5 stated, What happens when she attacks somebody else? Are you just going to put people in another room and say that settles that. On 12/13/18 at 9:58 am, the surveyor interviewed unit manager RN # 1 (registered nurse) about the allegations of abuse reported by Resident # 5. Unit manager RN # 1 stated, I am aware briefly, I only know that the family was acting inappropriate and threatened him (Resident # 5) and the police were involved. On 12/13/18 at 10:00 am, the surveyor interviewed the facility executive director about the allegations of abuse reported by Resident # 5. The facility executive director stated, I was called Saturday night saying the police had to come to the facility saying there was a yelling match with Resident # 5 and the alleged perpetrator. We had the daughters (the alleged perpetrator and her sister) come in Monday and we spoke to them and Resident # 5. The facility executive director informed the surveyor that he was in the process of investigating the incident and that a FRI (facility reported incident) was submitted. The facility executive director then stated that Resident # 5 had been known to lie and then come back and admit to lying and saying that he was sorry. The facility executive director also stated that the nurse that called him at home to report the incident had issues with the alleged perpetrator and her family and called him that night to report the incident. She asked if he was going to have them barred from the facility. The facility executive director stated, I don't really have any evidence. There were no eye witnesses. I will be finishing this investigation by Monday but I can't see where any abuse occurred. On 12/13/18 at 10:15 am, the surveyor observed a progress note documented in the clinical record for Resident # 5 on 12/9/18 at 3:29 pm. The progress note was documented as Resident is on medi part b total care with adls (activities of daily living) incontinent of bowel and bladder uses walker for ambulation upset due to incident with roommate family of them yelling and getting into his face refusing to let him use the bathroom police was called due to roommate family being nasty and inappropriate by yelling and getting in his face. On 12/13/18 at 10:28 am, the surveyor interviewed LPN # 1 (licensed practical nurse) about the allegation of abuse reported by Resident # 5. The surveyor asked LPN # 1 if she was working and responsible for providing care to Resident # 5 on 12/8/18. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if she was aware of an incident that occurred involving the alleged perpetrator and Resident # 5. LPN # 1 stated, Yes. LPN # 1 stated that Resident # 5 was in the therapy room playing games with the other Residents. LPN # 1 stated that Resident # 5 was coming out to go to the bathroom and get the hot chocolate from his room. LPN # 1 stated, as soon as Resident # 5 went in the room the alleged perpetrator started yelling at Resident # 5 and pinned him against the wall. LPN # 1 stated that she heard the alleged perpetrator state to Resident # 5, You're not going to the bathroom. I'm not done with you. The surveyor asked LPN # 1 if she saw the alleged perpetrator pin Resident # 5 against the wall. LPN # 1 stated, No but I heard it. LPN # 1 stated that she heard Resident # 5 tell the alleged perpetrator I don't know what you are talking about. LPN # 1 stated that she heard the alleged perpetrator tell Resident # 5 again, You can't use the bathroom until I am done with you. LPN # 1 stated that Resident # 5 came out into the hallway crying and asked her to call the police. LPN # 1 stated, We called the police and they came and the alleged perpetrator was yelling at the police officer. LPN # 1 stated, This was witnessed by Resident # 78's husband (Resident # 78 was not sampled) LPN # 1 stated that Resident # 78's husband stated to her, This happens every night. Something needs to be done. LPN # 1 stated that the police had the alleged perpetrator leave after she made a scene with them. Surveyor asked LPN # 1 if she reported this information to anyone. LPN # 1 stated that she called the executive director at home to let him know what happened. LPN # 1 stated, They never do anything about what we tell them. They don't want APS (adult protective services) to come in here. On 12/13/18 at 10:38 am, the surveyor reviewed the clinical record of the Resident #78 (not sampled) that LPN # 1 reported her husband witnessed the events. The surveyor observed documentation in the progress notes documented on 12/8/18 at 10:28 pm. The progress note was documented as Resident family member was being talked to nasty by (room number withheld) family and was told this is the worst facility and his wife will not be taken care of because we are the worst and miss treat the residents and son to sister was very rude to staff and resident family to where he felt uneasy and there comments bothered him and he could not make a statement to staff after incident because he was being bullied by family he change his statement to loud commasion (commotion) after he told police she was yelling at roommate and in his face and this happened every night to not wanting to say nothing felt very uneasy. On 12/13/18 at 3:08 pm, the surveyor interviewed CNA # 2 (certified nursing assistant). The surveyor asked CNA # 2 if she worked on the evening of 12/8/18 and if she was responsible for providing care to Resident # 5. CNA # 2 stated that she was on duty and responsible for providing care to Resident # 5 on 12/8/18. CNA# 2 stated, Resident # 5 went into his room and within seconds, you heard all this yelling. CNA # 2 stated that she heard the alleged perpetrator state, You are not going to the bathroom until I am through with you. CNA # 2 stated, I heard all this yelling and I told LPN #1 something is going on down there. CNA # 2 stated that Resident # 5 came down the hallway and said he wanted to call the police. CNA # 2 stated that Resident # 5 stated that the alleged perpetrator wouldn't let him use the bathroom. The surveyor asked CNA if Resident # 5 was incontinent at this time. CNA # 2 stated that Resident # 5 was incontinent. CNA # 2 also stated Resident # 5 was crying and upset. CNA # 2 stated that Resident # 5 had been working really hard trying bladder training because he wants to go home. CNA # 2 stated that another resident's husband was outside the room and heard the commotion and stated that she heard the alleged perpetrator tell Resident # 78's husband If you say anything they will treat your wife bad. CNA # 2 stated, I told the facility executive director what happened on Monday and he stated that he was investigating the issue. On 12/13/18 at 5:45 pm, the surveyor spoke with the facility executive director in the presence of the survey team and the facility administrative staff. The surveyor asked the facility executive director if he stated to her in an earlier conversation that he planned on closing the investigation on Monday and that he did not see where any abuse occurred. The facility executive director agreed to making that statement in the presence of the survey team. The surveyor asked the facility executive director to provide what evidence he had collected thus far in the investigation. On 12/13/18 at 6:03 pm, the facility executive director provided the surveyor with 4 pages of handwritten notes that were photocopied from a notepad. The notes were documented as follows: 12/10/18 Alleged perpetrator- she said the police escorted her out of the building. Resident # 5 came in the room. The alleged perpetrator asked if anything happened between (Resident's name withheld) and Resident # 5. Resident # 5 she very loud. This is my home you are not going to go around this place and talk about me. She wants to know who initiated the police call and why, what started it. LPN # 1 asked (Resident # 78 husband's name withheld) to write a statement. 12/10/18 Resident # 5- Resident # 5 went into the room alleged perpetrator waiting on him. Alleged perpetrator ask is there something wrong between you and (Resident name withheld) Resident # 5 said nothing. Alleged perpetrator-I want to know why you stopped paying attention to (Resident name withheld). You are not playing games with (Resident name withheld) Resident # 5-It's because the way your mom and (Resident name withheld) have been treating me and I am not (Resident name withheld) caregiver. Alleged perpetrator-Oh no you are not going to treat (resident name withheld) this way. Resident # 5 I am not doing anything to (Resident name withheld) Get out of the way I've got to go to the bathroom. Alleged perpetrator stepped in front of me and said you are going to talk to me. Resident # 5 move, I have got to use the bathroom. Alleged perpetrator you can wait a minute. Resident # 5 this is our room you need to get out of here you are just a guest. Alleged perpetrator- Oh know this is (Resident name withheld) room, he was here before you and he will be here after you. Resident # 5-he started urinating on himself and said get out of my way I have to use the bathroom. Alleged perpetrator -Go head but I will be out here waiting and you are going to talk to me she stepped out of the way from blocking the bathroom. Resident # 5 was in the bathroom he heard her telling (Resident name withheld) He is going to talk to me. Resident waited in the bathroom a long time he heard her say she was going to get his food. Resident # 5 came out of the bathroom when she left. Resident # 5 heard her say I am leaving but when I get back he is going to deal with me. Resident # 5 called the police. He went to the family room until they got here. Resident # 5 said he felt she attacked him and it is not right. 12/10/18 Call (Resident husband's name withheld) per facility executive director. Called at 4:14 pm (Telephone number withheld) Nurse asked him about that he said he was one door out in the hall, he didn't see or hear anything if something went on it was in the room. Why happened? We are trying to investigate if something happened. He saw police. 12/10/18 Resident # 5- meeting with facility executive director and Resident # 5. Resident # 5 wants alleged perpetrator not to be able to come back in the building. The facility executive director offered Resident # 5 to move to room (room number withheld) until another semi-private room comes available. Resident # 5 agreed. But said he does not want alleged perpetrator to come back into the building. The surveyor observed that there were no statements from LPN # 1 or CNA # 2 who both stated that they spoke with the facility executive director regarding the allegation of abuse reported by Resident # 5. On 12/13/18 at 6:10 pm, the surveyor reviewed the visitor log kept in the front of the building. The surveyor observed that no visitors had signed the visitor log on 12/13/18. On 12/13/18 at 6:15 pm, 2 surveyors toured the 600 hall and 700 hall of the facility. The two surveyors observed that Resident # 5 was in his room in the bathroom. The two surveyors also observed the alleged perpetrator, her mother, and grandson visiting with their loved one in the hallway outside of the resident's room. They were observed sitting at a square table that was outside of the resident's room playing a game. In the room directly beside where the alleged perpetrator was observed, the 2 surveyors observed a resident and a visitor sitting in the hallway. The visitor was identified as Resident # 78's husband that facility staff stated was bullied by the alleged perpetrator. On 12/14/18 at 8:36 am, the surveyor interviewed Resident # 5 again about his allegations of abuse. The surveyor asked Resident # 5 if he had any contact with the alleged perpetrator after the incident that occurred on 12/8/18. Resident # 5 stated, That happened on Saturday night and they came back in here Sunday and she jerked the table from underneath me. Resident # 5 stated, I went and talked to unit manager RN # 1 (registered nurse) and told her I couldn't believe she was in here after what she did to me, and she said it's his family they can come visit. Resident # 5 stated, I have the right to be protected. The surveyor asked Resident # 5 if he has had any contact with the alleged perpetrator since he was moved to his new room. Resident # 5 stated, No to be honest I have stayed in my room except for meals and therapy. The surveyor asked Resident # 5 if staying in his room is something that he normally does. Resident # 5 stated, No. The surveyor asked Resident # 5 why he was staying in his room if this is not something he normally does. Resident # 5 stated, I don't want to run into them. On 12/14/18 at 9:02 am, the surveyor interviewed the facility social services manager. The surveyor asked the facility social services manager if she was aware of the allegations of abuse reported by Resident # 5. The facility social services manager stated, Yes I found out Monday. The facility social services manager stated that the alleged perpetrator called her on Monday morning and that is how she found out about the incident. The surveyor asked the facility social services manager what the alleged perpetrator reported to her. The facility social services manager stated that the alleged perpetrator stated that the police were called for her on Saturday and she was escorted out of the building. The facility social service manager stated that the alleged perpetrator told her that she asked Resident # 5 what happened between him and (Resident's name withheld) and the alleged perpetrator stated that Resident # 5 started talking loudly and that Resident # 5 attacked her verbally said that she didn't know what happened. The facility social services manager stated that during her telephone call with the alleged perpetrator, the alleged perpetrator stated that her brother (Resident's name withheld) told her that for the past two weeks Resident # 5 has been treating him differently. The surveyor asked the facility social services manager if talking loudly and verbally attacking someone is a behavior that Resident # 5 would normally display. The facility social services manager stated, No he would not. Resident # 5 is usually very soft spoken. The surveyor asked the facility social services manager if she interviewed LPN # 1. The facility social services manager stated, I think she wrote a statement. The surveyor asked the facility social services manager if she interviewed Resident # 78's husband that the facility staff members reported witnessed the incident. The facility social services manager stated, I called (Resident # 78 husband's name withheld) and he said he didn't hear anything and didn't see anything. The surveyor asked the facility social services manager if she interviewed Resident # 5. The facility social services manager stated that she and the facility executive director met with Resident # 5 on Monday and wanted to make sure he felt safe. The facility social services manager stated that Resident # 5 was moved to a different room on Monday following the incident that had occurred on the previous Saturday. The facility social services manager stated that Resident # 5 said that he didn't want the alleged perpetrator to come back and the facility executive director said we had to complete the investigation. On 12/14/18 at 9:23 am, the surveyor interviewed the unit manager RN # 1. The surveyor asked the unit manager RN # 1 if she had a conversation with Resident # 5 where he expressed concerns about the alleged perpetrator being allowed back into the building. Unit manager RN # 1 stated that she did speak with Resident # 5 and he asked why was the alleged perpetrator still being allowed in the building after what she did to him. Unit manager RN # 1 stated that she told Resident # 5 that the facility executive director was aware and investigating the situation but she could not tell the alleged perpetrator that she could not visit her loved one. Unit manager RN # 1 told the surveyor that the facility did 15-minute safety checks on Resident # 5 to ensure he was safe. The surveyor requested a copy of the safety checks. On 12/14/18 at 9:39 am, the surveyor interviewed the director of clinical services regarding the allegation of abuse reported by Resident # 5 on 12/8/18. The director of nursing stated, It happened on the weekend. I didn't do any of the interviews. The director of clinical services stated that the facility executive director and the facility social services manager did the interviews. The surveyor asked the director of clinical services if she was aware that Resident # 5 reported abuse. The director of clinical services stated, Of course his perception is his perception. The surveyor asked the director of clinical services how long does the facility have to report suspected abuse. The director of clinical services stated, 2 hours typically. The surveyor asked the director of clinical services what is the procedure for suspected resident to resident abuse. The director of clinical services stated they are automatically separated and if needed we can do one to one. The surveyor asked the director of clinical services what was the procedure to staff to resident abuse. The director of clinical services stated that the employee is suspended pending investigation. The surveyor asked the director of clinical services what was the procedure for allegations of visitor to resident abuse. The director of clinical services stated we ask them to leave the facility until the investigation is complete. The surveyor asked the director of clinical services why the alleged perpetrator was allowed to return to the facility if the investigation into Resident # 5's allegation of abuse had not been completed. The director of clinical services stated, There's a fine line when telling them they can't visit their loved one. They haven't had contact. The director of clinical services stated, I wish I could give you more information but the investigation is not complete. On 12/14/18 at 11:05 am, the surveyor interviewed the facility executive director in the presence of the survey team. The surveyor asked the facility executive director what the procedure was for allegations of resident to resident abuse. The facility executive director stated, Separate and investigate. The surveyor asked the facility executive director what the procedure was for allegations of staff to resident abuse. The facility executive director stated that the employee was to be suspended pending investigation. The surveyor asked the facility executive director what was the procedure for allegations of visitor to resident abuse. The facility executive director stated, that a facility reported incident would be submitted, the incident would be investigated, and the visitor would be asked to stay away until the investigation is complete. The surveyor asked the facility executive director why the family was not asked to stay away during the investigation of the allegation of abuse reported by Resident # 5. The facility executive director stated, Or they meet with me and the director of nursing and we determine if they can come back. I met with the family on Monday and with Resident # 5's history of 3 or 4 occasions that he has lied, the residents were separated and Resident # 5 was moved to another room. I decided that the alleged perpetrator could return to the building. The surveyor asked the facility executive director how he could make that determination when the investigation had not been completed. The facility executive director stated, I don't think it happened. Resident # 5 tells lies. In the past he has made accusations and said this happened and he comes back 3 or 4 days later and says he is sorry. I am more concerned with this nurse LPN # 1, I think she put Resident # 5 up to calling the police. It's a lot of drama involved in this with CNA # 2 and LPN # 1. They have issues with the family. My issue is more with LPN # 1 and I will deal with her after this is over. The surveyor asked the facility executive director if he interviewed CNA # 2. The facility executive director stated that he did not. The facility executive director stated that the facility social services manager interviewed CNA # 2. On 12/14/18 at 11:20 am, unit manager RN # 1 provided the surveyor with a copy of the Resident Safety Check log for Resident # 5. The surveyor observed that the facility staff did not begin documenting resident safety checks for Resident # 5 until 12/12/18 at 7:00 am which was 4 days after the initial allegation of abuse that was reported by Resident # 5, and 2 days after he was transferred into a different room. The surveyor observed that the facility staff did not document 15 minute safety checks for Resident # 5 from 11:00 pm on 12/12/18 through 7:00 am on 12/13/18. There were no documented safety checks from 11:00 pm on 12/13/18 through 7:00 am on 12/14/18. Also there were no documented checks on 12/14/18 at 11:00 am and 11:15 am. On 12/14/18 at 11:47 am, two surveyors met with the facility executive director per his request. The facility executive director stated, I felt bad about how I came across about not believing him. We always believe him. It may turn out that it's true. I wouldn't have done anything differently. We separated them. We met with the family. The surveyor stated to the facility executive director that the alleged perpetrator returned to the building on Sunday and Resident # 5 stated that she jerked the table from under him. The facility executive director stated, No she wasn't, I was here all day and no one came in. I drove staff back and forth to the hotel. The surveyor asked the facility executive director if he knows for a fact that the alleged perpetrator did not enter the building because on 12/13/18 after viewing the visitor sign in log and seeing that no one had signed in as a visitor, 2 surveyors toured the facility saw the alleged perpetrator along with her mother and grandson visiting with their loved one in the hallway at the same table that Resident # 5 said the alleged perpetrator jerked from underneath him. The facility executive director did not respond. The surveyor informed the facility executive director that Resident # 5 became tearful during the interview when he reported what happened. The surveyor told the facility executive director that Resident # 5 had been working on his toileting and stated that the alleged perpetrator yelled at him and prevented him from using the bathroom causing him to urinate on himself. The facility executive director stated, She says she sat on the bed talking to him. The surveyor stated to the facility executive director that he stated that Resident # 5 tells lies but the facility is still obligated to protect him. The surveyor informed that facility executive director that Resident # 5 stated that he isn't coming out of his room like he normally does and is only coming out for meals because he does not want to run into the alleged perpetrator and this is not a normal behavior for Resident # 5. The facility executive director stated, I don't know what the solution is. (Resident name withheld) has been in that room forever and he doesn't want to move. They fought for years to get him back to that unit. The surveyor told the facility executive director that she was unable to advise him on what to do but he has an obligation to protect Resident # 5 and all residents. The facility policy on Abuse, Neglect, Exploitation & Misappropriation contained documentation that included but was not limited to: .Mental and verbal abuse include but are not limited to: Harassing a resident Mocking, insulting, ridiculing Yelling or hovering over a resident, with intent to intimidate Threatening residents, depriving a resident of care or withholding a resident from contact with family and friends Neglect is the failure of the center, 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. Examples include put are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Procedure Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible prosecution. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. Actions such as striking a resident, restraining a resident improperly or without authorization, and other such acts which can be seen as causing physical pain to a resident are strictly forbidden. Acts such as teasing, humiliating, degrading, or intentionally ignoring a resident may constitute abuse and will be dealt with no less severely than acts causing physical harm. Non-action, which results in emotional, psychological, or physical injury in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of [REDACTED]. Furthermore, the Administration of the company recognizes that resident abuse can be committed by other residents, visitors, or volunteers. Employee Obligation All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation d (TRUNCATED)

Based on staff interview, resident interview, facility document review and clinical record review, the facility staff failed to ensure 2 of 23 residents were free from abuse and neglect, Resident #5 and Resident # 89. The findings included: 1. The facility staff failed to ensure that Resident # 5 was free from abuse as evidenced by another resident's family member cornered Resident # 5 in his room, verbally threatened and belittled him and caused him to urinate on himself. Resident # 5 was a [AGE] year-old-male who was admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 5 was reviewed on 12/13/18 at 10:41 am. The most recent MDS (minimum data set) assessment for Resident # 5 was a quarterly assessment with an ARD (assessment reference date) of 9/3/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 5 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 15 was cognitively intact. The plan of care for Resident # 5 was reviewed and revised on 11/9/18. The facility staff documented a focus area for Resident # 5 as, Resident # 5 is independent on staff for activities, cognitive stimulation, social interaction r/t (related to) anxiety, depression, [MEDICAL CONDITIONS] limited mobility, [MEDICAL CONDITION], pain, participating in activities of choice, self acts in room such as TV (television), computer, phone, sitting on porch, parties, bingo, music, socializes with staff and residents. Resident # 5 goes by cab on community outings. Interventions included but were not limited to; Report resident c/o (complaint of) pain, discomfort, breathing difficulties or any other c/o that interferes with the resident's ability to participate in activities to the nurse prn (as needed). The surveyor reviewed the entire plan of care for Resident # 5 and did not see an update that Resident # 5 made statements that are untrue. On 12/13/18 at 7:55 am, the surveyor was in Resident # 5's room conducting a Resident interview. During the interview Resident # 5 reported to the surveyor that on 12/8/18, the alleged perpetrator (his former roommate's sister) Got in my face, yelled at me and blocked the bathroom and wouldn't let me use the bathroom. Resident # 5 stated that he was going back to his room to get hot chocolate for a group of Residents that he was socializing with and to use the bathroom because he is on a bladder-retraining program. Resident # 5 stated that when he got to his room, the alleged perpetrator asked him What's going on with you and (Resident's name withheld)? Resident # 5 stated that he told the alleged perpetrator nothing was going on and that he did not know what she was talking about. Resident # 5 then stated that the alleged perpetrator got in his face and began to yell at him stating that Resident # 5's former roommate told the alleged perpetrator that Resident # 5 had been treating him differently and that Resident # 5 was going to tell her what was going on. Resident # 5 stated that he told the alleged perpetrator that he needed to use the bathroom. Resident # 5 stated that the alleged perpetrator stood in front of the bathroom door and told him he was not going to use the bathroom until she was done with him. Resident # 5 stated that he told the alleged perpetrator, This is our room and you are a guest here. You need to get out of here. Resident # 5 stated that the alleged perpetrator continued to block the door to the bathroom. Resident # 5 stated that he began to urinate on himself. Resident # 5 stated, I felt awful, I cried. Resident # 5 stated that the alleged perpetrator finally allowed him to go into the bathroom after he had urinated on himself and stated to him, I am going to be right here when you get out because you are going to tell me what's going on with you and (Resident's name withheld). Resident # 5 stated that the alleged perpetrator continued to yell at him through the door while he was in the bathroom. Resident # 5 stated that he called the police. Resident # 5 stated that the police came and She threw a fit. Resident # 5 stated that the police made her leave that evening but it would be up to them (the facility) if they bar her from the facility. Resident # 5 stated that later that same evening other family members of his former roommate came in and intimidated him. Resident # 5 stated that his former roommate's family members sat on the other side of the room saying mean things to him and stated, If something happens to (Resident's name withheld) their asses is mine. Resident # 5 stated, They made me feel like I was a piece of crap. Resident # 5 stated the next day They came back in here like it was nothing. Resident # 5 stated that the day after the incident that the alleged perpetrator approached him as he was sitting at a square table in the hallway outside of their room and jerked the table away from me. Resident # 5 stated that he asked a staff member why the alleged perpetrator was allowed to come back into the facility after what she did to him. Resident # 5 stated that he was told she has a right to visit her family member. Resident # 5 stated that he spoke with the facility executive director on Monday and the facility executive director told Resident # 5 they would move him to a different room. Resident # 5 stated that the facility executive director stated to him, we got it all handled. Resident # 5 stated that he replied, It handles the room but it doesn't handle what she did to me. Resident # 5 stated that the facility executive director stated to him, You let me handle that. I got 2 days to investigate that. Resident # 5 then stated to the surveyor, It does not make any sense how she treated me. It made me feel like I was worthless, and they let her come back in here like it was nothing after the law put her out. I thought with me being a patient here I would be protected more. The surveyor observed at this time that Resident # 5 became tearful. Resident # 5 stated, What happens when she attacks somebody else? Are you just going to put people in another room and say that settles that. On 12/13/18 at 9:58 am, the surveyor interviewed unit manager RN # 1 (registered nurse) about the allegations of abuse reported by Resident # 5. Unit manager RN # 1 stated, I am aware briefly, I only know that the family was acting inappropriate and threatened him (Resident # 5) and the police were involved. On 12/13/18 at 10:00 am, the surveyor interviewed the facility executive director about the allegations of abuse reported by Resident # 5. The facility executive director stated, I was called Saturday night saying the police had to come to the facility saying there was a yelling match with Resident # 5 and the alleged perpetrator. We had the daughters (the alleged perpetrator and her sister) come in Monday and we spoke to them and Resident # 5. The facility executive director informed the surveyor that he was in the process of investigating the incident and that a FRI (facility reported incident) was submitted. The facility executive director then stated that Resident # 5 had been known to lie and then come back and admit to lying and saying that he was sorry. The facility executive director also stated that the nurse that called him at home to report the incident had issues with the alleged perpetrator and her family and called him that night to report the incident. She asked if he was going to have them barred from the facility. The facility executive director stated, I don't really have any evidence. There were no eye witnesses. I will be finishing this investigation by Monday but I can't see where any abuse occurred. On 12/13/18 at 10:15 am, the surveyor observed a progress note documented in the clinical record for Resident # 5 on 12/9/18 at 3:29 pm. The progress note was documented as Resident is on medi part b total care with adls (activities of daily living) incontinent of bowel and bladder uses walker for ambulation upset due to incident with roommate family of them yelling and getting into his face refusing to let him use the bathroom police was called due to roommate family being nasty and inappropriate by yelling and getting in his face. On 12/13/18 at 10:28 am, the surveyor interviewed LPN # 1 (licensed practical nurse) about the allegation of abuse reported by Resident # 5. The surveyor asked LPN # 1 if she was working and responsible for providing care to Resident # 5 on 12/8/18. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if she was aware of an incident that occurred involving the alleged perpetrator and Resident # 5. LPN # 1 stated, Yes. LPN # 1 stated that Resident # 5 was in the therapy room playing games with the other Residents. LPN # 1 stated that Resident # 5 was coming out to go to the bathroom and get the hot chocolate from his room. LPN # 1 stated, as soon as Resident # 5 went in the room the alleged perpetrator started yelling at Resident # 5 and pinned him against the wall. LPN # 1 stated that she heard the alleged perpetrator state to Resident # 5, You're not going to the bathroom. I'm not done with you. The surveyor asked LPN # 1 if she saw the alleged perpetrator pin Resident # 5 against the wall. LPN # 1 stated, No but I heard it. LPN # 1 stated that she heard Resident # 5 tell the alleged perpetrator I don't know what you are talking about. LPN # 1 stated that she heard the alleged perpetrator tell Resident # 5 again, You can't use the bathroom until I am done with you. LPN # 1 stated that Resident # 5 came out into the hallway crying and asked her to call the police. LPN # 1 stated, We called the police and they came and the alleged perpetrator was yelling at the police officer. LPN # 1 stated, This was witnessed by Resident # 78's husband (Resident # 78 was not sampled) LPN # 1 stated that Resident # 78's husband stated to her, This happens every night. Something needs to be done. LPN # 1 stated that the police had the alleged perpetrator leave after she made a scene with them. Surveyor asked LPN # 1 if she reported this information to anyone. LPN # 1 stated that she called the executive director at home to let him know what happened. LPN # 1 stated, They never do anything about what we tell them. They don't want APS (adult protective services) to come in here. On 12/13/18 at 10:38 am, the surveyor reviewed the clinical record of the Resident #78 (not sampled) that LPN # 1 reported her husband witnessed the events. The surveyor observed documentation in the progress notes documented on 12/8/18 at 10:28 pm. The progress note was documented as Resident family member was being talked to nasty by (room number withheld) family and was told this is the worst facility and his wife will not be taken care of because we are the worst and miss treat the residents and son to sister was very rude to staff and resident family to where he felt uneasy and there comments bothered him and he could not make a statement to staff after incident because he was being bullied by family he change his statement to loud commasion (commotion) after he told police she was yelling at roommate and in his face and this happened every night to not wanting to say nothing felt very uneasy. On 12/13/18 at 3:08 pm, the surveyor interviewed CNA # 2 (certified nursing assistant) The surveyor asked CNA # 2 if she worked on the evening of 12/8/18 and if she was responsible for providing care to Resident # 5. CNA # 2 stated that she was on duty and responsible for providing care to Resident # 5 on 12/8/18. CNA# 2 stated, Resident # 5 went into his room and within seconds, you heard all this yelling. CNA # 2 stated that she heard the alleged perpetrator state, You are not going to the bathroom until I am through with you. CNA # 2 stated, I heard all this yelling and I told LPN #1 something is going on down there. CNA # 2 stated that Resident # 5 came down the hallway and said he wanted to call the police. CNA # 2 stated that Resident # 5 stated that the alleged perpetrator wouldn't let him use the bathroom. The surveyor asked CNA if Resident # 5 was incontinent at this time. CNA # 2 stated that Resident # 5 was incontinent. CNA # 2 also stated Resident # 5 was crying and upset. CNA # 2 stated that Resident # 5 had been working really hard trying bladder training because he wants to go home. CNA # 2 stated that another resident's husband was outside the room and heard the commotion and stated that she heard the alleged perpetrator tell Resident # 78's husband If you say anything they will treat your wife bad. CNA # 2 stated, I told the facility executive director what happened on Monday and he stated that he was investigating the issue. On 12/13/18 at 5:45 pm, the surveyor spoke with the facility executive director in the presence of the survey team and the facility administrative staff. The surveyor asked the facility executive director if he stated to her in an earlier conversation that he planned on closing the investigation on Monday and that he did not see where any abuse occurred. The facility executive director agreed to making that statement in the presence of the survey team. The surveyor asked the facility executive director to provide what evidence he had collected thus far in the investigation. On 12/13/18 at 6:03 pm, the facility executive director provided the surveyor with 4 pages of handwritten notes that were photocopied from a notepad. The notes were documented as follows: 12/10/18 Alleged perpetrator- she said the police escorted her out of the building. Resident # 5 came in the room. The alleged perpetrator asked if anything happened between (Resident's name withheld) and Resident # 5. Resident # 5 she very loud. This is my home you are not going to go around this place and talk about me. She wants to know who initiated the police call and why, what started it. LPN # 1 asked (Resident # 78 husband's name withheld) to write a statement. 12/10/18 Resident # 5- Resident # 5 went into the room alleged perpetrator waiting on him. Alleged perpetrator ask is there something wrong between you and (Resident name withheld) Resident # 5 said nothing. Alleged perpetrator-I want to know why you stopped paying attention to (Resident name withheld). You are not playing games with (Resident name withheld) Resident # 5-It's because the way your mom and (Resident name withheld) have been treating me and I am not (Resident name withheld) caregiver. Alleged perpetrator-Oh no you are not going to treat (resident name withheld) this way. Resident # 5 I am not doing anything to (Resident name withheld) Get out of the way I've got to go to the bathroom. Alleged perpetrator stepped in front of me and said you are going to talk to me. Resident # 5 move, I have got to use the bathroom. Alleged perpetrator you can wait a minute. Resident # 5 this is our room you need to get out of here you are just a guest. Alleged perpetrator- Oh know this is (Resident name withheld) room, he was here before you and he will be here after you. Resident # 5-he started urinating on himself and said get out of my way I have to use the bathroom. Alleged perpetrator -Go head but I will be out here waiting and you are going to talk to me she stepped out of the way from blocking the bathroom. Resident # 5 was in the bathroom he heard her telling (Resident name withheld) He is going to talk to me. Resident waited in the bathroom a long time he heard her say she was going to get his food. Resident # 5 came out of the bathroom when she left. Resident # 5 heard her say I am leaving but when I get back he is going to deal with me. Resident # 5 called the police. He went to the family room until they got here. Resident # 5 said he felt she attacked him and it is not right. 12/10/18 Call (Resident husband's name withheld) per facility executive director. Called at 4:14 pm (Telephone number withheld) Nurse asked him about that he said he was one door out in the hall, he didn't see or hear anything if something went on it was in the room. Why happened? We are trying to investigate if something happened. He saw police. 12/10/18 Resident # 5- meeting with facility executive director and Resident # 5. Resident # 5 wants alleged perpetrator not to be able to come back in the building. The facility executive director offered Resident # 5 to move to room (room number withheld) until another semi-private room comes available. Resident # 5 agreed. But said he does not want alleged perpetrator to come back into the building. The surveyor observed that there were no statements from LPN # 1 or CNA # 2 who both stated that they spoke with the facility executive director regarding the allegation of abuse reported by Resident # 5. On 12/13/18 at 6:10 pm, the surveyor reviewed the visitor log kept in the front of the building. The surveyor observed that no visitors had signed the visitor log on 12/13/18. On 12/13/18 at 6:15 pm, 2 surveyors toured the 600 hall and 700 hall of the facility. The two surveyors observed that Resident # 5 was in his room in the bathroom. The two surveyors also observed the alleged perpetrator, her mother, and grandson visiting with their loved one in the hallway outside of the resident's room. They were observed sitting at a square table that was outside of the resident's room playing a game. In the room directly beside where the alleged perpetrator was observed, the 2 surveyors observed a resident and a visitor sitting in the hallway. The visitor was identified as Resident # 78's husband that facility staff stated was bullied by the alleged perpetrator. On 12/14/18 at 8:36 am, the surveyor interviewed Resident # 5 again about his allegations of abuse. The surveyor asked Resident # 5 if he had any contact with the alleged perpetrator after the incident that occurred on 12/8/18. Resident # 5 stated, That happened on Saturday night and they came back in here Sunday and she jerked the table from underneath me. Resident # 5 stated, I went and talked to unit manager RN # 1 (registered nurse) and told her I couldn't believe she was in here after what she did to me, and she said it's his family they can come visit. Resident # 5 stated, I have the right to be protected. The surveyor asked Resident # 5 if he has had any contact with the alleged perpetrator since he was moved to his new room. Resident # 5 stated, No to be honest I have stayed in my room except for meals and therapy. The surveyor asked Resident # 5 if staying in his room is something that he normally does. Resident # 5 stated, No. The surveyor asked Resident # 5 why he was staying in his room if this is not something he normally does. Resident # 5 stated, I don't want to run into them. On 12/14/18 at 9:02 am, the surveyor interviewed the facility social services manager. The surveyor asked the facility social services manager if she was aware of the allegations of abuse reported by Resident # 5. The facility social services manager stated, Yes I found out Monday. The facility social services manager stated that the alleged perpetrator called her on Monday morning and that is how she found out about the incident. The surveyor asked the facility social services manager what the alleged perpetrator reported to her. The facility social services manager stated that the alleged perpetrator stated that the police were called for her on Saturday and she was escorted out of the building. The facility social service manager stated that the alleged perpetrator told her that she asked Resident # 5 what happened between him and (Resident's name withheld) and the alleged perpetrator stated that Resident # 5 started talking loudly and that Resident # 5 attacked her verbally said that she didn't know what happened. The facility social services manager stated that during her telephone call with the alleged perpetrator, the alleged perpetrator stated that her brother (Resident's name withheld) told her that for the past two weeks Resident # 5 has been treating him differently. The surveyor asked the facility social services manager if talking loudly and verbally attacking someone is a behavior that Resident # 5 would normally display. The facility social services manager stated, No he would not. Resident # 5 is usually very soft spoken. The surveyor asked the facility social services manager if she interviewed LPN # 1. The facility social services manager stated, I think she wrote a statement. The surveyor asked the facility social services manager if she interviewed Resident # 78's husband that the facility staff members reported witnessed the incident. The facility social services manager stated, I called (Resident # 78 husband's name withheld) and he said he didn't hear anything and didn't see anything. The surveyor asked the facility social services manager if she interviewed Resident # 5. The facility social services manager stated that she and the facility executive director met with Resident # 5 on Monday and wanted to make sure he felt safe. The facility social services manager stated that Resident # 5 was moved to a different room on Monday following the incident that had occurred on the previous Saturday. The facility social services manager stated that Resident # 5 said that he didn't want the alleged perpetrator to come back and the facility executive director said we had to complete the investigation. On 12/14/18 at 9:23 am, the surveyor interviewed the unit manager RN # 1. The surveyor asked the unit manager RN # 1 if she had a conversation with Resident # 5 where he expressed concerns about the alleged perpetrator being allowed back into the building. Unit manager RN # 1 stated that she did speak with Resident # 5 and he asked why was the alleged perpetrator still being allowed in the building after what she did to him. Unit manager RN # 1 stated that she told Resident # 5 that the facility executive director was aware and investigating the situation but she could not tell the alleged perpetrator that she could not visit her loved one. Unit manager RN # 1 told the surveyor that the facility did 15-minute safety checks on Resident # 5 to ensure he was safe. The surveyor requested a copy of the safety checks. On 12/14/18 at 9:39 am, the surveyor interviewed the director of clinical services regarding the allegation of abuse reported by Resident # 5 on 12/8/18. The director of nursing stated, It happened on the weekend. I didn't do any of the interviews. The director of clinical services stated that the facility executive director and the facility social services manager did the interviews. The surveyor asked the director of clinical services if she was aware that Resident # 5 reported abuse. The director of clinical services stated, Of course his perception is his perception. The surveyor asked the director of clinical services how long does the facility have to report suspected abuse. The director of clinical services stated, 2 hours typically. The surveyor asked the director of clinical services what is the procedure for suspected resident to resident abuse. The director of clinical services stated they are automatically separated and if needed we can do one to one. The surveyor asked the director of clinical services what was the procedure to staff to resident abuse. The director of clinical services stated that the employee is suspended pending investigation. The surveyor asked the director of clinical services what was the procedure for allegations of visitor to resident abuse. The director of clinical services stated we ask them to leave the facility until the investigation is complete. The surveyor asked the director of clinical services why the alleged perpetrator was allowed to return to the facility if the investigation into Resident # 5's allegation of abuse had not been completed. The director of clinical services stated, There's a fine line when telling them they can't visit their loved one. They haven't had contact. The director of clinical services stated, I wish I could give you more information but the investigation is not complete. On 12/14/18 at 11:05 am, the surveyor interviewed the facility executive director in the presence of the survey team. The surveyor asked the facility executive director what the procedure was for allegations of resident to resident abuse. The facility executive director stated, Separate and investigate. The surveyor asked the facility executive director what the procedure was for allegations of staff to resident abuse. The facility executive director stated that the employee was to be suspended pending investigation. The surveyor asked the facility executive director what was the procedure for allegations of visitor to resident abuse. The facility executive director stated, that a facility reported incident would be submitted, the incident would be investigated, and the visitor would be asked to stay away until the investigation is complete. The surveyor asked the facility executive director why the family was not asked to stay away during the investigation of the allegation of abuse reported by Resident # 5. The facility executive director stated, Or they meet with me and the director of nursing and we determine if they can come back. I met with the family on Monday and with Resident # 5's history of 3 or 4 occasions that he has lied, the residents were separated and Resident # 5 was moved to another room. I decided that the alleged perpetrator could return to the building. The surveyor asked the facility executive director how he could make that determination when the investigation had not been completed. The facility executive director stated, I don't think it happened. Resident # 5 tells lies. In the past he has made accusations and said this happened and he comes back 3 or 4 days later and says he is sorry. I am more concerned with this nurse LPN # 1, I think she put Resident # 5 up to calling the police. It's a lot of drama involved in this with CNA # 2 and LPN # 1. They have issues with the family. My issue is more with LPN # 1 and I will deal with her after this is over. The surveyor asked the facility executive director if he interviewed CNA # 2. The facility executive director stated that he did not. The facility executive director stated that the facility social services manager interviewed CNA # 2. On 12/14/18 at 11:20 am, unit manager RN # 1 provided the surveyor with a copy of the Resident Safety Check log for Resident # 5. The surveyor observed that the facility staff did not begin documenting resident safety checks for Resident # 5 until 12/12/18 at 7:00 am which was 4 days after the initial allegation of abuse that was reported by Resident # 5, and 2 days after he was transferred into a different room. The surveyor observed that the facility staff did not document 15 minute safety checks for Resident # 5 from 11:00 pm on 12/12/18 through 7:00 am on 12/13/18. There were no documented safety checks from 11:00 pm on 12/13/18 through 7:00 am on 12/14/18. Also there were no documented checks on 12/14/18 at 11:00 am and 11:15 am. On 12/14/18 at 11:47 am, two surveyors met with the facility executive director per his request. The facility executive director stated, I felt bad about how I came across about not believing him. We always believe him. It may turn out that it's true. I wouldn't have done anything differently. We separated them. We met with the family. The surveyor stated to the facility executive director that the alleged perpetrator returned to the building on Sunday and Resident # 5 stated that she jerked the table from under him. The facility executive director stated, No she wasn't, I was here all day and no one came in. I drove staff back and forth to the hotel. The surveyor asked the facility executive director if he knows for a fact that the alleged perpetrator did not enter the building because on 12/13/18 after viewing the visitor sign in log and seeing that no one had signed in as a visitor, 2 surveyors toured the facility saw the alleged perpetrator along with her mother and grandson visiting with their loved one in the hallway at the same table that Resident # 5 said the alleged perpetrator jerked from underneath him. The facility executive director did not respond. The surveyor informed the facility executive director that Resident # 5 became tearful during the interview when he reported what happened. The surveyor told the facility executive director that Resident # 5 had been working on his toileting and stated that the alleged perpetrator yelled at him and prevented him from using the bathroom causing him to urinate on himself. The facility executive director stated, She says she sat on the bed talking to him. The surveyor stated to the facility executive director that he stated that Resident # 5 tells lies but the facility is still obligated to protect him. The surveyor informed that facility executive director that Resident # 5 stated that he isn't coming out of his room like he normally does and is only coming out for meals because he does not want to run into the alleged perpetrator and this is not a normal behavior for Resident # 5. The facility executive director stated, I don't know what the solution is. (Resident name withheld) has been in that room forever and he doesn't want to move. They fought for years to get him back to that unit. The surveyor told the facility executive director that she was unable to advise him on what to do but he has an obligation to protect Resident # 5 and all residents. The facility policy on Abuse, Neglect, Exploitation & Misappropriation contained documentation that included but was not limited to: .Mental and verbal abuse include but are not limited to: Harassing a resident Mocking, insulting, ridiculing Yelling or hovering over a resident, with intent to intimidate Threatening residents, depriving a resident of care or withholding a resident from contact with family and friends Neglect is the failure of the center, 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. Examples include put are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Procedure Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible prosecution. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. Actions such as striking a resident, restraining a resident improperly or without authorization, and other such acts which can be seen as causing physical pain to a resident are strictly forbidden. Acts such as teasing, humiliating, degrading, or intentionally ignoring a resident may constitute abuse and will be dealt with no less severely than acts causing physical harm. Non-action, which results in emotional, psychological, or physical injury in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of [REDACTED]. Furthermore, the Administration of the company recognizes that resident abuse can be committed by other residents, visitors, or volunteers. Employee Obligation All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation d (TRUNCATED)

Based on clinical record review, Resident interview, staff interview, and facility document review, the facility staff failed to provide effective pain management for 1 of 12 Residents in the survey sample, Resident # 102. The findings included The facility staff failed to ensure that the physician ordered [MEDICATION NAME] was in the facility and available for administration, which resulted in incomplete and late dose administrations. This caused Resident # 102 to report a pain scale of 9/10 and 10/10, and experience withdrawal symptoms because of not having the [MEDICATION NAME] in the facility. Resident # 102 was a [AGE] year-old-male who was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 102 was reviewed on 2/12/19 at 12:42 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 12/4/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 102 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 102 was cognitively intact. The plan of care for Resident # 102 was reviewed and revised on 2/17/18. The facility staff documented a focus area for Resident # 102 as, Resident # 102 has alterations in pain R/T (related to) [MEDICAL CONDITION] C5-C7, [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease), wounds, [MEDICAL CONDITIONS], [MEDICATION NAME] [DIAGNOSES REDACTED], chronic pai[DIAGNOSES REDACTED], low back pain, muscle spasms. Interventions included but were not limited to, Medications per MD orders, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Resident # 102 had current orders for [MEDICATION NAME] HCI Tablet 10 mg (milligram) Give 12 tablet by mouth one time a day for pain, which was initiated by the physician on 11/29/18. Resident # 102 also had orders for [MEDICATION NAME] HCI tablet 5 mg Give 2 tablet by mouth every 6 hours as needed for pain related to low back pain, which was initiated by the physician on 12/6/18. On 2/12/19 at 1:00 pm, the surveyor reviewed the (MONTH) 2019 Medication Administration Record [REDACTED]. According to the Chart Codes/Follow Up Codes 9 = Other/ See Nurses Notes. Upon review of the progress notes for Resident # 102, the surveyor observed a Medication Administration Note for Resident # 102 documented on 2/11/19 at 10:16 am. The medication administration note was documented as, [MEDICATION NAME] HCI Tablet 10 mg give 12 tablet by mouth one time a day for pain notified pharmacy and md about order. On 2/12/19 at 3:13 pm, the surveyor interviewed LPN # 2 (licensed practical nurse) via telephone. LPN # 2 confirmed that she was responsible for administering medications to Resident # 102 on 2/11/19. The surveyor asked LPN # 2 why Resident # 102 did not receive the physician ordered [MEDICATION NAME] at 9:00 am on the morning of 2/11/19. LPN # 2 stated, He didn't have it there. LPN # 2 stated that the facility called the pharmacy that morning and the facility was charged and paid for the [MEDICATION NAME] and the pharmacy delivered the [MEDICATION NAME] to the facility. The surveyor asked LPN # 2 what time Resident # 102 received the [MEDICATION NAME] on 2/11/19. LPN # 2 stated, He didn't get it until 11 something. The surveyor asked LPN # 2 if Resident # 102 reported pain while he did not have the physician ordered [MEDICATION NAME]. LPN # 2 stated, He said that he was hurting but I gave him two [MEDICATION NAME]. He was very upset and said he was going to call the ombudsman. On 12/13/19 at 12:00 pm, a Resident interview was conducted with Resident # 102 in the presence of 3 surveyors. Resident # 102 stated that on Monday 2/11/19, he was waiting for the nurse to give him his medicine. Resident # 102 stated that he usually received his medication first because he was the first room on the hall. Resident # 102 stated that he noticed that the nurse kept skipping his room and he was in pain. Resident # 102 stated that he finally got up and walked down the hall and asked the medication nurse for his medication. Resident # 102 stated that the medication nurse informed him that they were out of his medication. Resident # 102 stated that he could not believe that the facility let him run out of his [MEDICATION NAME] again. Resident # 102 stated that he spoke with the unit manager RN # 1 (registered nurse). Resident # 102 stated that RN # 1 informed him that the pharmacy did not send his medication. Resident # 102 stated that he then told RN # 1 that he heard the facility staff nurses state that there was no prescription for his [MEDICATION NAME] and that a prescription had to be written that Monday morning (2/11/19). Resident # 102 stated that RN # 1 stated that she would look into the situation, later returned, and told him that he was correct and that the prescription for [MEDICATION NAME] had been obtained that morning. Resident # 102 stated, They should not let me run out of my [MEDICATION NAME]. The surveyor asked Resident # 102 if the facility staff provided him with anything for pain in place of the [MEDICATION NAME]. Resident # 102 stated that the facility staff gave him his prn (as needed) [MEDICATION NAME] 10 mg. The surveyor asked Resident # 102 if the [MEDICATION NAME] 10 mg helped to relieve his pain during the time that the facility did not have the [MEDICATION NAME]. Resident # 102 stated, No, I take 12 tablets of [MEDICATION NAME] at one time. The surveyor asked Resident # 102 to rate his pain during the time he went without his [MEDICATION NAME] on a scale of 0 to 10 with zero being no pain and 10 being the worst pain he could imagine. Resident # 102 rated his pain at a level of 9 out of 10. The surveyor asked Resident # 102 what level of pain is usually tolerable for him. Resident # 102 reported that a pain level of 5 out of 10 was tolerable for him. Resident # 102 stated, Last time this happened was New Year's and I went into full blown withdrawal. I had to wait for two days to get it back. I was vomiting and going to the bathroom on myself. I felt like I was going to die. On 2/13/19 at 1:00 pm, the surveyor reviewed the progress notes for Resident # 102. The surveyor observed the following progress notes. A progress note documented on 1/1/19 at 9:21 am was documented as, [MEDICATION NAME] in drawer is only 4 tablets. Refill was not sent from pharmacy. Called pharmacy spoke with (pharmacy employee's name withheld) and she told me medication would be on next run. Also called Richmond line and was told medication had already been put in to be sent on next run. 3-11 nurse notified that I spoke with pharmacy regarding medication. Resident received 4 pills in the cart awaiting delivery for full dose. Resident aware. A progress note documented on 1/1/19 at 6:24 pm, was documented as, Called pharmacy to deliver [MEDICATION NAME]. Pt. (patient) only received 40 mg dose today. Behaviors cursing staff and general moodiness, refusing evening meds. Pharm (pharmacy) was called would not send out until they receive new script. On call DR (doctor) (Physician's name withheld) was called and she wrote a one day script for 1/2/19. Pharmacy was called back and will send out on 1/2/19. A progress note documented on 1/2/19 at 10:36 am was documented as [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg Give 1 tablet by mouth every 6 hours as needed for nausea given for nausea vomiting. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg give 1 tablet by mouth every 6 hours as needed for nausea patient stated the [MEDICATION NAME] prn administration was ineffective. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME] HCI tablet 5 mg give 2 tablets by mouth every 6 hours as needed for pain related to low back pain [MEDICATION NAME] 5 mg every 6 hours prn 10/10 back pain. A progress note documented on 1/2/19 at 12:34 pm was documented as. This nurse spoke with (Pharmacy employee's name withheld) from (pharmacy name withheld), manager, about [MEDICATION NAME] not arriving in a timely manner. (Pharmacy employee's name withheld) verified medication was ordered on 12/31 online however due to the holiday it could not be filled. Then the next day nurse again called pharmacy again and requested the medication. Pt. received 40 mg which is what we had on hand. The pharmacy explained that they needed new script due to it being a holiday and needing to get med from a different pharmacy because it is controlled. Script was obtained and faxed med was not here 1/2/19 in the morning nurse again called pharmacy requested it stat in which (Pharmacy employee's name withheld) at (pharmacy's name withheld) stated it would be sent. 12 pm and medication was still not here. Nurse called back again spoke to (pharmacy employee's name withheld) in which she stated (pharmacy employee's name withheld) never put in as stat order. Order was not in as stat per (Pharmacy employee's name withheld), manager. This nurse assessed pt around 10 am. Pt appears pale, diaphoretic, states he is nauseated in which nurse gave 4 mg [MEDICATION NAME]. States he had been having diarrhea and urinating on himself all night. Vitals stable. Pt stable. This nurse informed him of plan to contact pharmacy and discuss how we will avoid this again and get medication in stat. Education provided to staff that meds will need to be reordered when the 4th card of meds is started and to order meds several days in advance of a holiday. Per (Pharmacy employee's name withheld) this nurse could keep track of med by reordering every week on wed (Wednesday), then the following week on fri (Friday) and then mon (Monday) on the third week to make sure it falls in line with insurance. Next script due jan (January) 21st. Stat medication is on it's way per (Pharmacy employee's name withheld). Will continue to monitor. Pt updated on plan of care. The surveyor observed that there was no documentation of physician notification of change of condition for Resident # 102. On 2/13/19 at 1:50 pm, the surveyor reviewed the Pain Level Summary in the clinical record for Resident # 102. The surveyor observed the following times that Resident # 102 reported pain levels of 10 during the time the [MEDICATION NAME] was not available for distribution in the facility. 1/1/19 at 6:44 pm, Resident # 102 reported a pain level of 10 1/1/19 at 7:42 pm, Resident # 102 reported a pain level of 10 1/1/19 at 8:35 pm, Resident # 102 reported a pain level of 10 1/2/19 at 4:30 am, Resident # 102 reported a pain level of 10 1/2/19 at 11:12 am, Resident # 102 reported a pain level of 10 1/2/19 at 2:00 pm, Resident # 102 reported a pain level of 10 1/2/19 at 2:21 pm, Resident # 102 reported a pain level of 10 On 2/13/19 at 3:08 pm, the surveyor interviewed the unit manager RN # 1. The surveyor asked RN # 1 if she was aware of any incidents where Resident # 102 did not have his physician ordered [MEDICATION NAME] in the facility for administration. RN # 1 stated that she was aware of the incident but could not recall the exact date. The surveyor asked RN # 1 if there was an incident that occurred on New Year's Day when Resident # 102 did not have his [MEDICATION NAME] available in the facility for administration. RN # 1 stated, Yes. RN # 1 stated that when she did come into the facility she went in to assess Resident # 102 and he was in full blown withdrawals. RN # 1 stated that Resident # 102 was shaking, diaphoretic, and was having diarrhea. The surveyor asked RN # 1 if there were any other incidents where Resident # 102's [MEDICATION NAME] was not available for administration. RN # 1 informed the surveyor that there was almost an incident on 2/11/19. RN # 1 stated that Resident # 102 got upset and came and spoke to her. RN # 1 stated that she called the physician and the pharmacy and got the medication into the facility. The surveyor then reviewed the progress note for Resident # 102 that was documented on 1/2/19 at 12:34 pm, with RN #1. The surveyor asked RN # 1 if she was the nurse that had documented the progress note in the clinical record for Resident # 102. RN # 1 stated that she had written the progress note on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 if she had informed the physician of the change of condition in Resident # 102 as documented in the progress note on 1/2/19 at 12:34 pm. RN # 1 stated that she did notify the nurse practitioner. RN # 1 reviewed the progress note along with the surveyor and agreed that she did not document physician notification of change in Resident # 102's status on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 who she made aware of the change in Resident # 102's condition on 1/2/19. RN # 1 stated that she made (Nurse practitioner's name withheld) aware. On 2/13/19 at 2:14 pm, the surveyor interviewed (Pharmacist name withheld) via telephone. The surveyor asked the pharmacist if a prescription for [MEDICATION NAME] had been received for Resident # 102. The pharmacist stated that a prescription had been received and on 1/2/19 at 2:09 pm 120 tablets of [MEDICATION NAME] was delivered to the facility for Resident # 102. The surveyor asked the pharmacist if there was an issue with the [MEDICATION NAME] prescription for Resident # 102 that would prevent the pharmacy from delivering the [MEDICATION NAME] to the facility to be available for administration. The pharmacist stated that a new prescription was needed because Resident # 102's insurance rejected the refill order. The pharmacist informed the surveyor that 60 tablets of [MEDICATION NAME] was delivered to the facility at 11:22 am on 2/11/19. On 2/13/19 at 3:30 pm, the surveyor spoke with (Nurse Practitioner's name withheld) via telephone in the presence of RN #1 and 2 other surveyors. The surveyor asked (Nurse Practitioner's name withheld) if he had been made aware of a change in Resident # 102's condition on 1/2/19. (Nurse practitioner's name withheld) stated, No. RN # 1 then interjected and stated, (Nurse practitioner's name withheld), I called you on that day to make you aware of the change with Resident # 102. (Nurse practitioner's name withheld) stated, You probably did. I must have forgotten. The surveyor asked (Nurse Practitioner's name withheld) if he would expect the nurses to make him aware when Resident's experience a change in condition. The nurse practitioner stated, Yes. The surveyor asked the nurse practitioner what he would have done for Resident # 102 if he had been made aware of his change of condition on 1/2/19. The nurse practitioner stated, Probably give him some [MEDICATION NAME]. The surveyor asked the nurse practitioner if that is all that he would have ordered for Resident # 102 The nurse practitioner stated, Yes. The facility policy on Notification of Change in Condition contained documentation that included but was not limited to, . Procedure The nurse to notify the attending physician and Resident Representative when there is a (n): Significant change in the patient/resident's physical, mental, or psychosocial status. The facility policy on Medication Shortages/Unavailable Medications contained documentation that included but was not limited to, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of this Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order to reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery;, 3.2.2 Use of an emergency (back-up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. 5. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. On 2/13/19 at 7:00 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 2/13/19. This is a complaint deficiency.

Based on clinical record review, Resident interview, staff interview, and facility document review, the facility staff failed to provide effective pain management for 1 of 12 Residents in the survey sample, Resident # 102. The findings included The facility staff failed to ensure that the physician ordered [MEDICATION NAME] was in the facility and available for administration, which resulted in incomplete and late dose administrations. This caused Resident # 102 to report a pain scale of 9/10 and 10/10, and experience withdrawal symptoms because of not having the [MEDICATION NAME] in the facility. Resident # 102 was a [AGE] year-old-male who was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 102 was reviewed on 2/12/19 at 12:42 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 12/4/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 102 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 102 was cognitively intact. The plan of care for Resident # 102 was reviewed and revised on 2/17/18. The facility staff documented a focus area for Resident # 102 as, Resident # 102 has alterations in pain R/T (related to) [MEDICAL CONDITION] C5-C7, [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease), wounds, [MEDICAL CONDITIONS], [MEDICATION NAME] [DIAGNOSES REDACTED], chronic pai[DIAGNOSES REDACTED], low back pain, muscle spasms. Interventions included but were not limited to, Medications per MD orders, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Resident # 102 had current orders for [MEDICATION NAME] HCI Tablet 10 mg (milligram) Give 12 tablet by mouth one time a day for pain, which was initiated by the physician on 11/29/18. Resident # 102 also had orders for [MEDICATION NAME] HCI tablet 5 mg Give 2 tablet by mouth every 6 hours as needed for pain related to low back pain, which was initiated by the physician on 12/6/18. On 2/12/19 at 1:00 pm, the surveyor reviewed the (MONTH) 2019 Medication Administration Record [REDACTED]. According to the Chart Codes/Follow Up Codes 9 = Other/ See Nurses Notes. Upon review of the progress notes for Resident # 102, the surveyor observed a Medication Administration Note for Resident # 102 documented on 2/11/19 at 10:16 am. The medication administration note was documented as, [MEDICATION NAME] HCI Tablet 10 mg give 12 tablet by mouth one time a day for pain notified pharmacy and md about order. On 2/12/19 at 3:13 pm, the surveyor interviewed LPN # 2 (licensed practical nurse) via telephone. LPN # 2 confirmed that she was responsible for administering medications to Resident # 102 on 2/11/19. The surveyor asked LPN # 2 why Resident # 102 did not receive the physician ordered [MEDICATION NAME] at 9:00 am on the morning of 2/11/19. LPN # 2 stated, He didn't have it there. LPN # 2 stated that the facility called the pharmacy that morning and the facility was charged and paid for the [MEDICATION NAME] and the pharmacy delivered the [MEDICATION NAME] to the facility. The surveyor asked LPN # 2 what time Resident # 102 received the [MEDICATION NAME] on 2/11/19. LPN # 2 stated, He didn't get it until 11 something. The surveyor asked LPN # 2 if Resident # 102 reported pain while he did not have the physician ordered [MEDICATION NAME]. LPN # 2 stated, He said that he was hurting but I gave him two [MEDICATION NAME]. He was very upset and said he was going to call the ombudsman. On 12/13/19 at 12:00 pm, a Resident interview was conducted with Resident # 102 in the presence of 3 surveyors. Resident # 102 stated that on Monday 2/11/19, he was waiting for the nurse to give him his medicine. Resident # 102 stated that he usually received his medication first because he was the first room on the hall. Resident # 102 stated that he noticed that the nurse kept skipping his room and he was in pain. Resident # 102 stated that he finally got up and walked down the hall and asked the medication nurse for his medication. Resident # 102 stated that the medication nurse informed him that they were out of his medication. Resident # 102 stated that he could not believe that the facility let him run out of his [MEDICATION NAME] again. Resident # 102 stated that he spoke with the unit manager RN # 1 (registered nurse). Resident # 102 stated that RN # 1 informed him that the pharmacy did not send his medication. Resident # 102 stated that he then told RN # 1 that he heard the facility staff nurses state that there was no prescription for his [MEDICATION NAME] and that a prescription had to be written that Monday morning (2/11/19). Resident # 102 stated that RN # 1 stated that she would look into the situation, later returned, and told him that he was correct and that the prescription for [MEDICATION NAME] had been obtained that morning. Resident # 102 stated, They should not let me run out of my [MEDICATION NAME]. The surveyor asked Resident # 102 if the facility staff provided him with anything for pain in place of the [MEDICATION NAME]. Resident # 102 stated that the facility staff gave him his prn (as needed) [MEDICATION NAME] 10 mg. The surveyor asked Resident # 102 if the [MEDICATION NAME] 10 mg helped to relieve his pain during the time that the facility did not have the [MEDICATION NAME]. Resident # 102 stated, No, I take 12 tablets of [MEDICATION NAME] at one time. The surveyor asked Resident # 102 to rate his pain during the time he went without his [MEDICATION NAME] on a scale of 0 to 10 with zero being no pain and 10 being the worst pain he could imagine. Resident # 102 rated his pain at a level of 9 out of 10. The surveyor asked Resident # 102 what level of pain is usually tolerable for him. Resident # 102 reported that a pain level of 5 out of 10 was tolerable for him. Resident # 102 stated, Last time this happened was New Year's and I went into full blown withdrawal. I had to wait for two days to get it back. I was vomiting and going to the bathroom on myself. I felt like I was going to die. On 2/13/19 at 1:00 pm, the surveyor reviewed the progress notes for Resident # 102. The surveyor observed the following progress notes. A progress note documented on 1/1/19 at 9:21 am was documented as, [MEDICATION NAME] in drawer is only 4 tablets. Refill was not sent from pharmacy. Called pharmacy spoke with (pharmacy employee's name withheld) and she told me medication would be on next run. Also called Richmond line and was told medication had already been put in to be sent on next run. 3-11 nurse notified that I spoke with pharmacy regarding medication. Resident received 4 pills in the cart awaiting delivery for full dose. Resident aware. A progress note documented on 1/1/19 at 6:24 pm, was documented as, Called pharmacy to deliver [MEDICATION NAME]. Pt. (patient) only received 40 mg dose today. Behaviors cursing staff and general moodiness, refusing evening meds. Pharm (pharmacy) was called would not send out until they receive new script. On call DR (doctor) (Physician's name withheld) was called and she wrote a one day script for 1/2/19. Pharmacy was called back and will send out on 1/2/19. A progress note documented on 1/2/19 at 10:36 am was documented as [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg Give 1 tablet by mouth every 6 hours as needed for nausea given for nausea vomiting. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME][MEDICATION NAME] disintegrating 4 mg give 1 tablet by mouth every 6 hours as needed for nausea patient stated the [MEDICATION NAME] prn administration was ineffective. A progress note documented on 1/2/19 at 11:12 am, was documented as, [MEDICATION NAME] HCI tablet 5 mg give 2 tablets by mouth every 6 hours as needed for pain related to low back pain [MEDICATION NAME] 5 mg every 6 hours prn 10/10 back pain. A progress note documented on 1/2/19 at 12:34 pm was documented as. This nurse spoke with (Pharmacy employee's name withheld) from (pharmacy name withheld), manager, about [MEDICATION NAME] not arriving in a timely manner. (Pharmacy employee's name withheld) verified medication was ordered on 12/31 online however due to the holiday it could not be filled. Then the next day nurse again called pharmacy again and requested the medication. Pt. received 40 mg which is what we had on hand. The pharmacy explained that they needed new script due to it being a holiday and needing to get med from a different pharmacy because it is controlled. Script was obtained and faxed med was not here 1/2/19 in the morning nurse again called pharmacy requested it stat in which (Pharmacy employee's name withheld) at (pharmacy's name withheld) stated it would be sent. 12 pm and medication was still not here. Nurse called back again spoke to (pharmacy employee's name withheld) in which she stated (pharmacy employee's name withheld) never put in as stat order. Order was not in as stat per (Pharmacy employee's name withheld), manager. This nurse assessed pt around 10 am. Pt appears pale, diaphoretic, states he is nauseated in which nurse gave 4 mg [MEDICATION NAME]. States he had been having diarrhea and urinating on himself all night. Vitals stable. Pt stable. This nurse informed him of plan to contact pharmacy and discuss how we will avoid this again and get medication in stat. Education provided to staff that meds will need to be reordered when the 4th card of meds is started and to order meds several days in advance of a holiday. Per (Pharmacy employee's name withheld) this nurse could keep track of med by reordering every week on wed (Wednesday), then the following week on fri (Friday) and then mon (Monday) on the third week to make sure it falls in line with insurance. Next script due jan (January) 21st. Stat medication is on it's way per (Pharmacy employee's name withheld). Will continue to monitor. Pt updated on plan of care. The surveyor observed that there was no documentation of physician notification of change of condition for Resident # 102. On 2/13/19 at 1:50 pm, the surveyor reviewed the Pain Level Summary in the clinical record for Resident # 102. The surveyor observed the following times that Resident # 102 reported pain levels of 10 during the time the [MEDICATION NAME] was not available for distribution in the facility. 1/1/19 at 6:44 pm, Resident # 102 reported a pain level of 10 1/1/19 at 7:42 pm, Resident # 102 reported a pain level of 10 1/1/19 at 8:35 pm, Resident # 102 reported a pain level of 10 1/2/19 at 4:30 am, Resident # 102 reported a pain level of 10 1/2/19 at 11:12 am, Resident # 102 reported a pain level of 10 1/2/19 at 2:00 pm, Resident # 102 reported a pain level of 10 1/2/19 at 2:21 pm, Resident # 102 reported a pain level of 10 On 2/13/19 at 3:08 pm, the surveyor interviewed the unit manager RN # 1. The surveyor asked RN # 1 if she was aware of any incidents where Resident # 102 did not have his physician ordered [MEDICATION NAME] in the facility for administration. RN # 1 stated that she was aware of the incident but could not recall the exact date. The surveyor asked RN # 1 if there was an incident that occurred on New Year's Day when Resident # 102 did not have his [MEDICATION NAME] available in the facility for administration. RN # 1 stated, Yes. RN # 1 stated that when she did come into the facility she went in to assess Resident # 102 and he was in full blown withdrawals. RN # 1 stated that Resident # 102 was shaking, diaphoretic, and was having diarrhea. The surveyor asked RN # 1 if there were any other incidents where Resident # 102's [MEDICATION NAME] was not available for administration. RN # 1 informed the surveyor that there was almost an incident on 2/11/19. RN # 1 stated that Resident # 102 got upset and came and spoke to her. RN # 1 stated that she called the physician and the pharmacy and got the medication into the facility. The surveyor then reviewed the progress note for Resident # 102 that was documented on 1/2/19 at 12:34 pm, with RN #1. The surveyor asked RN # 1 if she was the nurse that had documented the progress note in the clinical record for Resident # 102. RN # 1 stated that she had written the progress note on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 if she had informed the physician of the change of condition in Resident # 102 as documented in the progress note on 1/2/19 at 12:34 pm. RN # 1 stated that she did notify the nurse practitioner. RN # 1 reviewed the progress note along with the surveyor and agreed that she did not document physician notification of change in Resident # 102's status on 1/2/19 at 12:34 pm. The surveyor asked RN # 1 who she made aware of the change in Resident # 102's condition on 1/2/19. RN # 1 stated that she made (Nurse practitioner's name withheld) aware. On 2/13/19 at 2:14 pm, the surveyor interviewed (Pharmacist name withheld) via telephone. The surveyor asked the pharmacist if a prescription for [MEDICATION NAME] had been received for Resident # 102. The pharmacist stated that a prescription had been received and on 1/2/19 at 2:09 pm 120 tablets of [MEDICATION NAME] was delivered to the facility for Resident # 102. The surveyor asked the pharmacist if there was an issue with the [MEDICATION NAME] prescription for Resident # 102 that would prevent the pharmacy from delivering the [MEDICATION NAME] to the facility to be available for administration. The pharmacist stated that a new prescription was needed because Resident # 102's insurance rejected the refill order. The pharmacist informed the surveyor that 60 tablets of [MEDICATION NAME] was delivered to the facility at 11:22 am on 2/11/19. On 2/13/19 at 3:30 pm, the surveyor spoke with (Nurse Practitioner's name withheld) via telephone in the presence of RN #1 and 2 other surveyors. The surveyor asked (Nurse Practitioner's name withheld) if he had been made aware of a change in Resident # 102's condition on 1/2/19. (Nurse practitioner's name withheld) stated, No. RN # 1 then interjected and stated, (Nurse practitioner's name withheld), I called you on that day to make you aware of the change with Resident # 102. (Nurse practitioner's name withheld) stated, You probably did. I must have forgotten. The surveyor asked (Nurse Practitioner's name withheld) if he would expect the nurses to make him aware when Resident's experience a change in condition. The nurse practitioner stated, Yes. The surveyor asked the nurse practitioner what he would have done for Resident # 102 if he had been made aware of his change of condition on 1/2/19. The nurse practitioner stated, Probably give him some [MEDICATION NAME]. The surveyor asked the nurse practitioner if that is all that he would have ordered for Resident # 102 The nurse practitioner stated, Yes. The facility policy on Notification of Change in Condition contained documentation that included but was not limited to, . Procedure The nurse to notify the attending physician and Resident Representative when there is a (n): Significant change in the patient/resident's physical, mental, or psychosocial status. The facility policy on Medication Shortages/Unavailable Medications contained documentation that included but was not limited to, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of this Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order to reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery;, 3.2.2 Use of an emergency (back-up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. 5. If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. On 2/13/19 at 7:00 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 2/13/19. This is a complaint deficiency.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure physician ordered medications were available for administration for 1 of 23 residents (Resident #14). The findings included: The facility staff failed to ensure the physician ordered medication [MEDICATION NAME] was available for administration to Resident #14. The clinical record of Resident #14 was reviewed 12/12/18 through 12/14/18. Resident #14 was admitted to the facility 6/11/18 with [DIAGNOSES REDACTED]. Resident #14's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/13/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #14 had a physician order [REDACTED]. The surveyor reviewed the (MONTH) (YEAR) medication administration records (MARs). [MEDICATION NAME] 2.5 mg had been entered onto the MAR indicated [REDACTED]. The reverse side of the MAR indicated [REDACTED]. The surveyor reviewed the interdisciplinary progress notes for (MONTH) (YEAR). There was not a note for 10/12/18. The notes for 10/13/18 and 10/14/18 did not document the reason [MEDICATION NAME] was not administered. The surveyor informed the unit manager licensed practical nurse #2 on 12/13/18 at 10:26 a.m. L.P.N. #2 reviewed the Medication Administration Record [REDACTED]. The unit manager L.P.N. #2 was asked about the back-up pharmacy. The unit manager L.P.N. #2 stated CVS was the back-up pharmacy. The surveyor informed the administrator, the director of nursing, and the regional registered nurse of the above concern during the end of the day meeting on 12/13/18 at 4:29 p.m. The surveyor requested the pharmacy manifest for [MEDICATION NAME] and a list of the stat box medications. The DON informed the surveyor on 12/14/18 at 8:03 a.m. that there was not a pharmacy manifest for [MEDICATION NAME] and the medication was not in the facility stat box. No further information was provided prior to the exit conference on 12/14/18.

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure a safe transfer, which resulted in injury, for 1 of 21 residents (Resident #20). This is a past non-compliance. The findings included: Resident #20 sustained a mildly comminuted, mildly displaced and angulated transverse right proximal humeral neck fracture (right shoulder) and an L1 (lumbar) compression fracture while being transferred with a mechanical lift on 10/8/16. C.N.A. #1 transferred Resident #20 using a Sara Lift (sit to stand lift) by herself. The resident slid from the sit to stand lift and injured the right shoulder and the L1 vertebrae. Resident #20's comprehensive care plan directed that two people were required to transfer the resident as well as the facility policy on lifts. The surveyor reviewed Resident #20's clinical record 9/13/17 and 9/14/17. Resident #20 was admitted to the facility 10/25/12 with [DIAGNOSES REDACTED]. Resident #20's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/24/16 assessed the resident with a cognitive summary score of 15 out of 15. Resident #20 was not coded to have behaviors, psychosis, or delirium. Bed mobility and transfer ability was coded as 3/3 (extensive assistance of two+ people). Walk in room and walk in corridor were coded as 8/8 (activity did not occur). Resident #20 required extensive assistance of one person for personal hygiene and extensive assistance of two+ persons for bathing. Resident #20's balance and walking were assessed as follows: Not steady only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet, and from surface to surface (transfer between bed and chair or wheelchair). Walking and turning around did not occur. Resident #20's current comprehensive care plan initiated 4/20/16 and revised 6/28/16 identified the resident as a potential for injury r/t (related to) Multiple Sclerosis, bilateral LE (lower extremities) contractures, moderately impaired vision with readers-[DIAGNOSES REDACTED]. Interventions: Mechanical Lift-SARA-LIFT 2 person transfer, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). The Nurse Tech Information Kardex kept at the nurse's station for certified nurse's aides to review included Resident #20's transfer assist which was marked Sit to stand lift-TL (transfer lift) and transfers (assist of 2). In the clinical record, the surveyor noted a Quarterly Data Collection dated 7/14/16. Section A Safety had documentation that the resident was non-ambulatory, no history of falls, difficulty with trunk control and balance is currently on medications which would require safety precautions, and was visually challenged. Fall Risk Evaluation scored Resident #20 with a score of 15. Total score of 10 or above deems the resident to be at risk for falls. Resident #20 had no documentation of falls within the past 6 months. On 10/8/16 12pm, a nurse (licensed practical nurse #1) documented Res (resident) slid out of lift stand. Res's (resident's) knees buckled staff reported that resident slid out. 2 C.N.A.s witnessed fall. Notified supervisor. Res states Right and Left shoulder hurts. X-rays ordered. Notified RP (responsible party) to call us back on A/M (answering machine). No answer. Res states pain level is 10. Pain med (medication) given. Res ref (refused) shower, provides d/t (due to) pain (sic). Res doesn't want staff messing with her she stated. Res didn't hit head staff said. 10/8/16 6 pm, L.P.N. #1 documented I heard from another C.N.A. that 2 C.N.A.s weren't present when resident fell . Res told me personally about it. I notified supervisor. Res states she was on floor when 2nd C.N.A. responded not at time of transfer. Res states she didn't hit head. Daughter present when resident told me this. I notified supervisor, DON (director of nursing) and unit manager of incident. I was not notified of resident on floor when occurred. When I had arrived from lunch C.N.A. had told me about fall. Res was in bed when I was called about incident at 4pm (? Time). I immediately checked resident for injuries. I observed shoulders swollen and painful to touch. Pain med given. 10/8/16 9 pm, L.P.N. #1 documented Notified unit manager and supervisor that x-ray had been contacted 4 x's and had not come yet. Daughter upset. Supervisor and I asked daughter of she wanted her sent out. Daughter stated no; she would wait on x-ray. 10/8/16 11 pm, L.P.N. #1 documented Asked daughter again if she wanted her to go out. Res RP daughter stated yes she wanted her to go. Dr. (name omitted) but will be referred to as other #3 said 911 would be ok. 10/8/16 11:20 pm, L.P.N. #1 documented 911 arrived. RP went with her mom. 10/9/16 6:30 a.m., registered nurse #2 documented Returned from ED (emergency department) with right arm in sling. The surveyor reviewed the emergency department visit notes dated 10/9/16 3:08 a.m. The discharge notes read 83 yo (year old) F (female) with right shoulder pain after fall from Hoyer loft. XR (x-ray) with proximal humerus fracture. L1 compression fx (fracture) indeterminate age. Provided arm immobilizer, ortho (orthopedics) f/u (follow-up). Non ambulatory at baseline. Agrees d/c (discharge). Return as needed. Clinical Impression Primary Impression: Proximal humerus fracture. Secondary Impression: Compression fracture of L1 lumbar vertebrae. The surveyor discussed the complaint with the director of nursing on 9/13/17 at 3:05 p.m. The DON stated the facility had completed a plan of correction for the incident on 10/8/16. The DON provided the facility Investigative Report dated 10/14/16. The report gave a detailed description of the incident: resident was being assisted to transfer for shower and lost balance/became weak and slid out of the sit to stand lift to the floor. 2 C.N.A.s then assisted her from the floor to the bed. Injury occurred (proximal humeral fracture). RP, MD, APS, Ombudsman, and VDH notified as well as Department of Health Professions. Details of the investigation read: Investigation initiates interviews conducted with employees involved- C.N.A. #1 and C.N.A. #2. Sequence of events retraced with return demonstration as well conducted. Res was being assisted with transfer in room to shower-lost balance, knees buckled, and res became weak and slid to the floor during the transfer. 2 C.N.A.s then assisted her up from the floor to the bed. Outcome of investigation: see attached P(NAME), see below for system intervention. Transfer education will be heightened during orientation. Return demonstrations for transfers ongoing. Employee was educated at the time of hire regarding lift/safety requirements-we were not able to anticipate that this employee would make this decision. The DON stated certified nursing assistant #1 informed the DON that Resident #20's knees buckled when she was being transferred. C.N.A. #1 was the only C.N.A. involved in the transfer. The DON stated the facility policy on mechanical lifts require 2 people. The DON stated C.N.A. #1 did not transfer the resident per the facility policy and the careplan. The DON stated the facility determined the incident was an unavoidable accident. The DON provided the Determination of Unavoidable Accident form dated 10/8/16 at approximately 11:30 a.m. The DON stated the facility could not have anticipated that this employee (C.N.A. #1) would have made the decision she made; therefore, the event was unavoidable. This employee was educated upon hire regarding lift/safety education. The employee will no longer be employed for the facility. 5 pt (point) P(NAME) (plan of correction) implemented. The DON provided the surveyor with C.N.A. #1's corrective action form and witness statement as well as other staff involved in the occurrence on 10/8/16 that involved Resident #20. The form dated 10/10/16 read in part Used lift without assistance of 2 staff members. Rsd subsequently fell . Also, staff member put rsd back in bed without a nurse assessment. Witness statement dated 10/8/16 by C.N.A. #1 read Rst (resident) was in a standing position on lift sit to stand and knees began to buckle. Rst slid out from lift and slid on floor. I had assisted from other employee. Nurse notified. Neuro checks stat. Did not hit head. VS. C.N.A. #2 Witness Employee. Witness statement dated 10/10/16 as told to registered nurse #2 read Got her up with lift by myself. She sat on side of bed strap on her locked. Looked down the hall to see if anyone was coming to help. There was no one to help. Got her up, pulled the chair around and she was in the floor. Had on brown shoes. She just started coming out of the lift and sat down in the floor. I went out and got L.P.N. #1. L.P.N. #1 was at the desk. No not right before the nurse got in the room, we got her back to bed. I didn't even have her. I didn't have any help. I didn't use the lift on anyone else. I know I have been educated that there has to be 2 people for lifts. I've never had her. I never meant for this to happen. Didn't use lift to get her back to bed. C.N.A. #2 and I got under her arms and lifted her back into bed. I didn't know I was supposed to use a hoyer lift to get her back to bed. C.N.A. #1 was no longer working at the facility so an interview was unable to be completed. The agency C.N.A. (#2) corrective action form dated 10/9/16 was reviewed. The form read Rsd had fall and was put back to bed prior to a nurse assess rsd. Education on proper use of mech (mechanical lifts.) witnessed statement was reviewed. C.N.A. #2's witnessed statement read I C.N.A. #2 was called to help assist the lady (Resident #20) to get off the floor. I asked her did she notify a nurse to check her so then I went ahead and help sit her up then get on the bed. I was only a witness to seeing her already in the floor when I entered the room. I asked the girl did a nurse see her said yes so I went ahead and helped her get her up. I didn't see a nurse but I assumed she had already had a nurse see her. Then after that she came back with a paper and vital signs. This happened while the lunch trays was on the unit. I asked the cna did she need help before she went into the room with the lift, she told me no so I assumed she had found someone to help her. If I knew she was in there by herself I would have went in the room with her and helped. I also would have not touched the resident if I knew that a nurse was not notified and checked the patient first. I would have done things different if I knew different. C.N.A. #2 was not available for an interview by the surveyor. The DON stated immediately after the incident, C.N.A. #1 was suspended. The DON stated both C.N.A. #1 and the agency C.N.A. #2 were terminated from working at the facility. The DON stated C.N.A. #1 was asked to return to the facility for a demonstration of transfers. The observation occurred 10/10/16 and read 1. Knows to have 2 people. 2. Knows to have brakes on. 3. Knows to have nurse assess rsd prior to putting back to bed 4. Knows to use hoyer lift for rsds who fall not to lift under arms. The DON stated C.N.A. #1 made a bad decision. She had the education/demonstration. She admitted she should have used 2 people to transfer Resident #20. The DON provided the 5 Point Plan of Correction dated 10/8/2016 for Resident #20. 1. The employee was suspended pending investigation. Vital signs were obtained by nurse. MD and the RP were notified. New orders were given. The resident was medicated per the physician's orders [REDACTED]. 2. The employee was suspended and did not provide care/assistance to any other resident after the occurrence. No other residents were affected. The lift utilized was removed from service, locked and tagged out and not to be utilized until the manufacturer comes out to assess the lift for appropriate function. Other lifts were checked by the maintenance staff for appropriate function. 3. Nursing staff will be educated by the DCS (director of clinical services)/Nurse Manager/Designee regarding transfers, appropriate utilization of the lift, and where to find the appropriate information for individual resident transfers. a) Transfer assessments will be completed for residents residing in the facility. b) Resident Kardex will be updated on or before 10/12/2016 with the results of the transfer assessments. c) Resident careplans will be updated on or before 10/12/2016 to correspond with transfer assessments and Kardex's. d) The DCS/Nurse Manager/Designee will observe a transfer for nursing employees to ensure that appropriate transfer technique is being demonstrated during resident transfers. As of 10/12/2016, nurses and c.n.a.'s will be required to demonstrate a transfer successfully before they can work another shift. Nursing staff on shift on 10/9/16, demonstrated transfer technique prior to conducting any further transfers. e) Random weekly observations of transfers will be conducted by DCS/Nurse Manager/Designee for three (3) employees to ensure that appropriate transfer technique is being sustained by nursing staff during resident transfers. 4. An in-prompt QA/PI meeting was held 10/9/2016--10/10/2016 to discuss the plan of correction and corrective measures. Results of random weekly observation will be discussed at the monthly QA/PI meeting for three (3) months to sustain substantial compliance. 5. 10/12/2016. Attached to the 5 Point Plan of Correction was the QA/PI committee meeting with staffing signatures. The DON provided the surveyor the lift evaluations for the residents residing in the facility 10/9/16 and completed 10/10/16, weekly staff transfer technique observation from 10/2016 through 11/23/16, staff education on lifts dated 10/9/16 and 10/10/16, lift inspection sheet of 8 facility lifts dated 10/9/2016, the operating and maintenance instructions for the SARA Lift by Arjo, the Stand Up Patient Lift by Invacare, and the Steady Aid 3500/4500/7500 Series by tollos. Resident #20's Transfer/Mobility Status Criteria dated 10/10/16 documented the resident was assessed to be a SST-Sit-to-stand with 2 people. The surveyor reviewed C.N.A. #1's orientation checklist. C.N.A. #1's orientation occurred 9/6/16 and included Proper Lifting Techniques (S-305) and Ten Commandments of Body Mechanics (N-902). The DON also stated all new hires receive orientation on the floor. Therapy now spends 30 minutes educating new hires on transfer education/demonstration. Therapy now completes the transfer assessment of each resident. The surveyor reviewed the facility policy on transfers on 9/13/17. The policy titled Transfer/Mobility Evaluation Low Lift revised 11/30/2014 read in part 3. Two staff members are required when using a mechanical lift. The surveyor also reviewed the facility policy titled Low Lift Program effective date 11/30/2014. The policy read in part The Care Center is committed to providing the equipment and resources to achieve, as much as practicable, a lift free environment for both Residents and Staff. Procedure 1. Residents are evaluated on admission and with a significant change in condition using the Transfer/Mobility Status Criteria. 2. Identification of the residents lift status will be located: a. Resident's Care Plan b. Internal QA Nurse tech Kardex c. Using an identification system on the resident's door at each resident's nameplate that identifies the lift status. The surveyor interviewed certified nursing assistant #3 on 9/14/17 at 7:20 a.m. When asked where the resident's transfer status was located, the C.N.A. stated on a kardex at the nurse's station or ask another C.N.A. C.N.A. #3 stated she was observed doing transfers. The surveyor interviewed certified nursing assistant #4 on 9/14/17 at 7:21 a.m. She was also asked where the resident's transfer status was located. C.N.A. #4 stated at the nurse's desk. C.N.A. #4 stated she was observed doing transfers. The surveyor interviewed the certified occupational therapy assistant (COTA) other #4 on 9/14/17 at 9:00 a.m. Other #4 stated Resident #20 had been on caseload prior to the fall from 9/10/16 through 9/29/16. Other #4 stated she was seen for pain and decreased range of motion in her left knee. Other #4 stated resident #20 did well and was discharged from therapy with recommendations to use the sit to stand lift. Other #4 stated Resident #20 was very specific on how she wanted things done. Other #4 stated restorative nursing was not a recommendation. Resident #20 was no longer a resident of the facility; therefore, an observation of the sit to stand lift could not be observed with her. The surveyor did observe a sit-to-stand transfer on Resident #1 on 9/13/17 at 1:40 p.m. with C.N.A. #5 and C.N.A. #6. The surveyor id not observe any areas of concern with the transfer from the wheelchair to the bed. The surveyor informed the administrator and the director of nursing of the above findings on 9/14/17 at 11:00 a.m. The DON stated C.N.A. #1 made a bad decision when Resident #20 was transferred incorrectly. This is a past non-compliance and a complaint deficiency.