Every finding on record at PruittHealth-Crystal Coast

Based on record review, staff, Medical Director, and family member interviews, the facility failed to ensure Resident #1 received a mental health evaluation and monitoring, failed to implement suicide precautions and failed to heighten awareness amongst all staff after Resident #1 had disclosed suicidal ideations. On 6/8/26 at 10:00pm, Resident #1 was found in his bed with the cord to the bed control wrapped around his neck tight with no breath or pulse. Nurse #2 called a code blue (a facility wide announcement that a resident was not breathing and without a pulse) and began Cardiopulmonary Resuscitation (CPR) while Nurse Aide (NA) #1 called for emergency medical services. The Emergency Medical Services (EMS) arrived and after performing CPR for 45 minutes, pronounced Resident #1 deceased . This deficient practice was for 1 of 1 resident reviewed for mental health services (Resident #1). The findings included:The hospital admission dated 5/27/26 revealed Resident #1 had fallen at home and fractured his left prosthetic hip. The hospital records indicated Resident #1 had tested positive for opioids and fentanyl (pain medications). Resident #1 also had a blood alcohol level of 15 (8 and below are considered within normal limits).Resident #1 was admitted to a private room in the facility on 5/29/26 with multiple diagnoses that included non-operable fracture of the left hip, acute pain due to trauma, and moderate protein calorie malnutrition. Resident #1 did not have any mental health diagnoses. Resident #1's baseline care plan dated 5/29/26 revealed no goals or interventions for depression or mental health.Physician order dated 5/29/26 revealed an order for Resident #1 to have a pain evaluation every shift.Review of Resident #1's Medication Administration Record (MAR) from 5/29/26 to 6/8/26 revealed Resident #1's pain ranged from 0 (no pain) to a 10 (severe pain). On 6/8/26 during the 7:00am to 7:00pm shift Resident #1's pain was documented as an 8.Physician order dated 5/31/26 and discontinued on 6/4/26 revealed an order for Resident #1 to receive oxycodone (pain medication) 5 milligrams (mg) every 4 hours as needed.Physician order dated 6/3/26 revealed Resident #1 was to receive morphine (pain medication) 0.5 milliliters (ml) (10mg) every 2 hours as needed for pain greater than 6.Physician order dated 6/3/26 revealed an order for Resident #1 to receive morphine extended release 30mg twice a day for pain. Review of Resident #1's Medication Administration Record (MAR) from 5/29/26 to 6/8/26 revealed Resident #1had received his scheduled morphine as ordered and received his as needed morphine 4 times on 6/4/26, 3 times on 6/5/26 and 6/6/26, 1 time on 6/7/26, and 2 times on 6/8/26. Review of the Patient Health Questionaire-9 (PHQ9) for depression dated 5/31/26 completed by the Social Worker (SW) revealed Resident #1 (who was [AGE] years old) had thoughts over the last 2 weeks that he would be better off dead. There was also a written comment on the PHQ9 that Resident #1 had told the SW right now I'd be better off dead because of the amount of pain Resident #1 was experiencing. The PHQ9 score was a 10 which indicated moderate depression. There were no directions or guidance on the PHQ9 as to what should be done if a resident scored at a certain level. The Director of Nursing (DON) was interviewed on 6/17/26 at 3:11pm. She stated the SW never informed management of Resident #1's suicidal statements made on 5/31/26.The SW was interviewed on 6/18/26 at 2:40pm. The SW stated he met with Resident #1 on 5/31/26 to complete the PHQ9 depression screening. He confirmed while completing the PHQ9 the resident had told him that he had been having thoughts of wanting to die over the last 2 weeks and that he felt he would be better off dead because of the amount of physical pain Resident #1 had been feeling. The SW stated he documented Resident #1's comment in the electronic medical record along with the PHQ9 responses but had not notified administration or the Medical Director of Resident #1's comments/responses and had not informed the nurse about Resident #1's pain. The SW stated he did not begin any monitoring or make a referral to mental health services. The SW was unable to provide a response as to why he did not begin monitoring and/or make a referral for mental health services. He stated he would stick his head in Resident #1's room [ROOM NUMBER]-3 times a week to see how he was doing. The SW stated when he stuck his head in to see Resident #1, he would ask how he was doing and Resident #1 would respond that he was ok. The SW stated he would leave Resident #1's doorway and continue with other residents' visits. He discussed not knowing that he needed to inform administration and the Medical Director if any resident scored a 10 or above on the PHQ9 or voiced suicidal ideations. Review of Certified Occupational Therapy Assistant (COTA) #1's progress notes for Resident #1 dated 6/1/26 revealed she had a co-therapy session with Physical Therapy Assistant (PTA) #1. The note documented that during the session Resident #1 had told her that he would kill himself if he had the means. The progress note indicated that COTA #1 informed the Therapy Manager, Nurse #1, and completed a Stop and Watch form (a form that can be filled out by any staff member that has identified any change in a resident's condition). Review of the Stop and Watch form provided by the Administrator and allegedly completed on 6/1/26 by COTA #1 revealed no date on the form and a written statement I would take my own life. PTA #1 was interviewed on 6/17/26 at 2:28pm. PTA #1 confirmed she had performed a co-therapy session with COTA #1 on 6/1/26 with Resident #1. PTA #1 stated Resident #1 was in a lot of pain and that Resident #1 voiced being frustrated over the amount of pain he was experiencing. The PTA discussed Resident #1 telling her that he was suicidal and wanted to die. PTA #1 stated she encouraged Resident #1 to get out of his room and not to isolate. She also stated COTA #1 filled out a Stop and Watch form. PTA #1 stated she did not do anything about the suicidal statement because COTA #1 was informing the nurse and management. The PTA stated after 6/1/26, Resident #1 had not voiced any suicidal ideations and was more invested in his therapy. She also stated she would inform the nurse on duty if Resident #1 complained of pain.During an interview with COTA #1 on 6/18/26 at 8:27am, COTA #1 confirmed she was performing a co-therapy session with PTA #1 on 6/1/26 with Resident #1. She stated Resident #1 was refusing therapy on 6/1/26 so she discussed with the resident the importance of therapy. COTA #1 stated it was at this point Resident #1 told her he would kill himself if he had the means. She stated she immediately went and informed the Therapy Manager who instructed her to inform Nurse #1 and fill out a Stop and Watch form. COTA #1 stated she told Nurse #1 of the suicidal statements made by Resident #1 and leaving a copy of the Stop and Watch form in the therapy office for the Therapy Manager. She stated she could not remember if she ever gave a copy of the Stop and Watch form to Nurse #1 or administration as she had been taught. COTA #1 stated she would report Resident #1's pain to the nurse on duty. The Therapy Manager was interviewed on 6/18/26 at 8:37am. The Therapy Manager confirmed Resident #1 was admitted to the facility for rehabilitation services. The Therapy Manager indicated she was informed by COTA #1 that Resident #1 had made suicidal statements. She stated she instructed COTA #1 to inform Nurse #1 and fill out a Stop and Watch form. The Therapy Manager could not remember if she had instructed COTA #1 to provide Nurse #1 with a copy of the Stop and Watch form. The Therapy Manager explained a copy of the Stop and Watch form was to be provided to Nurse #1 and the other copy she kept in her desk. The Therapy Manager stated she did not follow up with nursing or administration related to any interventions or monitoring for Resident #1. She stated that residents were discussed in the management morning meetings and that Resident #1 had been discussed on 6/2/26, 6/3/26, 6/4/26 and 6/5/26. The Therapy Manager stated she could not remember what was discussed specifically regarding Resident #1 until 6/5/26 when she informed administration that Resident #1 had made suicidal statements on 6/1/26. The Therapy Manager did not have an explanation as to why she had not mentioned Resident #1's suicidal statement before 6/5/26 and stated she did not know what caused her to mention the statements on 6/5/26. She stated the SW was instructed to assess Resident #1 immediately on 6/5/26. A telephone interview occurred with Nurse #1 on 6/17/26 at 2:35pm. Nurse #1 confirmed he was assigned to Resident #1 from 7:00am to 7:00pm on 6/1/26. Nurse #1 stated he was made aware verbally of Resident #1's suicidal statement by therapy on 6/1/26. Nurse #1 indicated he told the Staff Educator of Resident #1's suicidal statements and asked the Staff Educator to please inform the Director of Nursing (DON). Nurse #1 stated he asked the Staff Educator several times if she had informed the DON of Resident #1's suicidal statements and Nurse #1 stated the Staff Educator told him she had. He stated he asked the Staff Educator several times because he wanted to make sure the DON would complete an assessment of Resident #1. Nurse #1 stated he did not go and assess Resident #1 after being made aware of the suicidal statements because he believed the DON would be assessing Resident #1. Nurse #1 stated he never informed administration or the Medical Director himself of Resident #1's suicidal statement. The Staff Educator was interviewed on 6/17/26 at 2:44pm. The Staff Educator discussed never being informed on 6/1/26 of Resident #1's suicidal statement. She explained Nurse #1 never mentioned to her to inform the DON of the suicidal statements reported for Resident #1. The Staff Educator discussed never receiving a copy of the Stop and Watch form or having a conversation with the DON related to Resident #1's suicidal statements.The DON was interviewed on 6/17/26 at 3:11pm. The DON discussed the Stop and Watch form. She stated the form was typically filled out by therapy and a copy was provided to the nurse on duty. She stated she was unsure if Nurse #1 had received a copy of the Stop and Watch form on 6/1/26. The DON confirmed she had not been made aware of Resident #1's suicidal statements made on 6/1/26 until 6/5/26. The Medical Director's note dated 6/3/26 revealed Resident #1 was miserable and having difficulty with pain. The Medical Director documented Resident #1 was upset, distraught, out of control with pain. The documentation also noted that Resident #1 had a long-term depression history and alcohol use. The document noted that Resident #1 was a widow and had been depressed at home for some time with severe economic limitations that were limiting his ability to obtain medications, medical help, and even food. The Medical Director documented that he was going to change Resident #1's pain medication from oxycodone to morphine. He also documented that getting Resident #1's pain under control was the number one concern and that Resident #1's depression would be addressed later once Resident #1's pain was controlled.During a telephone interview with the Medical Director on 6/18/26 at 10:07am, the Medical Director confirmed he had seen Resident #1 on 6/3/26. He stated he knew Resident #1 for many years on an outpatient basis. The Medical Director described Resident #1 as always being depressed and miserable. He stated he had tried to start Resident #1 on mental health medications when he saw him outpatient but Resident #1 refused. The Medical Director also stated he tried to have Resident #1 see a counselor for his depression and grief related to the death of his wife but Resident #1 refused. The Medical Director indicated when he saw Resident #1 on 6/3/26 in the facility, Resident #1 was in severe pain, miserable, very upset and distraught due to his pain. He stated he felt Resident #1's pain needed to be addressed first and did not believe Resident #1 would agree to mental health services. while the resident was in pain. The Medical Director stated he was never informed of Resident #1 voicing suicidal ideations on 5/31/26 and 6/1/26. He stated if he had known on 6/3/26 when he saw Resident #1, he would have pursued mental health services. The DON was interviewed on 6/17/26 at 3:11pm. She explained Monday through Friday administration had a morning meeting where all residents were discussed. The DON stated it was not until 6/5/26 when the Therapy Director informed the administration team of Resident #1's suicidal statements on 6/1/26. The DON indicated after the morning meeting on 6/5/26, she sent the SW to Resident #1's room to discuss his suicidal statements he had made on 6/1/26. The DON stated she felt the SW was most qualified because he had a background in mental health. She stated she was informed by the SW that Resident #1 was no longer feeling suicidal, so no further actions were taken. Another interview occurred with the SW on 6/17/26 at 1:45pm. The SW stated he attended the morning administration meetings Monday through Friday. The SW discussed on 6/5/26 he was informed to see Resident #1 after the administration had learned that Resident #1 had made suicidal statements. He stated he did not know when Resident #1 had made the statement, but he went to see Resident #1 on 6/5/26 and felt Resident #1 was doing well. The SW stated Resident #1 told him he was no longer intending to hurt himself. The SW explained he did not perform any type of assessment on 6/5/26. He also stated he was unaware of Resident #1's history of depression but was aware of the resident's history of alcohol abuse. The SW stated he informed administration that Resident #1 was no longer suicidal and was unaware of any follow up. He also stated he did not feel a referral to mental health was warranted because Resident #1 was no longer suicidal. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and feeling depressed for 2-6 days. Resident #1 did not have any behaviors documented. During an interview with Nurse #4 on 6/17/26 at 3:51pm, Nurse #4 confirmed she had been assigned to Resident #1 on 6/6/26 during the 7:00pm-7:00am shift. The nurse stated Resident #1 took his medications, did not have any complaints of pain or suicidal ideations. Nurse #4 stated Resident #1 was not cheerful or unpleasant. The nurse stated she was unaware of Resident #1's previous suicidal statements.Nurse #3 was interviewed on 6/17/26 at 3:29pm. Nurse #3 confirmed she was assigned to Resident #1 during the 7:00am to 7:00pm shift on 6/8/26. The nurse stated that Resident #1 had gone to a follow up orthopedic appointment that morning (6/8/26) and upon return refused his medication. Nurse #3 explained while Resident #1 was at the orthopedic appointment, the resident became upset because the Physician wanted to perform an x-ray and Resident #1 had informed the Physician, he was in pain and did not want to complete the x-ray. Nurse #3 stated she was told by the nurse at the orthopedic office that Resident #1 attempted to bite the Physician when the Physician tried to make Resident #1 have the x-ray. Nurse #3 also stated Resident #1 was ordered a urinalysis the morning of 6/8/26 however could not be completed on her shift due to Resident #1 being in pain. Nurse #3 clarified Resident #1's pain was in his left hip from the fracture. The nurse stated Resident #1 was alert and oriented, never conveyed any suicidal thoughts on 6/8/26 but did complain of not being able to handle his pain. Nurse #3 stated she was unaware of Resident #1's previous suicidal ideations made on 5/31/26 and 6/1/26. An interview with Occupational Therapist (OT) #1 occurred on 6/18/26 at 9:42am. OT #1 stated she had seen Resident #1 on 6/8/26 after he had returned from his appointment. She stated Resident #1 was irritated and refused therapy. OT #1 indicated this was the first time she had ever seen Resident #1 and was not informed about his previous suicidal statements. She stated on 6/8/26 Resident #1 requested to speak with the SW about going home. OT #1 stated she informed the SW that Resident #1 would like to speak with him and that Resident #1 was wanting to be discharged . During an interview with the SW on 6/18/26 at 10:02am, the SW stated he had seen Resident #1 on 6/8/26 after OT #1 had informed him that Resident #1 wanted to speak with him. The SW stated he discussed with Resident #1 the safety and care concerns of him discharging before he was ready. He stated Resident #1 told him he would stay. The SW stated Resident #1 did not have any complaints and did not appear depressed to him. During an interview with Nurse Aide (NA) #2 on 6/18/26 at 9:45am, NA #2 confirmed she had been assigned to Resident #1 during the 7:00am-7:00pm on 6/8/26. NA #2 stated she was familiar with Resident #1 and on 6/8/26 the resident did not appear any different from previous encounters. The NA stated Resident #1 did not voice any suicidal ideations to her. NA #2 explained she had not been made aware of Resident #1's prior suicidal statements.An interview was conducted with NA #1 on 6/18/26 at 11:12am. NA #1 confirmed she had been assigned to Resident #1 from the 7:00pm to 7:00am shift on 6/8/26. NA #1 explained this was the first evening she had been assigned to Resident #1. NA #1stated she entered Resident #1's room around 7:30pm. She discussed the resident being irritated (short with his answers, not looking at her) and appeared uncomfortable (shifting in his bed). NA #1 stated she had asked Resident #1 if there was anything she could help him with, and the NA stated Resident #1 told her that he wanted to be left alone. NA #1 stated she left Resident #1's room and reported to Nurse #2 that she felt Resident #1 was irritated and had asked to be left alone. The NA stated around 8:00-8:15pm, Nurse #2 had asked her to check on Resident #1 because the resident's daughter was trying to call him and he was not answering the phone. NA #1 stated when she arrived at Resident #1's room, his phone was ringing. She stated she asked the resident if he wanted help answering his phone and Resident #1 replied that he did not want to talk to anyone and asked for the phone to be unplugged. NA #1 stated she unplugged his phone and left his room. The NA stated she did not return to Resident #1's room until the code- blue was announced. NA #1 indicated she did not inform the nursing staff of Resident #1's request to unplug his phone and refused to talk with family.During a telephone interview with Nurse #2 on 6/17/26 at 4:12pm, Nurse #2 confirmed he had been assigned to Resident #1 from 7:00pm to 7:00am on 6/8/26. Nurse #2 stated she had been assigned to Resident #1 previously and that Resident #1 was usually agitated and in a lot of pain. Nurse #2 stated Resident #1 never made any suicidal statements to him and was unaware of Resident #1's previous suicidal statements on 5/31/26 and 6/1/26. The nurse explained he had received report from Nurse #3 when he arrived at work at 7:00pm. Nurse #2 stated the report consisted of Nurse #3 telling him that Resident #1 had been combative at an appointment earlier in the day and that he would need to perform an in and out catheterization on Resident #1 to test for a possible urinary tract infection. Nurse #2 stated he had not performed a walking round on his assigned residents, so he had not seen or spoken to Resident #1 until he entered Resident #1's room around 10:00pm. Nurse #2 stated when he entered Resident #1's room, the resident was on his back in the bed, unresponsive and not breathing. The nurse stated he saw the bed controller's cord wrapped tightly around Resident #1's neck. Nurse #1 stated he immediately called for help and activated a code blue. The nurse explained he performed CPR while NA #1 called for an ambulance.A follow-up telephone interview occurred with Nurse #2 on 6/18/26 at 12:32pm. Nurse #2 stated NA #1 had informed him on 6/8/26 at 7:30pm that Resident #1 was wanting to be left alone but stated he was not informed that Resident #1 had requested to have his phone unplugged. Nurse #2 stated if he had known that information, he would have checked on Resident #1 earlier because requesting his phone to be unplugged was unusual for Resident #1.The Emergency Medical Services (EMS) report dated 6/8/26 revealed EMS was answering a call from the facility for a cardiac arrest. The report stated upon EMS arrival the [NAME] fire department was performing chest compressions with an automatic external defibrillator (AED) attached to Resident #1. Upon assessment EMS learned the cardiac arrest was associated with intentional self-harm by hanging. The report indicated, once EMS consulted the hospital physician, lifesaving efforts were discontinued and death was pronounced at 10:48pm.The death certificate dated 6/9/26 revealed the manner of death was suicide at 10:48pm on 6/8/26. The description of injury was self-strangulation with bed control cord. The Medical Examiner was interviewed by telephone on 6/18/26 at 11:04am. The Medical Examiner stated she was called to the facility by the police department but stated she could not answer any further questions.The Medical Examiner's report was not available at the time of the investigation. A follow-up interview was conducted with the DON on 6/18/26 at 9:30am. The DON stated the process at the change of shift was for the on-coming nurse to go room to room and check on all the residents prior to starting their medication pass. She stated she was unaware that Nurse #2 did not perform this task until after the incident with Resident #1. The DON stated NA #1 had been in Resident #1's room twice prior to the incident. She also stated herself and the Administrator had spoken to the Medical Director on 6/5/26 but could not remember whether either of them reported Resident #1's suicidal statements to the Medical Director. The Administrator was interviewed on 6/18/26 at 1:52pm. The Administrator discussed the Stop and Watch form and stated she should have been given a copy of the form regarding any changes in the residents' condition. The Administrator stated she was not made aware of Resident #1's suicidal statements until 6/5/26. She explained that the SW went and spoke with Resident #1 on 6/5/26 and she was informed that Resident #1 was no longer suicidal so there was no need for a mental health consult or monitoring. She stated the SW was sent to talk with Resident #1 on 6/5/26 because he had experience in mental health. The Administrator stated she did not remember meeting with the Medical Director on 6/5/26 and that she had not informed him of Resident #1's suicidal statements made on 6/1/26. She also stated she was unaware of Resident #1's suicidal statements made on 5/31/26 to the SW until after the incident. The Administrator was notified of immediate jeopardy on 6/18/26 at 4:19pm.The facility provided the following corrective action plan:How will corrective action be accomplished for those residents found to have been affected by the deficient practice?Resident#1 was admitted status-post non-repairable fracture to his left prosthetic hip. Social worker evaluated him on 5/31/26 and performed a PHQ-9 which is a questionnaire for depression screening. He responded that he felt like he would be better off dead. The Social Worker did not escalate his findings to the Director of Health Services, Administrator or Medical Director. There was no psychiatric referral made with these findings. On 6/1/26 resident #1 voiced suicidal ideations to the Physical Therapy Assistant and Occupational Therapy Assistant who reported it to the floor nurse and the Therapy Manager. This statement was not communicated to Administration, Director of Health Services or the Physician. On 6/3/26 Resident #1 was seen by the Medical Director who documented that the resident was depressed, anxious, distraught and reported that his pain was not controlled. The Medical Director only made changes to the resident's pain medication and did not address his depression or anxiety. On 6-5-26 the Therapy Manager stated in morning meeting that the resident had voiced suicidal ideation on 6-1-26. The Social Worker immediately went and met with the resident who stated that he was no longer suicidal. There were not any additional evaluations of the resident's mood/depression, and no referrals were made for psychiatric services. Medical director was not notified of suicidal ideations on 6-1-26 or 6-5-26. On 6-8-26 resident was found around 10PM by Nurse #2 lying in bed with a cord wrapped around his neck, not responsive, not breathing, and without a pulse. Nurse #2 immediately called for help and initiated CPR. Crash cart was obtained and other staff supported in CPR until EMS arrived. Physician, family/responsible party, and appropriate authorities notified by the Director of Health Services (DHS) immediately on 6-8-26. Comprehensive investigation completed by DHS and administrator from 6-8-26 to 6-10-26. Medical records reviewed and secured by medical records on 6-9-26. Crisis counseling and support offered to residents and staff affected by the event by [NAME] Health Hospice Chaplain on 6-9 and 6-11 at 2pm and 8pm. Social Worker received one to one education from the Administrator on 6/10/2026 on escalation of PHQ-9 scores of 10 or higher, resident stating that they would be better off dead, sign and symptoms of depression or suicidal ideation. Social worker educated to report these findings to the Director of Health- Services or Administrator immediately so they can be escalated to the Medical Director and Psychiatric Services. The Therapy Manager was educated on 6/10/26 by the Administrator and Director of Health Services on the importance of escalating resident's suicidal ideation(s) to the charge nurse, Director of Health Services and the Administrator. The nurse received disciplinary action from the Director of Health Services on 6/10/2026. The Director Health Services had one-to-one education with Medical Director on notifying the Director of Health Service and Administrator immediately when concerns for severe depression are identified. How will the facility identify other residents having the potential to be affected by the same deficient practice?All residents in the facility had a PHQ-9 performed on 6-9-26 by Clinical Competency Coordinator and the Infection Preventionist. All residents PHQ-9 were reviewed by the Director of Health Services, Senior Care Partner, Clinical Competency Coordinator, and Infection Preventionist on 6-10-26. Three residents were found to have a PHQ-9 score of 10. No resident scored higher than 10 or answered yes to the question Life is not worth living, wishes for death, or attempts to harm- self - presence. All resident's records were reviewed for a diagnosis of depression by Senior Care Partner and the Infection Preventionist utilizing the PHQ-9 questionnaire for accuracy 6/9/2026. The Physician was notified of these results by Director of Health Services and Senior Care Partner. The three residents with a score greater than 10 were immediately referred to psychiatric services per physician order on 6-10-26. The Psychiatric Services Provider was notified by the Infection Preventionist and Senior Care Partner via email or phone on 6/10/2026. All responsible parties were notified of the referral and reason for the referral on 6/10/2026. All Resident's records were reviewed for diagnosis of depression by Infection Preventionist and Senior Care Psychiatric services were provided on 6-10-26 to the one resident who agreed to receive services, no new medication ordered continue to monitor per psychiatric response. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur?On 6/10/2026, the Interdisciplinary team(IDT) (Medical Provider, Administrator, Director of Health Services, Therapy Manager, Social Worker, Senior Care Partner, Infection Preventionist, Dietary Manager, Maintenance Director, Activities Director, Medical Records, Financial Counselor , Human Resources, Case Mix Director, Housekeeping Manager, Pharmacist and Unit Managers) reviewed the suicide risk management process to ensure timely identification, assessment, communication, and interventions for resident exhibiting depression and suicidal ideations. After the review it was determined the education would be initiated.Clinical Competency Coordinator educated 100% of staff to include dietary, housekeeping, nursing, administrative, maintenance, medical director, therapy, consultant pharmacist and activities on recognition and monitoring for suicidal warning signs, depression screening, PHQ-9 review, reporting requirements for suicidal ideation, Physician and IDT team notification, documentation expectation and referral process for psychiatric services. This education was completed by the Clinical Competency Coordinator on 6/15/2026. All new hires will be educated on this process in new hire orientation by the Clinical Competency Coordinator. On 6/10/2026 the IDT decided that all residents will receive a PHQ-9 questionnaire review a minimum of every quarter. On 6/10/2026 the Administrator directed the Social Worker, Senior Care Partner and all licensed nurses, that a questionnaire will be completed immediately if changes in depressive behaviors or suicidal behaviors as outlined below. Findings will be reported to the Charge Nurse who will then report to the Provider, Director of Health Services, Responsible Party and Administrator. Depressive or Suicidal BehaviorsDepressive symptoms:Disheveled appearance - poor personal hygieneIncreased anxietyLack of concentration Isolation from family or friendsUnexplained fatigueChange in sleep patternsChange in appetite Suicidal behaviors:Giving away personal itemsObsession with deathMaking suicidal remarksMaking a suicide planWriting a suicide noteAttempting suicide Suicide Risk:History of suicide attempt(s)Family history of suicideFamily history of child abuse or neglectHistory of domestic violence or sexual abuseHistory of mental disorders, particularly clinical depressionHistory of alcohol/drug abuse and/or addictionImpulsive/aggressive tendencies, limited self-regulation skillsExperiencing a traumatic, triggering event such as the death of a loved one or receiving a terminal diagnosisChronic illness or unmanage painAccess to lethal means to complete suicideThe Medical Director and Responsible Party will be notified.On 6/10/2026 the IDT determined all newly admitted residents with a PHQ-9 score greater than 10 will be referred to psychiatric services on admission or if they answer yes to the question of Life is not worth living, wishes for death, or attempts to harm- self - presence, the Medical Director/Provider will be notified immediately for further orders. The party responsible will be notified of the change in condition and any new orders by the Senior Care Partner, Director of Health Services, and Social Worker. On 6/10/2026 the Administrator directed the Social Worker and Senior Care Partner that will be responsible for all admission PHQ-9s. This Plan of Correction was discussed in our Ad Hoc QAPI meeting on 6-10-26. How will the facility monitor its corrective actions to ensure the deficient practice will not recur?Effective 6/9/2026 The Director of Health Services was directed by the Administrator to complete an audit of residents with the diagnosis of depression, PHQ-9 screening questionnaire score of 10 and greater, and suicidal ideations. This audit will include monitoring for physician notification, social service follows up, psychiatric referrals, and care plan revision. This audit will be completed weekly x 4 weeks and then monthly x 3 months. All PHQ-9 will be reviewed during clinical meetings by the Director of Health Services. The Consultant Pharmacist in collaboration with the Medical Director will continue to do a monthly review of all residents' medications for a potential medication adjustment. This will be audited by The Director of Health Services monthly x 3 months or until a pattern of compliance is obtained.The Administrator will interview a sample of 10 staff mem[TRUNCATED]

Based on observations, record review, and resident, staff, and Medical Doctor interviews, the facility failed to administer oxygen at the physician prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #48). The findings included:Resident #48 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, chronic diastolic (congestive) heart failure, acquired absence of lung (part of), and dependence on supplemental oxygen.A review of Resident #48's physician's orders, Oxygen at 3 LPM [liters per minute] via nasal cannula (tubing that delivers oxygen from an oxygen source to the resident's nose) and was written on 1/8/26.A review of Resident #48's care plan, initiated on 1/9/26, revealed a problem of at risk for shortness of breath and respiratory distress due to chronic respiratory failure with hypoxia [a deficiency in the amount of oxygen reaching the body tissues, cells or organs, preventing them from maintaining normal healthy function], requiring continuous O2 [oxygen] use via nasal cannula. Interventions included oxygen as ordered.A review of Resident #48's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #48 to be cognitively intact and on oxygen therapy.An observation and interview with Resident #48 was conducted on 1/20/26 at 12:27 PM. She was observed sitting on the side of her bed with her overbed table in front of her and was receiving oxygen therapy via nasal cannula. The oxygen concentrator was placed next to her nightstand and was set to deliver oxygen at 2 LPM. Resident #48 stated she thought the reason she was on oxygen was because she had lung cancer years ago. She did not know what the oxygen flow rate on the concentrator was supposed to be set at. A telephone interview was conducted with Nurse #2 on 1/21/26 at 3:39 PM. Nurse #2 confirmed she had been Resident #48's nurse on 1/20/26 from 7:00 AM to 7:00 PM. Nurse #2 stated she knew that Resident #48's oxygen orders were for 3 LPM. When asked if she recalled checking the resident's oxygen concentrator on 1/20/26, she stated she had so much going on that day that she might not have checked the settings on the oxygen concentrator. Nurse #2 said that Resident #48's O2 sats (oxygen saturation) were usually always within normal limits. A second observation of Resident #48 was made on 1/21/26 at 8:51 AM. She was lying in her bed and was observed receiving oxygen therapy via nasal cannula. The oxygen concentrator was placed next to her nightstand and was set to deliver oxygen at 2 LPM. An interview was conducted with Nurse #1 on 1/21/26 at 8:53 AM. Nurse #1 stated she was Resident #48's nurse on that date, from 7:00 AM to 7:00 PM. She explained that nurses were supposed to check the settings on an oxygen concentrator against the physician's orders once a shift. She admitted she had not done that when she went into Resident #48's room around 8:30 AM to 9:00 AM. Nurse #1 explained this was the first time she had worked on the hall where Resident #48 resided and did not know the residents well yet. She checked Resident #48's physician orders for oxygen and stated the concentrator should be set to deliver at 3 LPM. A third observation of Resident #48's oxygen concentrator's settings was made on 1/21/26 at 8:58 PM with Nurse #1. Nurse #1 confirmed the oxygen concentrator was set to deliver oxygen at 2 LPM. Nurse #1 then increased the oxygen concentrator's settings to deliver oxygen at 3 LPM. Nurse #1 stated she would continue to monitor the Resident. A telephone interview was conducted with the facility's Medical Doctor (MD) on 1/22/26 at 4:17 PM. The MD stated Nurse #1 had informed him of Resident #48's oxygen concentrator set to deliver oxygen at a rate of 2 LPM, instead of 3 LPM. The MD stated that no harm came to Resident #48 and explained that the difference between 3 LPM and 2 LPM was so minimal that it really would not have made a difference in the Resident's oxygen saturations.An interview was conducted with the Director of Nursing (DON) on 1/21/26 at 2:00 PM. The DON explained after Nurse #1 informed her that Resident #48's oxygen concentrator had been set to deliver 2 LPM instead of 3 LPM, she instructed the nurse to call and inform the MD, and that she would call the family to inform them. The DON further explained that the family member she called was also a nurse at the facility and when they spoke, she had asked him if Resident #48 would ever mess with the settings on an oxygen concentrator. She said the family member informed her that Resident #48 would occasionally do that when she was at home. The DON did not know how the settings on Resident #48's concentrator got changed. The DON stated it was her expectation that nursing staff check the settings on the oxygen concentrator against the doctor's orders every shift.An interview was conducted with the Administrator on 1/21/26 at 2:04 PM. She stated it was her expectation that nursing staff follow the MD orders and facility policy regarding oxygen therapy.

Based on record review, staff and physician interviews, the facility failed to provide close supervision to a severely cognitively impaired resident and to implement effective interventions to prevent further falls when a resident was readmitted from the hospital after a fall. Resident #3 was at high risk for falls due to generalized weakness, lack of coordination, and impaired judgment. This deficient practice affected 1 of 3 residents reviewed for accidents. The findings included: Resident #3 was initially admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare for fracture of left hip joint, presence of an artificial hip joint, Alzheimer's disease, vascular dementia severe with mood disturbance, peripheral vascular disease, osteoarthritis, chronic kidney disease stage 4, and long-term use of aspirin. A review of Resident #3's admission Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired and had behavioral symptoms not directed towards others 1 to 3 days which put her at significant risk for physical illness or injury. The MDS indicated the resident had impairment on one side of her lower extremities and used a wheelchair as a mobility device. The MDS assessment indicated Resident #3's functional abilities as follows: 1) totally dependent on staff for sit to stand, chair/bed-to-chair transfer, and toilet transfers; 2) required the substantial/maximal assistance of staff for sit to lying and lying to sitting on side of bed; 3) walking 10 feet or her ability to bed/stoop from a standing position to pick up a small object was not assessed due to medical conditions or safety concerns. The MDS indicated Resident #3 had a fall in the last month prior to admission and had a fracture related to a fall in the 6 months prior to admission and had two or more falls since admission and had an injury (not major) on one fall. Resident #1's hospital discharge summary dated 10/4/24 indicated she was admitted on [DATE] following a fall and was found to have areas of small volume subarachnoid hemorrhage (occurs when a blood vessel bursts and bleeds into the space between the brain and the membrane that covers it) at her right cerebral (brain) hemisphere. Neurosurgery recommended nonoperative management. She was noted to reply to questions, did not open her eyes, and was not oriented. Her discharge condition was listed as fair. The resident was discharged back to the facility on [DATE]. A review of Resident #3's Care Plan, active as of 10/04/24, included a problem/focus area for being at risk for falls and fall-related injury due to generalized weakness, lack of coordination, psychotropic drug use, personal history of falls and impaired judgement secondary to dementia (initiated 9/18/24). The goal of this problem was that the resident would have a reduced risk for falls and fall-related injury. Approaches to this problem included assisting for toileting and transfers as needed; cueing for safety awareness as often as necessary; frequent rounds to monitor for attempts to ambulate without assistance; if head injury is suspected, nursing to initiate neurological checks per facility protocol; and keep environment safe; and place call light within reach; fall from bed times two without injury on 09/23/24; moved closer to a nurses' station to facilitate more frequent observation; and fall mats to bedside to reduce risk for injury related to falls were discussed during morning meeting and declined at this time due to increased risk for falls due to weakness, lack of coordination, and impaired cognition limiting ability to navigate mats. A review of Resident #3's 10/05/24 fall incident report, completed by Nurse #1 on 10/05/24, indicated the resident had an unwitnessed fall and had been found lying on the floor of her room, with her face up, at 6:45 A.M. Nurse #1 indicated Resident #3 had an injury to her left lower extremity and that the resident complained of pain, rating it 6 out of 10 (10 being excruciating pain). The nurse noted the resident told her she had hit her head but had no obvious injuries. Nurse #1 indicated Resident #3's speech was clear, she responded to her name, she was agitated and complained of a headache. The nurse documented the resident's neurological exam as being normal, and documented first aid was rendered to the left lower extremity skin tear versus laceration by applying a dressing. The report indicated Resident #3 was not moved from the floor and a nursing assistant (NA) stayed with her until an Emergency Medical Technician (EMT) arrived. A review of the Facility Event Investigation form, dated 10/05/24, revealed Resident #3 had been found on the floor, face up, next to her bed. Prior to the fall, the author of the form indicated the resident had been in her bed, which had been in a low position, and that her call bell was in place. The author indicated that Resident #3 was very confused and unaware of her limitations and noted that dementia and prior falls had been contributing factors. A review of Resident #3's change in condition communication form, completed by Nurse #1 on 10/05/24, revealed that Resident #3 was sent to the emergency room (ER). It indicated history of falls and dementia as other relevant information. Vital signs were documented as within normal limits and the nurse documented that Resident #3 has been more agitated and vocal tonight and that she had been yelling a lot this shift and had a 4 inch laceration versus skin tear to her left lower extremity. Nurse #1 documented the resident was having pain and wrote that it was hard to tell if pain is new, has been yelling all night. The nurse documented notifications were made to the facility's medical director and the resident's Responsible Party and 911 had been called. A telephone interview was conducted with Nurse #1 on 11/14/24 at 9:24 A.M. Nurse #1 confirmed she worked on 10/04/24 from 7PM until 7AM on 10/05/24 and had been assigned to care for Resident #3. Nurse #1 explained that she rounded on all of her residents after getting report from the off-going nurse. Nurse #1 stated that Resident #3 was always extremely confused and frequently tried to climb out of her bed. She stated that she was not sure of the falls prevention interventions that may have been in place for Resident #3, but she always made sure that all of her residents' beds were in the low position, that they had non-skid socks on, placed their call bells within their reach, and educated the residents to call for assistance when needed. Nurse #1 stated Resident #3's cognition was poor and stated she tried to educate her on calling for assistance but before she would walk away, the resident had already forgotten what she told her. When asked about Resident #3's 10/05/24 fall, Nurse #1 stated she did not recall that fall. A telephone interview was conducted with Nurse #2 on 11/14/24 at 4:49 P.M. Nurse #2 confirmed she had been the one who found Resident #3 on the floor in her room on 10/05/24; she could not recall the time she found the resident, only that it was around the time of her medication pass. She explained she had been walking down the 600 hall and when she passed by Resident #3's room, she noticed her lying on the floor. She stated she went into the resident's room, quickly assessed her, and then called out for help. Nurse #2 stated there was a lot of blood and determined it had come from an injury one of her lower legs but was unable to recall which leg. She was able to recall that Resident #3 did not have socks on, her bed had been in the lowest position, and confirmed there were no fall mats beside the bed. Nurse #2 further explained that once Nurse #1 arrived at the resident's room, she stayed and dressed the resident's leg wound and then left the room. Nurse #2 stated she had been unaware that Resident #3 was considered a high fall risk and was unsure as to what fall prevention interventions had been in place for the resident. Nurse #2 stated she had been informed by Nurse #1 that the resident had other falls recently and that one of them had resulted in a brain bleed, and because of that, Nurse #1 told her that she was sending the resident out the ER for evaluation. A telephone interview was conducted with Nursing Assistant (NA) #2 on 11/14/24 at 10:53 A.M. NA #2 confirmed she had worked 10/04/24 from 7PM until 7AM on 10/05/24 and had been assigned to care for Resident #3. NA #2 stated she had never been assigned to care for the resident before that shift but had been aware the resident had a lot of falls and had been considered a high fall risk. NA #2 explained that Resident #3 had been very confused throughout the night and had been yelling out almost all night. NA #2 stated that another NA (who she had been unable to recall), informed her the resident was always trying to get out of her bed. She indicated because of this, she made sure to keep the resident's bed in a low position and used pillows around her body and under her legs to help keep her positioned in the center of the bed. NA #2 stated that because another resident (who resided in a room near Resident #3's room) was actively dying and had family present through the night, she had tried to check on Resident #3 frequently because she wanted to keep her clean and dry and attempt to calm and quiet her. NA #2 stated that despite using the pillows, Resident #3 would push them away or kick away the one under her legs. She said that one time during the night, she found the resident with her legs hanging off one side of the bed and she had to pick them up and position her body in the center of the bed. NA #2 stated she recalled that Resident #3 settled down and slept for approximately one hour that night but that the rest of the night had been a challenge. A telephone interview was conducted with NA #3 on 11/14/24 at 11:16 A.M. NA #3 confirmed she worked 10/04/24 from 7PM until 7AM on 10/05/24 and had not been assigned to care for Resident #3. NA #3 was unsure who found the resident on the floor the morning of 10/05/24 and thought it might have been a nurse. NA #3 stated she might have been assigned to care for the resident once or twice in the past but could not recall any specific fall prevention interventions that had been put into place for the resident. NA #3 stated she had been in the resident's room several times throughout the night because the resident had been hollering all night. After it was made known to her that the resident had fallen, she went to the room to assist. She stated she recalled noticing Resident #3's bed had been in the low position. NA #3 stated she thought the resident had gotten a cut on one of her legs but was unsure which leg and where the cut was. She remembered the resident did not complain about having any pain but said the resident kept telling the staff to get her up off the floor. NA #3 explained that she sat with the resident on the floor until EMS arrived. A telephone interview was conducted with Nurse #3 on 11/14/24 at 11:49 P.M. Nurse #3 confirmed he worked 10/05/24 from 7AM until 7PM on 10/05/24 and had been assigned to care for Resident #3. Nurse #3 stated he vaguely remembered caring for the resident that morning. He stated he knew that she had a fall that morning which required him to check her vital signs and do neurological checks and thought he may have had time to do one set of the neurological checks prior to the resident leaving with EMS. Nurse #3 stated he had been aware that Resident #3 was considered a high fall risk and that she had dementia and had been very confused. He was unsure of any injuries the resident may have sustained from the fall on 10/05/24 and stated the resident did not return to the facility that day. A review of the Emergency Medical Services (EMS) 10/05/24 transport record for Resident #3 revealed they had been called by the facility to transport Resident #3, who had fallen, to the local hospital. EMS assessments were documented and included normal vital signs and normal Glasgow Coma Scale (a clinical scale used to measure a person's level of consciousness after a brain injury) scores. Their documentation indicated Resident #3 had fallen 2 feet from her bed to the floor on 10/05/24 at 6:25 A.M. which resulted in a 1.5-inch abrasion to her inner right ankle. Computed Tomography (CT) scan of the head completed on 10/5/24 with a comparison to a previous CT scan from 10/02/24 indicated evolving right greater than left predominantly frontal convexity (surface of the brain) subarachnoid hemorrhages. An interview was conducted with the facility's Medical Director (MD) on 11/14/24 at 3:13 p.m. The MD stated that Resident #3 was very confused and also very fragile and weak. He stated that she was strong enough to stand up but not strong enough to stay up, so when she would stand up, she would go right down. The MD recalled she fell on the day of her admission to the facility (09/11/24) and had several more falls throughout the course of her stay. The MD thought that he remembered reading in her hospital records after the fall on 09/11/24 and that she might have had a mild heart attack which could have contributed to that fall. He explained she had been placed on Plavix (blood thinner) and aspirin for its anticoagulant properties as Resident #3 was not a candidate for a heart catheterization secondary to her multiple medical comorbidities including kidney disease. (Plavix and aspirin were held on readmission 10/04/24.) The MD stated he had been made aware of Resident #3's fall at the facility on 10/05/24 and could not recall the exact reason he sent her to the hospital but that he relied on the nurse's assessment and request to send her out for evaluation and treatment at the hospital as he had not been in the facility at the time of that fall. He also recalled her fall on 10/02/24 where her fall had caused a subarachnoid hemorrhage and stated the CT scan taken on 10/05/24 resulted in evolving right greater than left subarachnoid hemorrhages which he explained as the hemorrhages were worsening. In other words, he said the hemorrhages she had suffered from the 10/02/24 fall were not resolving. He further explained that Resident #3 was a very sick individual, and she had been sent back to the facility after the 10/02/24 fall because nothing could be done medically for her. The MD said he would expect the facility to have the same generic fall prevention interventions with all their residents who were considered a high fall risk. He did not elaborate on what these generic fall prevention interventions were. He also stated that the facility could not provide one on one supervision to residents who were considered a high fall risk. When asked, the MD stated that he would expect the facility to provide the same generic fall prevention interventions to a resident with a subarachnoid hemorrhage as they would to any resident that was deemed a high fall risk. The MD indicated Resident #3's prognosis was very grim as any resident's mortality rate increased after a fractured hip. He concluded and said that Resident #3 had significant mental status changes after the fall that resulted in her broken hip prior to admission to the facility. A telephone interview was conducted with the Director of Nursing (DON) on 11/15/24 at 2:53 P.M. The DON confirmed that he was responsible for reviewing residents' falls in the facility as he was the Falls Coordinator. He stated that he was not fully aware of the facility's policy related to falls and putting fall prevention interventions in place after a resident's fall. He explained that he had yet to be trained by anyone regarding this. The DON further explained that he had wanted to discuss the falls policy with a corporate consultant and had been told they would come to the facility for this, however, they never came. He stated that he did have conversations with Resident #3's family regarding them hiring someone to sit with her for a one-to-one supervision to help prevent falls but stated he was not sure of the facility's policy for allowing this. The Administrator provided a statement via email on 11/15/24 at 3:55 P.M. A root-cause-analysis of Resident #3's falls and/or corrective action plan was not completed before this date. The Administrator wrote, It is the expectation of our facility that all nursing staff follow our policies regarding falls.

Based on record review, staff interviews and physician interview the facility failed to inform the physician of a change in the residents' nutritional status and failed to notify the responsible party of changes in a resident's condition including skin integrity impairment and/or weight loss for 4 of 5 residents sampled for nutrition. (Resident #4, Resident #41, Resident #45, and Resident #81) The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including dysphagia. Review of Resident #4's weights revealed: 08/06/2024 112.1 pounds (lbs.) 09/03/2024 103.9 lbs. 09/16/2024 105.7 lbs. 09/23/2024 106 lbs. 10/01/2024 104.6 lbs. There was a decrease of 7.31% from 8/06/2024 (112.1lbs) to 9/03/2024 (103.9lbs). Review of Resident #4's medical record for September revealed there was no documentation that the physician was notified of the significant weight loss. An interview with the Physician was conducted on 10/02/24 at 11:46 AM. The physician stated he had not been informed of any weight loss for Resident #4. He also stated that he liked checks and balances and should have been informed of the weight loss. An interview with the DM was conducted on 10/02/24 at 11:42 AM. The DM stated Resident #4 had significant weight loss and when there was a significant weight change of 5% or more the physician should be called. The DM also stated she was responsible for calling the physician and she did not call due to an oversite. An interview with the Director of Nursing (DON) was conducted on 10/03/2024 at 1:04 PM. The DON stated when there was a significant weight loss of 5% or greater, the physician was supposed to be made aware and could not say why he was not made aware by the DM. An interview with the Administrator was conducted on 10/03/2024 at 1:14 PM. The Administrator stated when there was a decrease in weight of 5% or more then the physician was supposed to be made aware. 2. Resident #41 was admitted to the facility on [DATE] with diagnoses including coronary artery disease. Review of Resident #41 weights revealed: 08/06/2024 148.0 pounds (lbs.) 08/12/2024 141.3 lbs. 08/19/2024 143.7 lbs. 08/26/2024 139.4 lbs. 09/03/2024 144.5 lbs. 09/09/2024 140.2 lbs. There was a significant weight loss of 5.27% from 8/06/2024 (148) to 9/09/2024 (140.2). Review of Resident #4's medical record for September revealed there was no documentation the physician was notified of the significant weight loss. An interview with the Physician was conducted on 10/02/24 at 11:46 AM. The physician stated he had not been informed of any weight loss for the residents. He also stated that he liked checks and balances and should have been informed of the weight loss so that interventions could be implemented. An interview with the DM was conducted on 10/02/24 at 11:42 AM. The DM stated Resident #41 had a significant weight loss and when there was a significant weight change of 5% or more the physician should be called. The DM also stated she was responsible for calling the physician and she did not call due to an oversite. An interview with the Director of Nursing (DON) was conducted on 10/03/2024 at 1:04 PM. The DON stated when there was a significant weight loss of 5% or greater, the physician was supposed to be made aware and could not say why he was not made aware by the DM. An interview with the Administrator was conducted on 10/03/2024 at 1:14 PM. The Administrator stated when there was a decrease in weight of 5% or more then the physician was supposed to be made aware. 48007 3. Resident #45 was admitted into the facility on [DATE] with the diagnoses of adult failure to thrive, type 2 diabetes mellitus, severe protein calorie malnutrition and dementia, muscle weakness, chronic kidney disease stage 3, cachexia (loss of muscle, fat mass and weakness), hypertension, multiple myeloma (in remission), gastroesophageal reflux disease, congestive heart failure, diastolic congestive heart failure and metabolic encephalopathy. A review of Resident #45's admission Minimum Data Set, dated dated dated [DATE] revealed he was cognitively intact; his vision was highly impaired; he required his meal tray set up by staff and had no skin issues. A review of Resident #45's wound assessments revealed on 9/18/24 an area on his sacrum measuring 2 cm x 1cm was noted, on 10/1/24 a pressure area on his right heel measuring 2 centimeters (cm) x 2 cm was noted, also on 10/1/24 a stage I (intact blister) was noted on his left ankle. A review of Resident #45's weight record indicated on 8/29/24 he weighed 168.70 pounds and on 9/5/24 he weighed 149.70 a loss of 11.26% in one week, 9/29/24 he weighed 116 pounds indicating a 31.24 % weight loss in one month. A review of Resident #45's physician orders included an order for a liquid supplement twice a day with a start date of 9/11/24, on 10/2/24 an appetite stimulant was ordered, a liquid shake supplement ordered with meals three times a day, and another liquid supplement ordered four times a day with medications. An interview conducted with the resident's Responsible Party on 10/2/24 at 11:13 AM revealed that she was not notified by the facility of either the weight loss or the development of pressure areas. She stated that when she arrived at the facility, she was shocked when she pulled down the covers and saw how much weight he had lost. She further stated that because she does help with turning and repositioning that she had seen the area on his sacrum. She stated no one from the facility had notified her yesterday (10/1/24) regarding the newly developed areas on his right heel and left ankle. An interview conducted with the Dietary Manager on 10/2/24 at11:18 AM indicated that the facility does have a weekly weight meeting which consisted of the two Social Workers, the MDS Coordinator, Activity Director and herself. She stated that the Physician should have been notified after the first significant weight loss and interventions should have been put into place and it was an oversight on her part. She further stated that she had not called Resident #45's Responsible Party or the Physician regarding his weight loss and realized she should have. An interview conducted with the Physician on 10/02/24 11:46 AM indicated that he had not been informed of any weight loss of the residents. He stated that he liked checks and balances and should have been informed of the weight loss so that interventions could be implemented. An interview with the Wound Care Nurse on 10/2/24 at 1:00 PM revealed that she did not call the responsible party regarding new skin issues, but she does call them if the treatment was changed. She stated that she does not document when she talks to the resident's responsible parties and documents the bare minimum on areas that she is treating due to the amount of wound care that she does. She further revealed that she had not talked to or called Resident #45's Responsible Party regarding his areas on his sacrum, right heel or left ankle. An interview was conducted with the Administrator on 10/2/24 at 2:00 PM indicated that resident's responsible party should be notified of any changes in a resident's condition which included new orders, test results, and any areas that impacted the residents care and/or treatment. 4. Resident #81 was admitted into the facility on [DATE] with the diagnoses of pneumonia, hip fracture, cerebrovascular accident, dementia and anxiety disorder. A review of Resident #81's Minimum Data Set, dated dated dated [DATE] included she had moderately difficulty in hearing and used hearing aids, had no problems communicating, moderately cognitively impaired, had no behaviors or rejection of care and no indicators of psychosis. A telephone interview conducted with a family member on 10/2/24 at 6:00 PM revealed that Resident #81 was unable to speak and was in the dying process and she was the point of contact for her mother. She revealed that the family was not made aware of new orders, test results and the overall decline of their mother. She stated the family had seen a pressure ulcer above the crack of her mother's buttocks that they were never informed of during their mother's care. On Saturday September 28th, 2024, the family walked in, and Resident #81 was kind of communicating with them but not at all what she normally did and on Sunday September 29, 2024, Resident #81 would not wake up at first and later woke up a little and there was no notification from the facility on either day regarding their mother's condition. The family member further stated that Resident #81's anxiety medication that she had taken for 20 plus years was discontinued without their knowledge. During this time Resident #81 was confused, hallucinating, and paranoid. The family found out Resident #8's antianxiety medication had been discontinued on 8/29/24 once it was restarted on 9/9/24 all her mothers' symptoms of confusion, paranoia, and hallucinations were resolved. An interview was conducted with the Administrator on 10/2/24 at 2:00 PM indicated that families should be notified of any changes in a resident's condition which included new orders, test results, and any areas that impacted the residents care and/or treatment.

Based on record review, and resident, ombudsman, and staff interviews, the facility failed to allow the residents to personalize their space by restricting their ability to hang any items on the walls or doors to their rooms to include pictures and decorations and not permitting the residents to bring in their own furniture. The residents expressed feeling as though it was impossible to make their rooms homelike with these restrictions. This deficient practice affected 5 out of 5 residents (Resident #19, # 54, #50, #16 and #25) reviewed for homelike environment and had the potential to affect other facility residents. The findings included: A review of the Residents Council minutes revealed that on 1/16/24 a Resident Council meeting was attended by Residents #22, #27, #46, #24, #16, #37, #65, #3, #70, #57, #55, and #35. The meeting was conducted to explain and prepare the residents for the move to a new building. In that meeting it was discussed that certain things would not be allowed these included: - No items on the walls - No tape on the walls - No nails in the walls - Nothing on the floor - Nothing in the blinds - Nothing on the doors - No refrigerators The 5 residents (#19, #54, #50, #16, and #25) in the Resident Council Meeting conducted on 10/1/24 at 2:45 PM all stated that they were unable to make their own rooms to their liking which included hanging pictures on the walls and/or wreaths on the doors. The Resident Council President (Resident #50) stated they felt that not being able to decorate at all but put a few pictures on the furniture in the room was stopping them from making their rooms feel like their home. They further stated they wanted pictures of their families or just beautiful pictures on the wall and they only had a cloth-covered bulletin board to hang anything on. The residents also stated they were not able to keep any food from families in the facility refrigerators or have a refrigerator of their own. The residents in the Resident Council meeting stated it was impossible to make their rooms homelike with such restrictions. An interview was conducted with the Resident #50 10/1/24 at 3:30 PM who stated she wanted to be able to put pictures of her family on the walls, that right now her room was just like every other room in the building, so it did not feel like her home. An interview was conducted with Resident #54 on 10/1/24 at 3:40 PM who stated with the holidays coming up she wanted to hang different wreaths on her door to celebrate them but was not allowed to. She further stated that the only thing they had in their room was a cloth-covered bulletin board to put pictures on, which was not enough room for what she wanted to put up. She further stated that she wanted to be able to decorate her room how she wanted to make it feel like hers. An observation of a resident's room on 10/2/24 at 4:05 PM noted there was an area on the wall that had a wardrobe with shelves the residents could use to put pictures or whatever they wanted to on, a bedside table, and a cloth-covered bulletin board. An interview with the Ombudsmen on 10/2/24 at 2:50 PM revealed that the residents had also brought concerns of not being able to decorate the room or hang pictures on the walls to her attention when she met with them. She stated she was glad the residents brought their concern regarding not being able to put pictures on the walls or decorate their doors as she felt they should be able to but felt like her hands were tied. She stated she had discussed this with the Administration after the meeting and it was a directive from the corporate office that was being followed. The Ombudsmen further stated she had told the residents to continue to be patient, work with the facility and remember it was a new building. An interview with the Administrator on 10/3/24 at 9:00 AM indicated the directive she received from the corporate office said nothing on the walls, or doors, and residents may not bring their own furniture into the building. She stated prior to moving into the new building the residents that were coming over from the old building were made aware of the rules and it was part of the admission packet for all residents. She stated she was following the direction of her corporate office. She further stated that in the other building the residents covered their walls with pictures so that you could hardly see the color of the walls which was the reason for no pictures on the walls. She further stated that there was a wardrobe in the room with areas the residents could put pictures on along with a bedside table, so the residents were able to have pictures in their rooms.

Based on observation and staff interviews, the facility failed to label opened food items, stored in their walk-in refrigerator in the kitchen, with the date opened and a use-by or expiration date. This practice had the potential to affect foods served to the residents. The findings included: On 09/29/24 at 11:45 a.m., an observation of the of the walk-in refrigerator in the kitchen was conducted with the Assistant Dietary Manager (ADM). The observation revealed the following: --bag of thawed crab cakes - no label, no date opened, no use-by or expiration date --bag of shredded cheddar cheese - with a handwritten date of 09/23/24, no use-by or expiration date --bag of cheese slices - with a handwritten date of 09/16/24, no use-by or expiration date --bag of sliced ham - with a handwritten date of 09/25/24, no use-by or expiration date --bag of sliced ham - with a handwritten date of 09/23/24, no use-by or expiration date --bag of 1 thawed croissant - with a handwritten date of 09/21/24, no use-by or expiration date --bag of thawed croissants - with a handwritten date of 09/24/24, no use-by or expiration date An interview was conducted with the Assistant Dietary Manager (ADM) on 09/29/24 at 12:05 p.m. The ADM stated opened food items should be labeled with the date opened and a use-by and/or an expiration date. She stated opened food items should be discarded after three days. An interview was conducted with the Dietary Manager (DM) on 10/02/24 at 11:00 a.m. The DM explained the staff of the Dietary Department had been trained many times to label and date opened food items. She further explained that the number of staff working in the kitchen was based on the facility's census and she thought that their failure to label and date opened food items may have been because the staff felt hurried to complete their kitchen tasks timely while still trying to accommodate the residents many requests for certain foods at mealtimes. The DM stated that it was her expectation that staff label and date opened food items and to discard items after three days. An interview was conducted with the Administrator on 10/02/24 at 1:30 p.m. The Administrator stated it was her expectation that any time the kitchen staff open a new food item that it is labeled and dated and then discarded according to their policy.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately for hospice for 1 of 1 resident reviewed for hospice (Resident #6). The findings included: Resident #6 was admitted into the facility on [DATE] with diagnoses that included dementia, and chronic obstructive pulmonary disease. A review of Resident #6 Physician orders dated 8/31/24 revealed an order to admit to hospice services. A review of Resident #6's primary payer on her face sheet revealed it was hospice. A review of Resident #6's care plan dated 9/5/24 revealed a care plan problem of Resident #6 is receiving hospice services. A review of Resident #6's admission Minimum Data Set, dated dated dated [DATE] indicated that the resident was not on hospice care but did have a a condition or chronic disease that may result in a life expectancy of less than 6 months A review of Resident #6's Care Area Assessment for MDS dated [DATE] revealed under cognitive loss/dementia section detailed under supporting documentation was noted to see the Brief Interview for Mental Status Assessment, Progress Notes, Hospice Notes, the International Classification of Diseases 10, and Mood Assessment. An interview conducted with the MDS Coordinator on 10/1/24 at 1:24 PM indicated that Resident #6 was admitted to hospice care on 8/31/24 and that hospice services are ongoing. A review of the admission MDS dated [DATE] indicated Resident #6 was not on hospice care was reviewed with the MDS Coordinator. The MDS Coordinator revealed the admission MDS assessment was incorrectly coded for hospice. She stated that it was simply an oversight on her part. An interview conducted with the Administrator on 10/2/24 at 9:00 AM stated the admission MDS assessment for resident # 6 should have been marked to indicate hospice and a modification would be completed.

Based on observation, record review, resident interview and staff interviews the facility failed to provide food in a form to meet the individual needs of a resident with a physician's order to upgrade diet to mechanical soft/finger foods with thin liquids for 1 of 5 Residents sampled for nutrition (Resident #4). Findings included: Resident#4 was admitted to the facility on [DATE] with diagnoses including dysphagia. Review of a progress note by the Dietary Manager (DM) dated 08/05/2024 revealed Resident receiving a puree diet. Resident stated no chewing or swallowing problems. Resident wants to be upgraded in his diet and informed resident he must be evaluated by Speech Therapy (ST) before that can happen and he understood. Resident # 4 was independent with meals after tray set up. Continue to monitor weight and meal intake. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #4 coded as cognitively intact, required supervision with eating and he was on a mechanically altered diet with no oral issues. Review of a speech therapy note dated 09/17/2024 revealed Resident #4 was currently on puree diet. The Resident has had eating trials of mechanically soft diet with no overt signs and symptoms of aspiration. Review of physician's order dated 09/20/2024 revealed an order to upgrade diet to mechanical soft/finger foods with thin liquids. Review of speech therapy note dated 09/26/2024 revealed Resident #4 seen in room for dysphagia therapy. Trial meal mechanical soft with thin liquids. There were no overt signs or symptoms of aspiration with solids or liquids. Resident #4 does need assist to cut finger foods into manageable pieces. Recommend diet upgrade to mechanical soft/ finger foods with thin liquids. Review of Resident #4's meal ticket dated 09/30/2024 revealed regular pureed diet. Observation of Resident #4 on 09/30/2024 at 12:26 PM Resident #4 was served a pureed regular diet. Review of dietary communication form dated 10/03/2024 revealed Resident #4 diet change to mechanical soft with finger foods and regular liquids. An interview with Resident #4 was conducted on 09/30/2024 at 12:26 PM. Resident #4 stated he spoke with the DM and told her he wanted to stop the pureed diet because he did not like the texture. He had speech therapy for about a month and had completed it. Resident #4 indicated he could eat a more textured diet with finger foods. An interview with the DM was conducted on 09/30/2024 at 12:47 PM. The DM stated he was referred to speech therapy and she did not know if he passed his swallow test and did not follow up on it. The DM also stated that is the reason he still was on a pureed diet. An interview with Speech Therapy (ST) was conducted on 10/03/2024 at 11:55 AM. The ST stated Resident #4 had been on a pureed diet off and on over the years due to dysphagia. He was referred to speech therapy due to weight loss and he did not have any swallowing issues, and his diet was upgraded to mechanical/soft with finger foods and thin liquids. The ST also stated she put in the order for the upgraded diet and was waiting for the physician to sign the order and did not follow up on it. Another interview with the DM was conducted on 10/03/2024 at 12:36 PM. The DM stated when there was an upgraded diet from the ST, the ST gives her a dietary communication form and she changes the diet. The DM also stated she did not receive a communication form for Resident #4 until today (10/03/2024). An interview with the Director of Nursing (DON) was conducted on 10/03/2024 at 1:04 PM. The DON stated when there was a diet change then it was expected to be changed at the time of the change without delay so the residents can receive the most therapeutic diet. An interview with the Administrator was conducted on 10/03/2024 at 1:14 PM. The Administrator stated Resident #4 did have a diet upgrade from the ST and it should have been communicated to the DM at the time of the diet change.

Based on observations, staff and resident interviews, the facility failed to keep 3 of 8 resident rooms (Rooms #204, #206 and #706) and 4 of 4 day rooms at a temperature of 71 degrees to 81 degrees Fahrenheit (F). Findings included: An observation of the thermostat in the 700 hall day room on 8/14/24 at 8:40 AM revealed the temperature to be 61 degrees F. The thermostat was set for the room to be 72 degrees F. The room felt cold. A resident in a wheelchair was in the room and she stated her hands were cold. An observation of the thermostat in the 400 hall day room on 8/14/24 at 12:54 PM revealed the temperature to be 65 degrees F and the room felt cold. The thermostat was set for the room to be 72 degrees F. An observation of the thermostat in the 200 hall day room on 8/14/24 at 1:05 PM revealed the temperature to be 64 degrees F and the room felt cold. The thermostat was set for the room to be 71 degrees F. An observation of the thermostat in the 100 hall day room on 8/14/24 at 1:15 PM revealed the temperature to be 66 degrees F and the room felt cold. The thermostat was set to 71 degrees F. An interview with 1 of the 3 residents who resided in room [ROOM NUMBER] on 8/15/24 at 11:30 AM, revealed his room was cold so he was wearing a sweater. He stated the hallway was cold as well. Resident #1 revealed he did not know how to operate the thermostat in his room. He further revealed he had not asked staff to adjust the thermostat. An observation of the thermostat in the room revealed the temperature to be 69 degrees F. During an interview with 1 of the 3 residents who resided in room [ROOM NUMBER] on 8/15/24 at 11:35 AM, he stated his room was too cold. He further stated he was wearing a quilted jacket to keep warm. The resident revealed the hallway was colder than his room and he did not know how to operate the thermostat in his room. Resident #2 had not asked staff to adjust the thermostat. An observation of the thermostat in the room revealed the temperature to be 68 degrees. During an interview with 1 of the 3 residents who resided in room [ROOM NUMBER] on 8/15/24 at 11:45 AM, he stated his room was too cold, but he did not know how to work the thermostat in his room. He further stated he wore extra layers to keep warm. He had not asked staff to adjust the thermostat. An observation of the thermostat in the room revealed the temperature to be 68 degrees. An interview with Nurse #1 on 8/14/24 at 8:30 AM revealed the 700 hallway and day room were very cold today and she had called the Maintenance Director to tell him the rooms were cold. She stated the building had problems with being too cold since it opened in March. Nurse #1 further stated she did not know how to operate thermostats in resident rooms and the day room thermostat was locked so it could only be accessed by Maintenance. Follow up observations conducted on 8/15/24 from 2:00 PM until 2:12 PM revealed the temperature to be 72 degrees F in room [ROOM NUMBER], 72 degrees F in room [ROOM NUMBER], and 72 degrees F in room [ROOM NUMBER]. Follow-up observations were conducted with the Maintenance Director on 8/15/24 from 2:34 PM to 2:44 PM of the temperatures in the day rooms on the 100 hall, 200 hall, 400 hall, and 700 hall. The observation of the 700 hall dayroom revealed the air temperature to be 68 degrees F, tested by temperature gun in the center of the room pointed straight ahead. The observation of the 400 hall dayroom revealed the air temperature to be 67 degrees F, tested by temperature gun in the center of the room pointed straight ahead. The observation of the 200 hall dayroom revealed the air temperature to be 66 degrees F, tested by temperature gun in the center of the room pointed straight ahead. The observation of the 100 hall dayroom revealed the air temperature to be 65 degrees F, tested by temperature gun in the center of the room pointed straight ahead. In an interview with the Maintenance Director on 8/14/24 at 8:45 AM in the 700 hall day room, he revealed the facility had been having issues with the heating, ventilation and air conditioning (HVAC) since the building opened in March of 2024. He stated he called the company that installed the system about 3 times a month with temperature control issues that resulted in parts of the system having to be replaced or repaired. He had just contacted them regarding the 700 hall day room at 8:40 AM, on the date of the interview. During a follow-up interview with the Maintenance Director on 8/15/24 at 11:55 AM he was made aware Resident's #1, #2 and #3 had concerns they were cold and their room temperatures were below 71 degrees F. He stated he would go to see them. The Maintenance Director stated on 8/15/24 at 1:54 PM he had adjusted the thermostats for Resident's #1, #2 and #3. In an interview with the Administrator on 8/15/24 at 3:00 PM she stated she was aware the building was having trouble with the HVAC system and that the Maintenance Director had the company that installed it come in at least twice a month.

Based on observations and staff interviews the facility failed to secure resident medications stored in an unattended medication cart and left medications on top of the cart in a unit with residents with dementia (800 hall medication cart), for 1 of 4 medication carts. The findings included: A continuous observation was conducted of the 800 hall medication cart, on a unit with residents with dementia, on 8/15/24 from 11:40 to 11:45 AM, followed immediately by an interview with Nurse #1. The cart was parked midway down the hall near room [ROOM NUMBER], facing out. The cart was not visible from the nurse's station. The medication cart was observed to have the red dot on the push lock visible, which meant the push lock was not engaged. There was no staff member with the medication cart. Nurse #1 came out of resident room [ROOM NUMBER] which was approximately 2 doors down the hall on the opposite side. She returned to the medication cart at 11:45 AM. Nurse #1 opened the top drawer without having to unlock the cart. During an interview with Nurse #1 when she returned to the cart, she stated she left the medication cart unlocked. She further stated the cart should be locked any time she was not using it. During the interview, and upon closer observation, it was observed there was an unattended medication cup of pills on top of the unattended medication cart. Nurse #1 stated she should have locked the pills in cart before she walked away. An interview with the Administrator was conducted on 8/15/24 at 3:00 PM and she revealed medication carts should not be unlocked unless the nurse was using it. The Administrator stated the nurse assigned to that medication cart was responsible for it for their entire shift. She further stated medication should not be left unattended and the nurse should lock them in the cart if not administering them immediately.

Based on resident and family interviews, staff interviews, and record review, the facility failed to have an effective rodent control program. Findings included: Record review of invoices from the pest service company indicated exterior and interior rodent service was completed on 3/2/22, 4/8/22, and 5/5/22. Services included checking and replacing exterior bait stations and checking and resetting traps throughout the facility. During an interview on 5/10/22 10:10 AM, Resident #52's family member reported that upon admission to the facility, she was told to buy plastic containers for food and belongings due to a mouse infestation. She had not seen a mouse since admission. During an interview on 5/10/22 at 10:45 AM, Resident #17 reported the facility had an ongoing problem with mice. She had seen a mouse in her room within the past 2-3 days. During an interview on 5/11/22 at 2:20 PM, Nurse #1 indicated that the facility had a problem with mice. A pest company comes quarterly but she had seen a mouse within the past week on a trap in a resident's room. During an interview on 5/11/22 at 2:25 PM, the Maintenance Director revealed a pest control company came to the facility to place mouse traps. He believed the mice were getting in through gaps near the radiators and this was blocked with expanding foam. He indicated the infestation had gotten better but they were still trapping 2-3 mice per week. He further revealed the pest service did not have further recommendations for controlling the mice in the building. During an interview on 5/12/22 at 9:44 AM, the Administrator revealed that due to location of the facility, mice were an issue. She indicated that the pest service place traps and maintenance had sealed the entry points. The facility encouraged residents to put food in plastic containers and minimize clutter to help control the issue. She was aware the issue was ongoing.

Based on record review and staff interviews, the facility failed to ensure a resident assessment for Level II Preadmission Screening and Resident Review (PASRR) was completed for 1 of 1 resident (Residents #50) reviewed for Level II PASARR. Findings included: Review of Resident #50's PASRR Level I Determination Notification dated 6/3/18 indicated that No further PASARR screening is required unless a significant change occurs within the individual's status which suggests a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's medical record indicated a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50's comprehensive Minimum Data Set (MDS) dated [DATE] indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He received an antidepressant for the past 7 days. During an interview on 5/11/22 at 11:00 AM, the Social Worker indicated that she had not submitted the PASRR Level II Determination for Resident #50. She indicated that the evaluation should be completed with a new mental illness diagnosis. She revealed the MDS nurse usually alerted her of new mental health diagnoses, and she submitted the Level II PASRR evaluation. During an interview on 5/12/22 at 10:45 AM, the Administrator revealed any new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and staff interviews the facility failed to submit information for Preadmission Screening and Resident Review (PASARR) for a level II re-evaluation for 1 of 2 sampled resident (Resident #26). The findings included: Resident #26 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's Significant Change Minimum Data Set (MDS) assessment dated on 08/01/19 revealed that the resident cognition was intact. The resident was coded as receiving antipsychotic medication for 7 of the 7 days during the assessment period. The resident was coded on the MDS as having a [DIAGNOSES REDACTED]. Review of Resident #26 ' s care plan dated on 10/01/19 indicated that she was care planned for antidepressant medication use due to having a [DIAGNOSES REDACTED].#26 was also care planned for inappropriate and disruptive behaviors. Review of the hospital discharge summary dated on 07/26/18 revealed that the resident had [DIAGNOSES REDACTED]. Review of the PASARR screening form dated on 07/27/18 revealed that no was checked for mental health diagnoses. During an interview with the Administrator on 01/17/20 at 10:50 AM indicated that the Social Worker handles the PASSRR's and going forward all residents PASARR's from the hospital will be checked against their [DIAGNOSES REDACTED]. During an interview with the Social Worker on 01/17/20 at 11:15 AM indicated that she was not aware that she needed to check the PASARR's screening application from the hospital to make sure mental health illnesses were included if the resident has a [DIAGNOSES REDACTED]. She further stated that moving forward she will recheck the PASARR's from the hospital to make sure they are accurate. If they are not accurate the resident will be re-evaluated for PASSAR level II.

Based on resident and staff interviews and record review, the facility failed to accurately code the Oral/Dental Status assessment in the Minimum Data Set (MDS) of a resident admitted with broken natural teeth and missing teeth for 1 of 20 residents reviewed (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated Resident #7 had been cognitively intact, had been able to make himself understood and had the ability to understand others. The MDS indicated Resident #7 did not have any dental problems which included broken natural teeth and missing teeth. A review of Resident #7's Comprehensive Oral Evaluation, dated 08/16/18, revealed Resident #7 had been missing upper teeth #'s 1, 8, 10 and 16 and lower teeth #'s 19, 29, 30 and 32. The evaluation revealed Resident #7 had root tips present on teeth 6, 18 and 20. During an interview with Resident #7 on 03/02/19 at 8:37 a.m., Resident #7 stated he had been admitted to the facility with several missing teeth and broken teeth. During an interview with the MDS nurse coordinator on 03/03/19 at 9:08 a.m., the MDS nurse coordinator stated she had not been at the facility at the time of Resident #7's admission to the facility. The MDS nurse coordinator stated she did not know the reason Resident #7's Oral/Dental Status assessment on the admission MDS had been inaccurately coded. During an interview with the Administrator on 03/03/19 at 9:47 a.m., the Administrator stated it was her expectation the MDS assessments are completed accurately.

Based on record review, resident and staff interviews, the facility failed to report an abuse allegation to the state agency within 2 hours of the facility being aware of the allegation for 1 of 1 resident to resident abuse investigations reviewed. Resident #1 attempted to smother Resident #2 by placing a pillow over his face with no negative outcome to Resident #2. The findings included: 1 a. Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) dated on 05/29/18 indicated he was cognitively intact. b. Resident #2 was admitted to the facility on [DATE]. Resident #2's Quarterly MDS dated on 04/30/18 indicated he had moderate cognitive impairment. Review of the Initial Allegation Report dated 06/06/18 indicated that the facility was aware of an incident which occurred on 06/04/18 at 8:30 AM when Resident #1 placed a pillow over Resident #2's face. The incident was reported to the law enforcement on 06/04/18 at 8:45 AM. Review of the facility's Investigation Report dated on 06/06/18 read in part Resident #1 was angry with Resident #2 because he was loud and talking. According to Resident #2 they were cursing each other and the Resident #1 came over to his bed. Resident #2 said he thought they were friends and at times they curse each other just like friends might do. Resident #2 said that he thought Resident #1 was joking when he picked up the pillow, but realized he was not joking when he placed the pillow over his head. The deputy later asked Resident #2 if he was having any problems breathing when the pillow was over his face and he said I was starting to when he took it off. Resident #1 admitted to becoming angry and placing a pillow over his roommate's face. He stated that he held the pillow for about 10 seconds and then he said common sense and God told him that he should not do that. Further review of the Initial Allegation Report and the Investigation Report revealed it was faxed to the state agency's Health Care Personnel Investigations Section on 06/06/18 at 6:45 PM. During an interview with Resident #2 on 06/21/18 at 10:20 AM he stated Resident #1 did place a pillow over his face earlier in the month, but at first, he thought Resident #1 was just kidding and not really mad at him. During an interview with the Interim Administrator on 06/21/18 at 4:10 PM, she stated that she was not aware that resident to resident abuse had to be reported to the state agency until she made a call to the state agency to verify. She confirmed the facility did not notify the state agency of the 06/06/18 incident when Resident #1 placed a pillow over Resident #2's face until over 10 hours after the facility was aware of the incident. The administrator further stated that it was her expectation that any abuse allegation to include resident to resident abuse be reported to the state agency within 2 hours after the facility was notified of the incident.

Based on observations, interview with staff and the resident's medical record review, facility failed to place the call light within reach for 1 of 1 sampled Residents (Resident # 41) . Findings included: Resident #41 was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognition was moderately impaired. She required extensive assist with one person for bed mobility, dressing and toilet use. The resident's care plan updated 11/17/2017 indicated the resident had a problem with self-care deficit of daily living related to poor cognitive and physical status. Observations were made on 1/9/2018 at 12:30 PM and 1/9/2018 at 1:45 PM. The call light was out of reach for Resident # 41. On 1/9/2018 at 1:45 PM, the resident was interviewed. During the interview with the resident she reported she was wet and needed to be changed but she could not reach her call light. Nurse Assistant (NA) #1 was interviewed on 1/9/2018 at 1:50 PM. The NA # 1confirmed she was assigned to take care of Resident #41. The NA # 1 stated she had been trained to place the call light within resident's reach at the beginning of the shift. She acknowledged the call light was not placed within the resident's reach and he had no explanation as to why the call light was not within the resident's reach. Nurse #1 was interviewed on 1/9/2018 at 2:15 PM. She stated nurses and NAs were taught to keep the call light within the resident's reach. The nurse added it was the responsibility of the NAs to make sure the call light was placed within the residents reach at the facility. On 1/10/2018 at 2:55 PM, the Director of Nursing stated her expectation was for the call light to be placed within the residents reach at all time.

Based on record review and resident and staff interviews the facility failed to ensure a resident was seen by a physician within 30 days of admission (Resident #53) and failed to ensure residents were seen every 30 days thereafter by a physician or physician ' s assistant for the first 90 days after admission and every 60 days for residents who had been in the facility longer than 90 days for 5 of 26 residents reviewed (Resident #53, #9, #27, #36 and #42. The findings included: 1a. Resident # 53 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician ' s Admission History and Physical dated 10/30/15 signed by a physician ' s assistant. There were no physician ' s progress notes on the chart. On 2/4/16 at 4:01 PM, the MDS (Minimum Data Set) Nurse stated in an interview that she had called the physician ' s office and they had no other documentation of physician ' s visits for the resident. The Clinical Care Coordinator (CCC) stated in an interview on 2/4/16 at 4:21 PM the physician ' s assistant (PA) made rounds on Mondays and the physician made rounds on Wednesday evening. The CCC stated the facility had a list of new admissions, residents with new concerns and family members that wanted to talk with the physician. The CCC stated if a resident had an acute problem they called the physician at that time. The CCC stated the physician would dictate his visit in a computer and print out the progress notes at his office and the office was supposed to fax the notes to the facility. The CCC stated the facility had a difficult time getting the notes from the physician ' s office. The Director of Nursing (DON) stated in an interview on 2/4/16 at 4:31 PM that the physician always saw new admissions and there should be a physician ' s note somewhere. The DON was not able to provide documentation to show the physician had seen the resident within the first 30 days of admission. The MDS (Minimum Data Set) Coordinator stated in an interview on 2/5/16 at 12:54 PM that she had been assigned to make rounds with the physician and the PA. The MDS Coordinator stated they had a communication book for the physician and the staff would write non-emergent resident concerns in the book. The MDS Coordinator stated when the current Director of Nursing (DON) started the DON took over the role of rounding with the physician. On 2/5/16 at 1:31 PM the DON stated in an interview they recently realized they had an issue with progress notes not being where they needed to be. The DON stated she had been making rounds with the physician for the past 3 weeks and it was a work in progress. The DON stated the physician had seen every resident in the building in the past 2 weeks. The DON stated she did not have a written plan of correction. The facility ' s Physician stated in an interview on 2/5/16 at 1:45 PM that on his visits to the facility the staff provided a list of residents to be seen and he saw the residents on that list. On 2/5/16 at 1:43 PM the Interim Administrator stated the previous administrator had notified him on 1/21/16 that there was a problem with physician ' s visits and progress notes that were not being done. The Administrator stated he had been at the facility for 2 weeks and had not yet met the physician who was also the medical director. The Administrator stated the corporation had a medical director to oversee all their facilities and this person had been contacted to speak with their physician regarding the problem. The Administrator stated they were looking at the issue but did not have a written plan of correction. 1b. Resident # 53 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was seen by a physician ' s assistant on 10/30/15. There were no additional progress notes to show the resident had been seen by a physician or a physician ' s assistant prior to the resident ' s discharge on 1/14/16. On 2/4/16 at 4:01 PM, the MDS (Minimum Data Set) Nurse stated in an interview that she had called the physician ' s office and they had no other documentation of physician ' s visits for the resident while in the facility. The Clinical Care Coordinator (CCC) stated in an interview on 2/4/16 at 4:21 PM the physician ' s assistant made rounds on Mondays and the physician made rounds on Wednesday evening. The CCC stated the facility had a list of new admissions, residents with new concerns and family members that wanted to talk with the physician. The CCC stated if a resident had an acute problem they called the physician at that time. The CCC stated the physician would dictate his visit in a computer and print out the progress notes at his office and the office was supposed to fax the notes to the facility. The CCC stated the facility had a difficult time getting the notes from the physician ' s office. The MDS (Minimum Data Set) Coordinator stated in an interview on 2/5/16 at 12:54 PM that she had been assigned to make rounds with the physician and the PA. The MDS Coordinator stated they had a communication book for the physician and the staff would write non-emergent resident concerns in the book. The MDS Coordinator stated when the current Director of Nursing (DON) started the DON took over the role of rounding with the physician. On 2/5/16 at 1:31 PM the DON stated in an interview they recently realized they had an issue with progress notes not being where they needed to be. The DON stated she had been making rounds with the physician for the past 3 weeks and it was a work in progress. The DON stated the physician had seen every resident in the building in the past 2 weeks. The DON stated she did not have a written plan of correction. The facility ' s Physician stated in an interview on 2/5/16 at 1:45 PM that on his visits to the facility the staff provided a list of residents to be seen and he saw the residents on that list. On 2/5/16 at 1:43 PM the Interim Administrator stated the previous administrator had notified him on 1/21/16 that there was a problem with physician ' s visits and progress notes that were not being done. The Administrator stated he had been at the facility for 2 weeks and had not yet met the physician who was also the medical director. The Administrator stated the corporation had a medical director to oversee all their facilities and this person had been contacted to speak with their physician regarding the problem. The Administrator stated they were looking at the issue but did not have a written plan of correction. 2. Resident #9 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Review of the clinical record for 2015/2016 revealed physician ' s progress notes dated 3/30/15 and 10/22/15. The facility was unable to provide additional progress notes for the resident. The Clinical Care Coordinator (CCC) stated in an interview on 2/4/16 at 4:21 PM the physician ' s assistant made rounds on Mondays and the physician made rounds on Wednesday evening. The CCC stated the facility had a list of new admissions, residents with new concerns and family members that wanted to talk with him. The CCC stated if a resident had an acute problem they called the physician at that time. The CCC stated the physician would dictate the visit in a computer and print out the progress notes at his office and the office was supposed to fax the notes to the facility. The CCC stated the facility had a difficult time getting the notes from the physician ' s office. The MDS (Minimum Data Set) Coordinator stated in an interview on 2/5/16 at 12:54 PM that she had been assigned to make rounds with the physician and the PA. The MDS Coordinator stated they had a communication book for the physician and the staff would write non-emergent resident concerns in the book. The MDS Coordinator stated when the current Director of Nursing (DON) started the DON took over the role of rounding with the physician. On 2/5/16 at 1:31 PM the DON stated in an interview they recently realized they had an issue with progress notes not being where they needed to be. The DON stated she had been making rounds with the physician for the past 3 weeks and it was a work in progress. The DON stated the physician had seen every resident in the building in the past 2 weeks. The DON stated she did not have a written plan of correction. The facility ' s Physician stated in an interview on 2/5/16 at 1:45 PM that on his visits to the facility the staff provided a list of residents to be seen and he saw the residents on that list. On 2/5/16 at 1:43 PM the Interim Administrator stated the previous administrator had notified him on 1/21/16 that there was a problem with physician ' s visits and progress notes that were not being done. The Administrator stated he had been at the facility for 2 weeks and had not yet met the physician who was also the medical director. The Administrator stated the corporation had a medical director to oversee all their facilities and this person had been contacted to speak with their physician regarding the problem. The Administrator stated they were looking at the issue but did not have a written plan of correction. 3. Resident #27 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the clinical record for 2015/2016 revealed a physician ' s progress note dated 2/18/15. On 2/4/16 at 11:29 AM the Director of Nursing (DON) provided physician ' s progress notes faxed to the facility by the physician ' s office dated 2/18/15 and stated these were the most recent notes on file. The Clinical Care Coordinator (CCC) stated in an interview on 2/4/16 at 4:21 PM the physician ' s assistant made rounds on Mondays and the physician made rounds on Wednesday evening. The CCC stated the facility had a list of new admissions, residents with new concerns and family members that wanted to talk with him. The CCC stated if a resident had an acute problem they called the physician at that time. The CCC stated the physician would dictate the visit in a computer and print out the progress notes at his office and the office was supposed to fax the notes to the facility. The CCC stated the facility had a difficult time getting the notes from the physician ' s office. The MDS (Minimum Data Set) Coordinator stated in an interview on 2/5/16 at 12:54 PM that she had been assigned to make rounds with the physician and the PA. The MDS Coordinator stated they had a communication book for the physician and the staff would write non-emergent resident concerns in the book. The MDS Coordinator stated when the current Director of Nursing (DON) started the DON took over the role of rounding with the physician. On 2/5/16 at 1:31 PM the DON stated in an interview they recently realized they had an issue with progress notes not being where they needed to be. The DON stated she had been making rounds with the physician for the past 3 weeks and it was a work in progress. The DON stated the physician had seen every resident in the building in the past 2 weeks. The DON stated she did not have a written plan of correction. The facility ' s Physician stated in an interview on 2/5/16 at 1:45 PM that on his visits to the facility the staff provided a list of residents to be seen and he saw the residents on that list. On 2/5/16 at 1:43 PM the Interim Administrator stated the previous administrator had notified him on 1/21/16 that there was a problem with physician ' s visits and progress notes that were not being done. The Administrator stated he had been at the facility for 2 weeks and had not yet met the physician who was also the medical director. The Administrator stated the corporation had a medical director to oversee all their facilities and this person had been contacted to speak with their physician regarding the problem. The Administrator stated they were looking at the issue but did not have a written plan of correction. 4. Resident #36 was originally admitted to the facility with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Admission History and Physical dated 7/22/15, which was signed by the physician. There were no other physician progress notes [REDACTED]. On 2/4/16 at 4:01 PM, the MDS (Minimum Data Set) Nurse stated in an interview that she had called the physician ' s office and they had no other documentation of physician's visits for the resident. The Clinical Care Coordinator (CCC) stated in an interview on 2/4/16 at 4:21 PM the physician ' s assistant (PA) made rounds on Mondays and the physician made rounds on Wednesday evening. The CCC stated the facility had a list of new admissions, residents with new concerns and family members that wanted to talk with the physician. The CCC stated if a resident had an acute problem they called the physician at that time. The CCC stated the physician would dictate his visit in a computer and print out the progress notes at his office and the office was supposed to fax the notes to the facility. The CCC stated the facility had a difficult time getting the notes from the physician ' s office. The DON was not able to provide documentation to show the physician had seen the resident within the first 30 days of admission. The MDS (Minimum Data Set) Coordinator stated in an interview on 2/5/16 at 12:54 PM that she had been assigned to make rounds with the physician and the PA. The MDS Coordinator stated they had a communication book for the physician and the staff would write non-emergent resident concerns in the book. The MDS Coordinator stated when the current Director of Nursing (DON) started the DON took over the role of rounding with the physician. On 2/5/16 at 1:31 PM the DON stated in an interview they recently realized they had an issue with progress notes not being where they needed to be. The DON stated she had been making rounds with the physician for the past 3 weeks and it was a work in progress. The DON stated the physician had seen every resident in the building in the past 2 weeks. The DON stated she did not have a written plan of correction. The facility's Physician stated in an interview on 2/5/16 at 1:45 PM that on his visits to the facility the staff provided a list of residents to be seen and he saw the residents on that list. On 2/5/16 at 1:43 PM the Interim Administrator stated the previous administrator had notified him on 1/21/16 that there was a problem with physician's visits and progress notes that were not being done. The Administrator stated he had been at the facility for 2 weeks and had not yet met the physician who was also the medical director. The Administrator stated the corporation had a medical director to oversee all their facilities and this person had been contacted to speak with their physician regarding the problem. The Administrator stated they were looking at the issue but did not have a written plan of correction. 5. Resident #42 was originally admitted to the facility with [DIAGNOSES REDACTED]. Review of the clinical record revealed an Admission History and Physical dated 10/15/15, which was signed by the physician. There were no other physician progress notes [REDACTED]. On 2/4/16 at 4:01 PM, the MDS (Minimum Data Set) Nurse stated in an interview that she had called the physician ' s office and they had no other documentation of physician ' s visits for the resident. The Clinical Care Coordinator (CCC) stated in an interview on 2/4/16 at 4:21 PM the physician ' s assistant (PA) made rounds on Mondays and the physician made rounds on Wednesday evening. The CCC stated the facility had a list of new admissions, residents with new concerns and family members that wanted to talk with the physician. The CCC stated if a resident had an acute problem they called the physician at that time. The CCC stated the physician would dictate his visit in a computer and print out the progress notes at his office and the office was supposed to fax the notes to the facility. The CCC stated the facility had a difficult time getting the notes from the physician ' s office. The MDS (Minimum Data Set) Coordinator stated in an interview on 2/5/16 at 12:54 PM that she had been assigned to make rounds with the physician and the PA. The MDS Coordinator stated they had a communication book for the physician and the staff would write non-emergent resident concerns in the book. The MDS Coordinator stated when the current Director of Nursing (DON) started the DON took over the role of rounding with the physician. On 2/5/16 at 1:31 PM the DON stated in an interview they recently realized they had an issue with progress notes not being where they needed to be. The DON stated she had been making rounds with the physician for the past 3 weeks and it was a work in progress. The DON stated the physician had seen every resident in the building in the past 2 weeks. The DON stated she did not have a written plan of correction. The facility ' s Physician stated in an interview on 2/5/16 at 1:45 PM that on his visits to the facility the staff provided a list of residents to be seen and he saw the residents on that list. On 2/5/16 at 1:43 PM the Interim Administrator stated the previous administrator had notified him on 1/21/16 that there was a problem with physician ' s visits and progress notes that were not being done. The Administrator stated he had been at the facility for 2 weeks and had not yet met the physician who was also the medical director. The Administrator stated the corporation had a medical director to oversee all their facilities and this person had been contacted to speak with their physician regarding the problem. The Administrator stated they were looking at the issue but did not have a written plan of correction.

Based on record review and staff and physician interviews, the facility failed administer an antibiotic medication for one of five residents reviewed for medications (#76). The findings included: Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. an order written [REDACTED]. [MEDICATION NAME] is an antibiotic. Review of the Medication Administration Record [REDACTED]. Review of the facility ' s Standing Orders revealed no standing order for [MEDICATION NAME]. Review of the weekly vital sign sheet for 1/13/16 and 1/21/16 documented the Resident had a normal temperature. Review of the nurse ' s notes revealed no sudden onset of severe pain in abdomen. The Director of Nursing (DON) stated in an interview on 2/4/16 at 9:40 AM, the Physician meant to give 5 days [MEDICATION NAME]([MEDICATION NAME]) and even though the order does not say it, the nurses knew that the Physician treated urinary tract infections [MEDICAL CONDITION] for 5 days and the resident had a history of [REDACTED]. The DON stated the staff should have clarified the order with the Physician since it was written to be given daily without an end date and it was not done. The Physician who wrote the order stated in an interview on 2/5/16 at 4:59 PM that Resident #76 had liver [MEDICAL CONDITION] with portal hypertension and ascites and he had prescribed the daily dose of [MEDICATION NAME] to prevent a condition the Resident was at risk for called Spontaneous Bacterial Peritonitis (SBP is an infection of ascetic fluid in the abdomen) and not to treat a UTI. The Physician further stated he intended the Resident to be on the medication continuously and if she did not receive the [MEDICATION NAME] more than 4 days she would be only at a low to moderate risk of SBP but he did want her started back on the antibiotic that day. The DON stated in an interview on 2/5/16 at 5:05 PM the Physician had just told her that the [MEDICATION NAME] should have been given daily to prevent SBP and not to treat UTI and she had written a clarification order.

Based on observations and interviews the facility failed to post State client advocacy groups and Medicare/Medicaid information in a prominent location in the facility for three consecutive days of the survey. The findings included: During a tour of the facility on 2/2/16 at 7:13 AM, there were no numbers posted for State client advocacy services such as the State survey and certification agency, the State licensure office, the Medicaid Fraud Unit, and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility. There was no written information posted about how to apply for Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an observation on 2/3/16 at 3:30 PM, there were no numbers posted for State client advocacy services such as the State survey and certification agency, the State licensure office, the Medicaid Fraud Unit, and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility. There was no written information posted about how to apply for Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an observation on 2/4/16 at 1:57 PM, there were no numbers posted for State client advocacy services such as the State survey and certification agency, the State licensure office, the Medicaid Fraud Unit, and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility. There was no written information posted about how to apply for Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an observation on 2/5/16 at 2:33 PM, there were no numbers posted for State client advocacy services such as the State survey and certification agency, the State licensure office, the Medicaid Fraud Unit, and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility. There was no written information posted about how to apply for Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an observation on 2/5/16 at 3:24 PM the Administrator looked through the facility for the advocacy numbers and the Medicare and Medicaid information, however he was not able to find the information. During an interview on 2/5/16 at 3:28 PM, the Administrator stated he located the information. He said the maintenance man removed the information prior to painting and he had not replaced the information.

Based on observations and staff interviews, the facility failed to post accurate daily staffing in a prominent location in the facility for two days of the survey. The findings include: During an interview on 2/2/16 at 7:10 AM the Director of Nursing revealed the staff posting was posted on a bulletin board in the dietary area of the facility. During an observation on 2/2/16 at 7:13 AM after passing through double doors with a sign posted Restricted Area, Authorized Access Only the Daily Staff Posting was located on a communication board in the dietary area. The date posted on the Daily Staff Posting was 1/31/16. During an observation on 2/3/16 at 4:00 PM after passing through double doors with a sign posted Restricted Area, Authorized Access Only, the Daily Staff Posting dated 2/2/16 was located on a communication board in the dietary area. A Dietary Staff person asked, May I help you? During an interview on 02/04/2016 at 4:07 PM with the Director of Nursing and the Nurse Consultant, the Nurse Consultant revealed the previous Administrator had the staff posting in the back area of the facility and the Interim Administrator started last week and the staff posting was put up today. During an interview on 02/05/2016 at 4:30 PM, the Director of Nursing revealed when the Nurse arrived in the morning she would usually post the Staff Posting and the night nurse would make adjustments to the Staff Posting. She said there was a bulletin board near her office and the information was shifted to another area in the process of painting being done.