Every finding on record at River Hills Health and Rehabilitation Center

Based on interview and record, the facility failed to ensure they maintained documentation related to staff COVID-19 vaccination that includes at the COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) for 1 of 1 facility reviewed for immunizations. The facility failed to ensure documentation of immunizations related to COVID-19 were maintained for all staff. This failure could result in the spread of infection. Findings included: Record review of the facility documents titled EMPLOYEE Informed Consent for Influenza Vaccine reflected documents dated May 2026 for 80 staff members indicating their acceptance or declination of the influenza vaccination. In an interview with the DON on 8/20/2026 at 12:30 PM, she said the facility was acquired by a new corporate company in May 2026, and they were instructed to re-offer all staff members the influenza vaccination from fall 2025 as part of the acquisition. She said she was not the DON of the facility in fall 2025, but it was her understanding that the influenza and COVID-19 vaccinations were offered to staff from the facility at the recommended time in early fall. She said the facility did not have records of these vaccinations because the records were owned by the former corporate company, and they were not allowed to keep them. Record review of the facility policy titled Immunizations- Staff dated April 2025 reflected the following: . 4. For staff who receive a vaccine from the facility, the facility will track, securely document and retain records related to staff vaccinations, including boosters or series vaccinations. Vaccine documentation includes the vaccine manufacturer, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination in the employee's medical records.5. If a staff member declines a recommended vaccine for reasons other than medical contraindication, this shall be documented on the Employee Informed Consent for Immunization.6. Staff may obtain their vaccines from their personal physicians or other healthcare sources. Documentation of previous vaccination or vaccination outside of the facility should be provided to the facility .

Based on interviews and record review the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility for five of seven anonymous residents who attended Resident Council meetings at the facility in that: The facility failed to follow up on concerns expressed by individual residents and documented by the facility activities director during Resident Council meetings held in April, June and July of 2026. This failure could result in the residents feeling unheard and undervalued in their place of residence. The findings included: During a confidential resident council group interview held at the facility at an undisclosed date and time, six of seven residents in attendance stated that they regularly attend resident council meetings. Three of the residents in attendance stated that nothing is done about the concerns/grievances that they voice. These residents mentioned that they have complained several times in resident council meetings about staff being on and talking on the phones during the shifts using earpieces and not being attentive to work duties but they have not heard any resolution or seen any changes in the behaviors. Five out of the seven residents in attendance verbalized that they have expressed their concerns and do not hear anything back from the staff about how the issue is being resolved. One resident stated that she goes to the Activities Director for concerns but is not sure who the Grievance Official is. Another resident stated that she reports concerns to the SW. None of the residents knew who the Grievance Official was for the facility. Review of resident council meeting notes dated 04/14/2026 revealed five incomplete resident grievance forms attached. Only the top portion of the documents are filled out and signed by the Activities Director. Review of resident council meeting notes dated 06/09/2026 revealed two incomplete resident grievances forms attached. Only the top portion of the documents are filled out and signed by the Activities Director. Review of resident council meeting notes dated 07/21/2026 revealed seven incomplete resident grievance forms attached. Only the top portion of the documents are filled out and signed by the Activities Director. A review of the facility grievance log on 08/20/2026 revealed that the grievance forms that were filled out during the resident council meetings by the Activities Director on 04/14/2026, 06/09/2026 and 07/21/2026 were not documented in the facility grievance log. During an interview with the facility Activities Director on 08/21/2026 at 1:33pm she verified that during each resident council meeting she documents each of the residents' grievances on a grievance form and hands them to the office in the front for the Administrator and SW to follow-up with. She was not sure what happened with the forms after she submitted them or who the Grievance Official was for the facility. Per interview with the facility Social Worker on 08/21/2026 at 2:44pm, she stated that she was the Grievance Officer for the facility. She stated that the residents may not be aware of this because there has not been a SW on staff for some time before she came. She stated that she received the grievances and handled them. Once a grievance has been processed, she will go to the resident's room and have them write their understanding of the resolution at the bottom of the grievance form and sign it. During an interview with the facility administrator on 08/21/2026 at 3:38pm, it was stated that anytime a resident or RP reports a concern to staff, a grievance is initiated. The grievance form is filled out by a staff member. If it is an easily resolved issue, the form may not be needed; it depends on the situation. Once grievance form is filled out, the IDT team reviews the grievance and investigates to find a solution. Solution is then discussed with the resident and/or RP. If the solution is satisfactory to the resident and/or RP, then the grievance if closed and filed. He stated that the Grievance Officer is normally the person filling out the grievance, and this can be any staff member. The Administrator stated that he was not aware of the grievances that were collected by the Activity Director at the resident council meetings. The June and July resident council meeting notes and attached incomplete grievance forms were provided to him for review. Review of the facility provided policy and procedure entitled, Grievances with original date of 11/2016 and last revision/review date of 4/2025 stated the following grievance procedure: 1. The facility's grievance official is responsible for overseeing the grievance process and for receiving and tracking grievances; leading any necessary investigations by the facility.issuing written grievance decisions to the resident, if requested.2. Information is made available to the resident and/or representative and posted in designated locations throughout the facility. Information includes . contact information of the facility grievance office to include name, business and email address, phone number, and reasonable expected time frame for completing review of the grievance. The procedure further states that 3. General concerns may be voiced at Resident and/or Family Council meetings and 6. The Grievance Official or designee responds to the individual expressing the concern within (3) three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. and 7. The Grievance official/designee completes the Grievance Resolution Forms, takes appropriate corrective action.The Grievance Official or designee will contact all parties with the outcome.

Based on record review and interview the facility failed to provide pharmaceutical services to include documentation (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1(#89) residents. The facility failed to ensure there was documentation of Resident #89's medication administration for Lactobacillus, Esomeprazole, and Levothyroxine in July 2026 and medication administration for Esomeprazole in August 2026. These failures may place residents at risk for receiving inaccurate medication as ordered by the physician. The findings include: Record review of Resident #89's face sheet, dated 08/18/2026, revealed an admission date of 08/14/2025. Resident #89 was an [AGE] year old male with diagnoses which included other specified diseases of the digestive system, ankylosing spondylitis of multiple sites in spine (arthritis that causes painful swelling in the spine and lower back), hypothyroidism (thyroid gland underproduces hormones resulting in a slowdown of body functions), paroxysmal atrial fibrillation (occasional irregular heartbeat) and congestive heart failure (condition in which the heart cannot pump blood effectively causing fluid to build up in the body).Record review of Resident #89's quarterly MDS assessment, dated 06/17/2026, revealed there was no BIMS score assessed for the resident although he was assessed to have adequate hearing, clear speech, the ability to make himself understood and the ability to understand others. Section GG assessing Resident #89's functional abilities showed he was dependent or required substantial/maximal assistance to complete the majority of his ADL's.Record review of Resident #89's 's care plan, dated 04/17/2026, revealed a focus of: .has hypothyroidism, at risk for complications with an intervention of Give thyroid replacement therapy as ordered.Record review of Resident #89 's order summary report, dated 08/18/2026, revealed there was an active order for Lactobacillus Oral Capsule - Give 1 capsule by mouth before meals for supplement (pills that add bacteria to the body to support digestion) ordered by the prescriber on 04/24/2026, an order for Levothyroxine Sodium oral tablet 75 mcg - Give 1 tablet by mouth one time a day for hypothyroidism (thyroid gland underproduces hormones resulting in a slowdown of body functions) written by prescriber on 04/24/2026 and an order for Esomeprazole Magnesium Capsule Delayed Release 20mg - Give 1 capsule by mouth two times a day for GERD (severe acid reflux disease) with an order date of 06/17/2026.Record review of Resident #89's MAR, dated 08/20/2026 for the month of July 2026, reflected a blank with no staff initials or check mark noted for the medication Lactobacillus during the 1600 (4:00 PM) administration time on the dates 07/2/2026, 07/3/2026 and 07/15/2026. In addition, the was a blank with no staff initials or check mark noted for the medication Levothyroxine scheduled for 7/29/2026 at 0500 (5:00AM)Record review of Resident #89's MAR, dated 08/19/2026 for the month of August 2026, reflected a blank with no staff initials or check marked noted for the medication Esomeprazole during the 5:00 AM administration time on the dates 08/04/2026 and 08/15/2026.During an interview with Resident #89 on 8/18/2026 at 11:46 AM, the resident stated that he sometimes did not receive medications as scheduled and was sometimes told I'll have to bring it later by the staff who administered medications, but Resident #89 stated he never received the medications.During an interview with LVN A, she stated she was not responsible for the missing documentation that occurred on 08/04/2026 and 08/15/2026. She stated Levothyroxine and Esomeprazole scheduled for the 5:00 AM period would have been given by the night staff, so this would have been a medication that was scheduled to be administered prior to her scheduled shift. She could not identify which staff were responsible for the missing documentation. When she reviewed the July 2026 MAR, she stated she would think the medication was not given if it was not signed off on.During an interview with LVN B on 08/21/2026 at 1:40 PM, upon reviewing the missing MAR documentation for July 2026, the LVN stated the medications were not signed for on these dates which made it look like the medications were not given. She identified that MA R was responsible for not documenting these medications.During an interview with MA R on 08/21/2026 at 1:43 PM, he stated he always signed when he gave medications. MA R did not verify whether or not he gave the medications on this date. Upon reviewing the July 2026 MAR with LVN B, he stated he might have accidentally missed the documentation and stated he knew he should always sign the MAR after administering medications so other staff knew the medication was given to the resident.During an interview with the DON on 08/21/2026 at 2:45 PM, she stated the missing documentation could potentially result in a resident receiving a second dose of medication if it had already been given by the previous nurse.A record review of the facility's policy entitled Medication Administration with the subject of Administration of Medication revealed: Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns was listed as one of The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 1 kitchen [TF1.1][SM1.2]reviewed for food and nutrition services.1. The facility failed to employ a qualified dietician or other clinically qualified nutrition professional on a full-time basis or on a part-time basis who designated a person to serve as the director of food and nutrition services. A director of nutrition services was last employed with the facility in February 2026. 2. The facility failed to employ a qualified director of food and nutrition services who met the minimum qualifications of a certified dietary manager; or a certified food service manager. The Dietary Supervisor was scheduled to begin certification training on 09/03/2026. These failures could place residents at risk of not having their nutritional needs met.The findings include:During an interview on 08/18/2026 at 10:00 a.m., the Dietary Supervisor revealed the facility employed a dietitian who consults on a part-time basis and he did not have a certification as a dietary manager or food service manager as he had yet to begin training. He stated he was scheduled to begin the Certified Dietary Manager course on 09/03/2026. He stated he started in this role as of February 2026.During an interview on 08/18/2026 at 10:35 a.m., the Administrator revealed he did not have a certified dietary manager and his dietitian only consulted on a part-time basis. He stated he was unsure as to when the facility had been without a certified dietary manager. He stated he would have to obtain this information. He stated with the acquisition on 05/01/2026 the facility changed consulting companies, and a new dietitian was on board. He stated the Dietary Supervisor was scheduled to begin his certification as a dietary manager sometime next month.During an interview on 08/21/2026 at 2:48 p.m., the Director of Nursing revealed she did not recall when the dietary manager was replaced by the Dietary Supervisor. She stated not having a certified dietary manager would leave staff not understanding the importance of following menus and guidelines, timeliness of meals, snacks being delivered to the halls, and offering substitute meals per policies. She stated all these practices were learned theory training and maintained by a certified dietary manager and currently without one could cause deficiencies to the facilities policies outlined for food and nutrition services. During an interview on 08/21/2026 at 3:13 p.m., the Administrator revealed a qualified dietary staff was significant as they would have a higher capacity to operate the dietary responsibilities of snacks, timeliness of meals, temperature checks, and food preparation at higher quality. He stated not having a certified dietary manager left regulations to not be reached and residents would not get quality foods.Record review of the facility's documents titled, Dietitian Consultation Reports, dated January 2026 - July 2026, revealed dietitian consultant provides less than full-time status at NF. Record review of the facility's policy titled, Dietary Support Personnel, Sufficient, revised 04/2025, revealed It is the policy of this facility to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required.

Based on observation, interview, and record review, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for two (lunch on 08/18/2026 and 08/19/2026) of two meals observed for dietary services. The facility failed to serve the 08/18/2026 and 08/19/2026 lunch meals on time at the scheduled time based on the meal postings for hall trays. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life.The findings included: Review of Resident #31's quarterly MDS assessment dated [DATE] reflected Resident #31 had a BIMS score of 14 indicating he was cognitively intact. Review of Resident #56's quarterly MDS assessment dated [DATE] reflected Resident #56 had a BIMS score of 06 indicating she was severely cognitively impaired. Review of Resident #79's modification of quarterly MDS assessment dated [DATE] reflected Resident #79 had a BIMS score of 13 indicating she was cognitively intact. Review of Resident #85's quarterly MDS assessment dated [DATE] reflected Resident #85 had a BIMS score of 14 indicating she was cognitively intact. Review of Resident #91's quarterly MDS assessment dated [DATE] reflected Resident #91 had a BIMS score of 09 indicating he was moderately cognitively impaired. During an interview and observation on 08/18/2026 at 1:13 p.m., Resident #79 was observed eating a bowl of dry cereal. She stated that 400 hallways do not get lunch trays until 1:30 p.m. - 2:00 p.m. daily. She stated that she keeps her snacks and meals available in her room because she tends to get hungry. During an interview and observation on 08/18/2026 at 1:31 p.m., Resident #56 revealed that she was waiting for her lunch tray. She stated that at times her lunch tray was usually delivered later than others. She stated she did not want to speak now as she was expecting her lunch tray to arrive soon. She was observed pacing back and forth in her room and into the hallway looking around for the nursing staff to have her lunch tray delivered. She stated that the lunch meal was often late. Observation revealed 400 hallways had not received their lunch trays yet. During an observation on 08/18/2026 at 1:26 p.m., Resident #79's lunch tray was delivered to her room. During an observation on 08/18/2026 at 1:34 p.m., Resident #56's lunch tray was delivered to her room. During an observation on 08/19/2026 at 1:14 p.m., Resident #85's lunch tray was delivered to her room. During an observation on 08/19/2026 at 1:19 p.m., Resident #31's lunch tray was delivered to his room. During an observation on 08/19/2026 at 1:33 p.m., Resident #91's lunch tray was delivered to his room. During an interview on 08/18/2026 at 10:00 a.m., the Dietary Supervisor revealed that mealtimes are 7 am for breakfast, 12 pm for lunch, and 5 pm for dinner. He stated that typically for breakfast the hallways were served first, and then the dining room was served after. He stated that for both lunch and dinner meals the dining room was served first followed by the hallways. During an interview on 08/20/2026 at 10:15 a.m., Dietary A revealed that he helps with preparing meals for delivery to halls. He stated meal trays are not usually late. He stated that the risk of residents receiving their meal trays late could be hunger or could cause a delay in taking their medications. During an interview on 08/20/2026 at 10:25 a.m., Dietary D stated that the risk of not getting snacks or meals out on time could negatively impact the residents. During an interview on 08/20/2026 at 10:30 a.m., the Dietary Supervisor revealed that lunch meals are late because nursing staff are not submitting resident meal tickets or sorting them before 11:45 am or at times forgot to turn them in. He stated these failures delay lunch trays getting out to the residents who are eating in their rooms. He stated that the dietary team was solid and had enough staff and were ready and waiting to make lunch trays. He stated that not having lunch trays out to residents at designated times can cause some residents to become upset, frustrated, and have a delay in medications administered. He stated that he constantly communicates to management that the delay of lunch was meal tickets being submitted late. He stated that some nursing staff recently have become frustrated and talked to management, but it falls on deaf ears. During an interview on 08/21/2026 at 2:29 p.m., LVN G revealed that if meals are delivered late, the residents will complain and they become a little frustrated. She stated that she does have some residents that will go directly to the dining room to see where their food was. During an interview on 08/21/2026 at 2:39 p.m., LVN H revealed that he helps deliver dinner meals to the residents. He stated that if a resident's meal was late, they would come out of their room and tell him they do not have their food. He stated that when meals are late some residents can become angry at times. During an interview on 08/21/2026 at 2:48 p.m., the Director of Nursing revealed that she had in -serviced all staff on mealtimes being on time. She stated that the expectation was for all meals to be delivered according to the mealtime schedule posted and on time. She stated that when meals are served more than 15 minutes late[VT46.1][SM46.2] this can cause residents to become anxious. During an interview on 08/21/2026 at 3:13 p.m., the Administrator revealed that posted mealtimes should be followed. He stated that late meals could result in cold food for residents. Record review of facility document titled, MEAL TIMES undated, and accessed on 08/20/2026 at 8:25 p.m. revealed, 12:00PM- DINING ROOM. 12:l5PM- 100/200 HALL TRAYS. 12:30PM 300/400 HALL TRAYS. Record review of policy titled, Policy undated and accessed on 08/21/2026 at 8:51 p.m., revealed Meal hours will be scheduled at regular times to ensure that each resident receives at least three (3) meals per day. Procedure 1. Posting of Meal Times A schedule of meal times and snack times will be posted in resident care areas and other designated locations accessible to residents, staff, and visitors. 3. Meal Schedule Scheduled meal times will be identified for each dining area within the facility and posted throughout the facility, including resident dining rooms and each resident hallway. 5. Monitoring The Dietary Manager and Administrator will monitor compliance with scheduled meal hours and posting requirements to ensure residents receive meals in accordance with federal and state regulations.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for nutrition services. 1.The facility failed to ensure that [NAME] I monitored that hot foods were held at 135 F or higher on the steam table on 8/20/2026.2.The facility failed to ensure dietary staff kept temperature logs that routinely monitored food temperatures on the steam table. These failures could lead to contamination and foodborne illness. The findings included: During an observation and interview on 08/20/2026 at 11:43 a.m., [NAME] I was preparing for lunch service without monitoring that hot foods were being held at 135 F or higher on the steam table. She stated that she does not check food temperatures of hot foods on the steam table prior to meal service. She stated she keeps a log of final food temperatures, but that she had not been trained or instructed to keep logs for foods held on the steam table. She asked if this practice was a new regulation, and she was directed to her dietary supervisor for guidance. During an interview on 08/21/2026 at 12:50 p.m., the Dietary Supervisor revealed that [NAME] I should be checking the temperatures of hot food held on the steam table before meal service, but that no log was kept. He stated he was unsure as to why [NAME] I would say that hot foods held on the steam table would not be required to be checked and that he would look further into this. He stated that checking food temperatures was important to keep food safe for residents to eat. During an interview on 08/21/2026 at 3:13 p.m., the Administrator revealed that the policy for checking food temperatures was staff were required to check temperatures for cooked foods and foods sitting on the steam table before service and logging. He stated that dietary staff should monitor food temperatures before leaving the kitchen. He stated that adequate food temps are necessary and not reaching appropriate temperatures could impact the food quality and residents could be getting cold food. Record review of policy titled, Dietary Department undated, revealed It is the policy of this facility to comply with all state, federal and local infection control standards and regulations concerning: Personnel requirements. Preparation and service. Equipment care. Food Preparation and Serving: 3. Cold foods must be kept at 45 F or below; hot foods must be kept at 140 F or above.

Based on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 2 of 15 residents (Resident #9, and Resident #100) and failed to keep confidential all information contained in the resident's records for 1 of 4 halls reviewed (300 hall) reviewed for clinical records, in that: 1.The facility failed to ensure Resident #9's medical record included physician orders to discontinue psychiatric services and that the PASRR Level 1 Screening was accurate upon admission.2.The facility failed to ensure Resident #100's medical record included physician orders to discontinue psychiatric services, PASRR Level 1 Screening was accurate upon admission, and Medical Diagnoses of anxiety disorder was coded. 3. The facility failed to ensure the records of the residents of 300 hall were kept confidential when a three-ring binder labeled CNA Binder was located on a small table outside on hall 300. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records and breach of confidentiality. The findings included: 1. Record review of Resident #9's admission Record, dated 08/20/2026, revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Resident #9's [family member] was listed as her financial responsible party and Emergency Contact #1. Record review of Resident #9's Medical Diagnoses, undated and accessed 08/20/2026 at 7:29 p.m., revealed diagnoses including Unspecified Dementia (medical classification used when a person has clear signs of dementia — such as significant memory loss, confusion, or difficulty with daily tasks — but the exact type of dementia has not yet been identified), Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), anxiety disorder (mental health disorder that causes frequent intense, excessive and persistent worry and fear about everyday situations), Progressive Vascular Leukoencephalopathy (PVL) (rare neurological disorder characterized by progressive damage to the brain's white matter due to injury or dysfunction of the brain's small blood vessels that can cause a range of neurological symptoms and impair daily functioning), major depressive disorder (MDD) (is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) cognitive communication deficit (occurs when a person's ability to communicate effectively is severely impaired due to a breakdown in the underlying cognitive processes that support language use, rather than a direct problem with speech or vocabulary). Record review of Resident #9's Quarterly review assessment, dated 07/28/2026 and signed 07/30/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #9 was documented having not exhibited any behavioral symptoms, including physical, verbal and other behavioral symptoms not directed toward others. Resident #9 was documented as requiring total care [dependent] and requiring the use of a wheelchair. Resident #9 was documented with diagnoses of non-Alzheimer's dementia, anxiety disorder, depression (other than bipolar), and schizophrenia. Resident #9 was documented as receiving hospice services and taking high-risk medications including, antipsychotic, antianxiety, and opioid. Record review of Resident #9's Care Plan, undated, and accessed 08/20/2026 at 7:26 p.m., revealed [Resident #9] is At risk for impaired cognitive function/dementia or impaired thought process r/t [related to] Dementia. [Resident #9] has ADL Self Care Performance Deficit. [Resident #9] has depression. [Resident #9] has demonstrated physical behaviors r/t [related to] yelling out, talking to self, biting self-causing skin issues, picks/eats clothing/blankets. Interventions included: Psychiatric/Psychogeriatric consult as indicated initiated 04/30/2026. [Resident #9] uses Anti-psychotic medication r/t [related to] dx [diagnosis] Schizophrenia initiated 04/30/2026 and revised 05/05/2026. [Resident #9] is on an anti-anxiety medication use r/t [related to] anxiety disorder initiated 05/03/2026 and revised 05/05/2026. Record review of Resident #9's Physician Progress Note dated 08/20/2026, revealed physician's assessment & plan: hospice care, anxiety disorder, psych follow-up as indicated. Record review of Resident #9's electronic medical record, undated and accessed 08/20/2026 at 7:35 p.m., revealed no physician orders to discontinue psychiatric services. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 09/12/2024 revealed Primary Treating: Major depressive disorder, 2. Generalized anxiety disorder, 3. Insomnia due to other mental disorder, 4. dementia in other disease. Reason for Referral: Depression, Withdrawal, Isolation Tearfulness, Anxiety Disorders, Anxiety, Worrying, Psychotic/Bipolar Disorders, Psychosis, Paranoia, Hallucinations, Delusions, Disorganized Speech, Paranoia. Assessment/Plan: 1. major depressive disorder, treated with Depakote 2. Generalized anxiety disorder, treated with quetiapine, Buspirone 3. Insomnia, Ativan BID 4. Dementia. Future visits Revisit in 4 weeks. Record review of Resident #9's physician orders revealed she had an active order for psychiatric services dated 02/07/2023. Record review of Resident #9's PASRR Level 1 Screening, dated 03/08/2022 and completed at the current nursing facility, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a Mental Illness recorded as a No. Observation and interview on 08/19/2026 at 11:50 a.m., Resident #9 was sitting in a Geri chair returning from lunch in the dining room. She was dressed well, groomed appropriately, with no odors. Resident #9's cognition was severely impaired, and she was unable to respond to interview questions. Observation on 08/20/2026 at 11:49 a.m., Resident #9 was sitting in Geri chair having lunch in the dining room. She was being provided with feeding assistance, and she was observed eating her ice cream. Nursing staff were observed communicating with Resident #9 during her meal, but she was non-responsive. 2. Record review of Resident #100's admission Record, dated 08/20/2026, revealed a [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #100 was listed as her own financial responsible party with her [family member] listed as Emergency Contact #1. Record review of Resident #100's Medical Diagnoses, undated and accessed on 08/20/2026 at 5:12 p.m., revealed diagnoses including dementia (characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) aphasia (language disorder that affects an individual's ability to communicate effectively), and major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Record review of Resident #100's Quarterly MDS dated [DATE] and signed 08/06/2026 as completed, reflected a BIMS of 00 indicating severe cognitive impairment. Resident #100's functional abilities were documented as requiring total care [dependent] assistance and uses a wheelchair. Resident #100 was documented with anxiety disorder and depression and was taking antianxiety, antidepressant, and opioid medications. Resident #100 was documented as receiving hospice care. Record review of Resident #100's Care Plan, undated and accessed on 08/20/2026 at 5:32 p.m., revealed [Resident #100] is on an Anti-anxiety medication use r/t [related to] anxiety disorder. TARGETED BEHAVIORS: RESTLESSNESS, ANXIETY, IRRITABILITY initiated 05/03/2026 and revised 05/04/2026, [Resident #100] has impaired cognition r/t [related to] dementia dated 05/03/2026, [Resident #100] has an ADL Self Care Performance Deficit dated 05/02/2026 and revised 05/03/2026 and [Resident #100] is Dependent on staff for activities, cognitive stimulation, social interaction r/t [related to] Cognitive deficits, Immobility dated 05/03/2026. Record review of Resident #100's electronic medical record, undated and accessed 08/20/2026 at 7:40 p.m., revealed no physician orders to discontinue psychiatric services. Record review of Resident #100's electronic medical record and Medical Diagnoses tab, undated and accessed 08/20/2026 at 5:40 p.m., did not reveal anxiety disorder coded. Record review of Resident #100's Mental Illness/Dementia Resident Review Form 1012 dated 08/19/2026, revealed section B. Dementia Review: Does this individual have a primary diagnosis of Dementia (or related disorder) recorded as a Yes and section C. Mental Illness (MI) Indication: Does the individual have a diagnosis of: Mood Disorder recorded as a Yes and Anxiety Disorder was not coded. Record review of Resident #100's Physician Progress Note dated 07/23/2026, revealed physician's assessment & plan: hospice care and continuation with psychiatric services. Record review of Resident #100's Physician Progress Note dated 07/20/2026, revealed Discussed with nursing staff - reports patient is at her baseline. Continuation with. psychiatric services. No medication changes or new orders were made at the last visit. Patient continued on current treatment plan with stable comfort-focused care. Encounter for palliative care: Patient continues under hospice services. management continues for psychiatric services. Maintained comfort-focused care with supportive measures. Patient is frail and confused but awake and alert during today's evaluation. Record review of Resident #100's Psychiatric Subsequent Assessment, dated 04/16/2025 revealed Reason for Referral: Depression, [NAME]/Loss Issues - patient seen today for multiple chronic conditions requiring prescription management. Assessment/Plan: 1. Major depressive disorder, treated with Escitalopram, 2. Generalized anxiety disorder is being treated with Escitalopram, 3. Dementia in other diseases classified. Future visits: Revisit in 4 weeks. Observation and interview on 08/18/2026 at 4:29 p.m., Resident #100 revealed she was sitting up in a high back wheelchair being transported from her room to the dining room. CNA F was observed parking Resident #100 in the hallway to assist another aid to transfer another resident from the bed to her chair. CNA F walked away from Resident #100 without communicating with her that she would be leaving her parked in the hallway for a few minutes to assist with another aid. Resident #100's cognition was severely impaired, and she was unable to respond to interview questions. CNA F returned to Resident #100 two minutes later and continued pushing her to the dining room. During an interview on 08/20/2026 at 6:44 p.m., the MDS Coordinator revealed that she was unsure as to why psych service notes were not loading for Resident #9 and Resident #100's electronic medical record. She stated that she had reached out to psych services today for documentation as there should be additional visits documented for Resident #9 and Resident #100. She stated that they recently had an acquisition and with the recent change the electronic medical records are not available to them. She stated that Resident #9 and Resident #100 had psych visits in 2025 and there was a discontinuation of services, but this documentation could not be located. She stated that she would continue working with the Director of Nursing to obtain a copy of these psych visits. She stated that PASRR Level 1 Screens were not accurately coded upon admission and that she and the management team were auditing all PASRR Level 1 Screenings for accuracy and taking the necessary steps required if not accurate. During an interview on 08/21/2026 at 2:48 p.m., the Director of Nursing revealed that she had reached out to psych services earlier today and was assured that staff had received orders to end psych services for Resident #9 and Resident #100, but she had not received this documentation yet and it was not located in the resident's electronic medical records. She stated that physician progress notes in both Resident #9 and Resident #100's electronic medical record inaccurately documented continued psych services. She stated she was unsure as to why the physician would document psych services on Resident #9 and Resident #100's last visits and only explanation was that the record was inaccurate. During an interview on 08/21/2026 at 3:13 p.m., the Administrator revealed that behavior health services that are ordered by the physician should be provided and documented in the residents' electronic medical records. He stated if assessments and resident electronic medical records are not being updated accurately it could impact the residents and they would not be getting adequate care. Record review of policy titled, Resident Assessments revised 04/2025, revealed It is the policy of this facility that resident will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible. 6. MDS data is signed/stored electronically in the clinical health record and is readily and easily accessible to all professionals who need to review the information in order to provide care to the resident. 7. Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained. 3. During an observation on 08/18/2026 at 10:18 a.m. revealed a three ring binder labeled CNA Binder, located on a small table outside resident room [ROOM NUMBER]. Further observation revealed the binder contained skin assessments with the names of residents listed as well as their respective skin conditions. Further observation revealed the binder contained pages with each resident's name and room number and noted those residents who required mechanical lifts, had foley catheters, and how much assistance each required to perform activities of daily living. During an interview with CNA Q on 08/18/2026 at 10:21 a.m., CNA Q stated she had been assigned to care for the residents of 300 hall, confirmed the binder contained resident names, room numbers, and sensitive personal health information, and stated the binder was utilized as a cheat sheet for staff to learn resident information. During an interview with the DON on 08/21/2026 at 2:15 p.m., the DON stated the binder with residents' personal information should have been stored in a secure location. Record review of the facility policy, HIPPA Compliance Policy and Procedure, reviewed 07/2021, revealed, Policy Covered Entity will;. Adhere to federal HIPAA rules except in cases where state law is more stringent.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #51 and Resident #11) of four residents and three (MA O, CNA C and CNA D) of seven staff observed for infection control practices in that: MA O failed to perform hand hygiene before he donned gloves and provided catheter and perineal care to Resident #51. CNA C failed to perform hand hygiene and change gloves prior to performing incontinence care for Resident #11. CNA D failed to remove her gloves, perform hand hygiene and don clean gloves after cleaning the buttocks areas and handling the soiled brief and soiled incontinence pad for Resident #11. CNA D failed to remove her gloves, perform hand hygiene and don clean gloves before she handled a clean washcloth that was used to dry the buttocks skin and before she applied barrier cream to the cleansed buttocks area of Resident #11. These failures could place residents at risk for cross contamination and the spread of infection.The findings include: Record review of Resident #51's face sheet, dated 08/20/2026, revealed a [AGE] year-old male with an original admission date of 10/16/2011. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration (sudden disruption of brain function due to a head injury), neuromuscular dysfunction of bladder (nerve damage affecting the bladder muscles resulting in difficulty with urination), obstructive and reflux nephropathy (blockage or backwards flow of urine that can cause kidney damage) and colostomy status (having undergone a surgical procedure that creates an opening in the abdomen through which bowel movements can be eliminated). Record review of Resident #51's quarterly MDS dated [DATE] section B revealed resident has no speech and rarely/never understands others, therefore the BIMS interview was not conducted (cognitive status was not assessed). Section GG of the MDS revealed that Resident #51 is dependent on staff for all ADL's, except for eating (for which he requires partial/moderate assistance). Section H revealed that the resident had an indwelling catheter and ostomy in place. Observation of catheter and perineal care on 08/20/2026 at 9:27am for Resident #51 performed by MA O and CNA B revealed that MA O (just after washing his hands and prior to donning gloves in preparation for providing care to Resident #51) was observed to pick up a stack of Resident #51's roommates belongings and handed it to him. MA O then touched the privacy curtain before gloving. MA O did not reperform hand hygiene prior to gloving and providing catheter and perineal care to Resident #51. During an interview with MA O on 08/20/2026 at 9:40am, he stated that there was a potential for cross contamination due to him not performing hand hygiene before providing care to the resident. He states that he was taught to sanitize or wash his hands and reglove after handling potentially contaminated items. Record review of Resident #11's face sheet, dated 08/20/2026, revealed a [AGE] year-old female with an admission date of 03/04/2020. Diagnoses included hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (brain tissue death due to a lack of blood supply) affecting left non-dominant side, type 2 diabetes mellitus (condition in which the body cannot process sugar correctly so it builds up in the blood) and unspecified dementia (brain disorder affecting memory and thinking skills). Record review of Resident #11's quarterly MDS dated [DATE] section B revealed resident has no speech and rarely/never understands others, therefore the BIMS interview was not conducted (cognitive status was not assessed). Section GG of the MDS revealed that Resident #51 is dependent on staff for all ADL's, including toileting hygiene. Section H revealed that the resident had frequent urinary incontinence and always had bowel incontinence. During observation of incontinent care for Resident #11 on 08/20/2026 at 9:52am, CNA C was observing touching the privacy curtain twice in succession with gloved hands just prior to starting care. She did not sanitize or wash her hands again. CNA D picked up a clean washcloth and patted Resident #11's buttocks area dry after cleaning the buttocks area with wipes and removing the soiled brief. CNA D then pushed the dirty incontinence pad under the resident and applied barrier cream to the previously cleansed buttocks area while wearing the same gloves. CNA D did not remove her gloves, wash or sanitize her hands or apply clean gloves prior to handling the clean washcloths or applying the barrier cream to the skin. CNA D then turned resident to her left side and pulled out the soiled brief and incontinence pad. She then took a wipe and wiped the left side of Resident #11's labia (outer folds of skin that surround and protect the female genitalia) and closed the new brief. During an interview with CNA C on 08/20/2026 at 10:02am, she stated that she should have washed her hands first after touching the privacy curtain because the curtain is contaminated. She stated that she was trained to wash her hands after touching items that are dirty and before providing care to the residents to prevent infection. During an interview with CNA D on 08/20/2026 at 10:04am, she revealed that there was a risk for infection because she did not change her gloves. She stated that she should have taken her gloves off and washed her hands before touching the clean towel and the cream, which is what she was trained to do. During an interview with the DON on 08/20/2026 at 10:15am, she stated that the CNA should have washed her hands prior to applying cream or handling the clean brief.During a follow-up interview on 08/21/2026 at 2:45pm, the DON said staff are trained to perform hand hygiene or wash hands prior to giving care, after care and in between handling the dirty and the clean to prevent infections. She stated that she would be doing a check-off on the perineal skills with the staff to reinforce this. Review of policy entitled Hand Hygiene original date: 05/2007 with last revision/review date of 04/2025 revealed the following: Procedure: 2. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial and water for the following situations: .b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care;.k. After handling used dressings, contaminated equipment, etc.: and l. After contact with objects (e.g., medial equipment) in the immediate vicinity of the resident;

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility reviewed for safe and functioning equipment in the kitchen.The facility had 1 walk-in freezer not in good functioning order, the freezer had ice buildup and not defrosting properly.This failure could place residents at risk of neglect by not storing food at proper temperatures. The findings included:During an observation and interview on 08/18/2026 at 10:00 a.m., revealed the walk-in freezer temperature of -7 F was maintained at a level to keep frozen food solid. The walk-in freezer fan, shelves, food boxes, and floor had ice buildup. The Dietary Supervisor stated that the walk-in freezer had been having this issue since he returned to employment at the facility back in November 2025. He stated that the freezer was not defrosting properly and the ice would accumulate over time. He stated that he had reported the issue to the Administrator numerous times during the morning staff meetings, and he had submitted several work orders over the last several months. He stated that there have been several repair companies that have completed diagnosis on the walk-in freezer, but due to cost nothing had been done to repair it. He stated that the patches of ice on the floor could cause staff to slip, the food gets freezer burned and he had to throw it out and order new food. He stated not having a functioning freezer was a challenge and can cause food to not be kept at safe temperatures.During an interview on 08/18/2026 at 10:35 a.m., the Administrator revealed that the walk-in freezer had been a problem for roughly a month. He stated that the facility had reached out to several companies that have come to the facility to provide diagnostics and stated that they are unsure what the issue was. He stated that he had been discussing with regional the need to replace the entire walk-in freezer. He stated that not having the walk-in freezer operating accurately could impact the food being stored. Administrator failed to provide documentation to support companies providing diagnostics of freezer prior to exit. During an interview on 08/20/2026 at 10:30 a.m., the Dietary Supervisor revealed that management was now moving forward with repairing the freezer. He stated that the impact of equipment not functioning properly would be a loss of food and constant reordering of food.During an interview on 08/20/2026 at 10:50 a.m., Maintenance N stated that he was hired at the facility three weeks back. He stated that he does not recall the date, but a company had been called out to look at the walk-in freezer. He stated that no work was done at that time. He stated that yesterday he looked over the walk-in freezer and made a repair to the timer and this may have been the issue. He stated another company was called out and was scheduled to stop by today and look at the walk-in freezer and determine what repairs could be done to get the walk-in freezer operating appropriately. Maintenance N stated that he recalled reviewing the work orders submitted by dietary staff that the walk-in freezer was not operating properly when he first arrived at the facility. He stated that with a lot of work currently being done at the facility since his arrival he was playing catch up and he not been able to work on the walk-in freezer. He stated the walk-in freezer repair was on his radar. He stated that with the walk-in freezer not working properly it could potentially cause freezer burns to foods the residents consume.Record review of facility document titled, Work Order #4762 dated 08/18/2026, revealed Dietary Supervisor submitted work order on [DATE] documenting Freezer not working properly. [priority] Medium. Assigned to nobody.Record review of facility document titled, Work Orders dated 08/19/2026, revealed Dietary Supervisor submitted work order #4613 on 05/07/2026 and #4672 on 05/28/2026 documenting freezer not working correctly . [priority] Medium.Record review of policy titled, Dietary Department undated, revealed It is the policy of this facility to comply with all state, federal and local infection control standards and regulations concerning: Personnel requirements. Preparation and service. Equipment care.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 8 (Resident #4 and Resident #100) residents in 1 of 1 dining room reviewed for resident rights.The facility failed to promote Resident #4's dignity during lunch when staff stood beside her while assisting her to eat. The facility failed to treat Resident #100 with respect and dignity when staff left her in the hallway without communicating they were leaving her to provide help to another staff. These failures could place residents at risk of diminished dignity and affect their quality of life.The findings included:1. Record review of Resident #4's admission Record, dated 08/20/2026, revealed a [AGE] year-old female admitted [DATE] and re-admitted [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (occurs when there is a sudden impairment in gas exchange between the lungs and the blood, causing hypoxia (low oxygen)). Resident #4 was listed as her own financial responsible party with her [family member] listed as Emergency Contact #1.Record review of Resident #4's Medical Diagnoses, undated and accessed 08/20/2026 at 3:58 p.m., revealed diagnoses including acute memory deficit following cerebral infarction (refers to a temporary or early-onset memory problem that develops after a cerebral infarction (also called an ischemic stroke), where blood flow to part of the brain is blocked, causing brain tissue damage), visuospatial deficit (refers to difficulties in perceiving, interpreting, and responding to visual information about space), dysphagia (difficult swallowing), dementia in other diseases [documented as not an acceptable primary diagnosis] (refers to a type of dementia that is not caused by Alzheimer's disease itself, but instead by another underlying medical condition), hemiplegia (complete loss of strength or paralysis on one side of the body) and hemiparesis (minor weakness to a severe weakness or paralysis on one side of the body). Record review of Resident #4's Quarterly MDS, dated [DATE] and signed 07/18/2026 as completed revealed Resident #4's functional abilities were documented as requiring dependent to moderate assistance and requiring the use of a manual wheelchair. Resident #4 was documented as having active diagnoses of malnutrition (happens when the body does not get enough food or the right amount or balance of nutrients it needs to function properly) and non-Alzheimer's dementia (general term for any form of dementia that is not caused by Alzheimer's disease.)Record review of Resident #4's Quarterly MDS, dated [DATE] and signed 06/24/2026 as completed, revealed a BIMS score of 06, indicating severe cognitive impairment.Record review of Resident #4's Care Plan, undated, accessed 08/20/2026 at 3:55 p.m., revealed Resident #4 has Hemiplegia/Hemiparesis [related to] Stroke initiated on 7/27/2026. Resident #4 has impaired cognition [related to] CVA [Cerebrovascular Accident] initiated 05/01/2026 and revised 05/01/2026. Focus [Resident #4] has an ADL Self Care Performance Deficit and interventions included EATING: Limited assist of one initiated 05/01/2026. Resident #4 Has unplanned/unexpected weight loss r/t [related to] Acute illness initiated 05/01/2026.Observation of Resident #4 on 08/18/2026 at 2:47 p.m., revealed her sitting up in her wheelchair, dressed well, groomed appropriately, with no odors. Resident #4 was preparing to head to physical therapy with therapist.2. Record review of Resident #100's admission Record, dated 08/20/2026, revealed a [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #100 was listed as her own financial responsible party with her [family member] listed as Emergency Contact #1.Record review of Resident #100's Medical Diagnoses, undated and accessed 08/20/2026 at 5:12 p.m., revealed diagnoses including dementia (characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) aphasia (language disorder that affects an individual's ability to communicate effectively), and major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) and did not reveal anxiety disorder.Record review of Resident #100's quarterly MDS dated [DATE] and signed 08/06/2026 as completed, reflected a BIMS score of 00 indicating severe cognitive impairment. Resident #100's functional abilities were documented as requiring total care [dependent] assistance and uses a wheelchair. Resident #100 was documented with anxiety disorder and depression and was taking antianxiety, antidepressant, and opioid medications. Resident #100 was documented as receiving hospice care.Record review of Resident 100's care plan undated and access 08/20/2026 at 5:32 p.m., revealed [Resident #100] is on an Anti-anxiety medication use r/t [related to] anxiety disorder. TARGETED BEHAVIORS: RESTLESSNESS, ANXIETY, IRRITABILITY initiated 05/03/2026 and revised 05/04/2026, [Resident #100] has impaired cognition r/t [related to] dementia dated 05/03/2026, [Resident #100] has an ADL Self Care Performance Deficit dated 05/02/2026 and revised 05/03/2026 and [Resident #100] is Dependent on staff for activities, cognitive stimulation, social interaction r/t [related to] Cognitive deficits, Immobility dated 05/03/2026.Observation and interview on 08/18/2026 at 4:29 p.m., with Resident #100 revealed she was sitting up in a high back wheelchair being transported from her room to the dining room. CNA F was observed parking Resident #100 in the hallway to assist another aide to transfer another resident from the bed to her chair. CNA F walked away from Resident #100 without communicating with her that she would be leaving her parked in the hallway for a few minutes to assist with another aide. Resident #100's cognition was severely impaired, and she was unable to respond to interview questions. CNA F returned to Resident #100 two minutes later and continued pushing her to the dining room.Observation and interview on 08/19/2026 at 12:43 p.m., with Resident #4 revealed nursing staff transferred her back to her room following lunch. She stated that she was returning from lunch, lunch was pleasant, she usually enjoyed it. She stated that she was doing well, she was taken care of, the nursing staff treated her well, and she had no concerns with the care. Observation of Resident #4 on 08/20/2026 at 12:28 p.m., revealed her sitting up in her wheelchair in the dining room having lunch. Admissions RN was observed providing feeding assistance to Resident #4. Admissions RN was observed standing directly to the right side of Resident #4 and feeding her. Resident #4 was observed eating 50% of her meal before Admissions RN cleaned her face and transferred her back to her room.During an observation and interview on 08/20/2026 at 12:32 p.m. Admissions RN was observed returning Resident #4 to her room after she completed her lunch. Admissions RN was knowledgeable of resident rights and provided examples. She stated that all facility staff help pitch in assisting residents with eating. She stated that the procedures when providing feeding assistance to a resident were to sit down and communicate with the resident. She stated that this is done to not intimidate residents and to make them feel comfortable. Admissions RN stated that she realized after the fact that she should have been sitting down when providing Resident #4 with feeding assistance.During an interview on 08/20/2026 at 6:40 p.m., the Director of Nursing revealed that the Admissions RN reported to her that she was observed standing and feeding a resident. She stated that the staff member was new to the facility. She stated that she immediately in-serviced her on resident rights and facility procedures for assisting residents with eating.During an interview on 08/20/2026 at 6:44 p.m., the MDS Coordinator revealed that she was provided with in-service on resident rights, she was knowledgeable and she provided examples. She stated that the policy for assisting residents with eating was that staff should be sitting down to feed them. She stated that standing over residents could be intimidating, and make residents feel rushed. She stated that the policy for resident rights was to communicate with residents the care you would be providing them with. She stated that if residents were left in the hallway without staff communicating with them, they could be made to feel abandoned.During an interview on 08/21/2026 at 2:29 p.m., LVN G revealed that she was provided resident rights training during new hire orientation two months back. LVN G was knowledgeable and provided examples of resident rights. She stated that the policy for assisting residents with feeding was that all staff should sit down with the residents. She stated that standing over residents when providing them with feeding assistance could make them feel intimidated and uncomfortable. She stated that the policy for communicating with residents prior to walking away was that all staff should communicate the care being provided to the residents. She stated that if staff did not communicate with residents this may leave them confused.During an interview on 08/21/2026 at 2:48 p.m., the Director of Nursing revealed that she provided the nursing staff with resident rights in-services roughly two weeks back. She stated that if staff do not respect resident rights, residents may feel depressed and anxious.During an interview on 08/21/2026 at 3:13 p.m., the Administrator revealed that resident rights training was ongoing at the facility. He stated that the important aspect of resident rights was that residents have a safe and homelike environment and wants and needs are being met. He stated that if staff did not follow resident rights policies, it may affect the residents' overall wellbeing and make them feel unfulfilled.Record review of policy titled, ADL, Services to carry out revised 1/2024, revealed, It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.Record review of policy titled, Dignity and Respect revised 07/2025, revealed, It is the policy of this facility that all residents be treated with kindness, dignity and respect. 1. The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 2 of 23 (Resident #22 and Resident #84 ) reviewed for advance directives, in that:1. Resident #22's OOH-DNR was executed by two physicians when the resident was not without guardian, agent, or proxy.2. Resident #84's OOH-DNR was not signed by a physician, and not signed twice by the executor or witnesses.This deficient practice could result in residents' wishes regarding advance directive remaining unknown or not honored. The findings were: Record review of Resident #22's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified diastolic (congestive) heart failure, type 2 diabetes mellitus with hyperglycemia, and vitamin D deficiency. Record review of Resident #22's quarterly MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderate cognitive impairment. Record review of Resident #22's care plan, initiated [DATE], revealed, DNR. Record review of Resident #22's OOH-DNR, dated [DATE], revealed it was executed by two physicians who signed in Section F. F. Directive by two physicians on behalf of the adult, who is incompetent or unable to communicate and without guardian, agent, proxy or relative: The person's specific wishes are unknown, but resuscitation measures are, in reasonable medical judgment, considered ineffective or are otherwise not in the best interests of the person. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Further review of Resident #22's facesheet, dated [DATE], revealed three relatives listed including the resident's wife, his adult daughter who was listed as medical power of attorney, and his adult son. During an interview with the Social Worker on [DATE] at 4:10 p.m., the Social Worker stated she was responsible for advance directives but had only been in the role for one month. The Social Worker confirmed Resident #22 had three qualified relatives who should have executed his OOH-DNR. The Social Worker stated she was unaware Resident #22's OOH-DNR had not been executed by one of his three qualified relatives and stated it was an oversight. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 05/2026, revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form F. This box is used when the order is being completed by two physicians on behalf of an adult patient who is incompetent or unable to communicate and without a guardian, proxy or relative. Further review revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is.filled out incorrectly.2. Record review of Resident #84's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, presence of cardiac pacemaker, and type 2 diabetes mellitus. Record review of Resident #84's admission MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #84's care plan, initiated [DATE], revealed, DNR. Record review of Resident #84's OOH-DNR, dated [DATE], revealed the resident's spouse signed in Section A which is reserved for the declaration of a competent adult who is executing their own advance directive rather than in Section B Declaration by legal guardian, agent or proxy or Section C Declaration by a qualified relative. Further review revealed Resident #84's OOH-DNR, dated [DATE], revealed it was not signed by a physician in any section. Further review revealed Resident #84's OOH-DNR, dated [DATE], revealed it was signed by two witnesses and a notary in the Witnesses section, but the executor, witnesses, and notary all failed to sign in the bottom section, All persons who have signed above must sign below, acknowledging that this document has been properly completed. During an interview with the Social Worker on [DATE] at 4:10 p.m., the Social Worker stated she was responsible for advance directives but had only been in the role for one month. The Social Worker confirmed Resident #84's OOH-DNR had been executed incorrectly in that the resident's spouse signed in the incorrect section, the physician had not signed at all, and the executor and witnesses failed to sign the bottom section and stated this was an oversight. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 05/2026, revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form: Declaration: A. This box is for patients who are competent. The patient should sign his/her name, date the document, and prints or types his/her name. B. This box is used when the order is being completed by a legal guardian, the person with medical power of attorney for the patient or a proxy in a directive to physician for a person who is incompetent or otherwise mentally or physically incapable of communication. The person acting on behalf of the patient must check the appropriate box in this section, sign and date the form and then print or type his/her name. C. This box is used when a qualified relative is acting on behalf of an adult person who is incompetent or incapable of communication. A qualified relative can be: (1) The patient's spouse; (2) the patient's reasonably available adult children; (3) the patient's parents; or (4) the patient's nearest living relative. The relative acting on behalf of the patient must check the appropriate box in this section, sign and date the form and then print or type his/her name. Witnesses: Two witnesses or a notary public must sign that they have witnessed the patient's signature or the signature of a person(s) acting on the patient's behalf in sections A-E. Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. Signatures: The statute requires that everyone who signed the form MUST sign the form again in the bottom section to acknowledge that the form has been completed.Further review revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility policy, Advance Directives and Associated Documentation, reviewed 04/2025, revealed, The facility recognizes and respects the resident's right to choose their treatment and make decisions about care to be received at the end of their life.

Based on observation, interview and record review the facility failed to ensure that residents with loss of bladder control receive treatment or services to prevent urinary tract infections and to restore continence to the extent possible for two of three residents reviewed for incontinent care. (Resident #11 and Resident #60) in that: CNA D failed to completely wipe Resident #11's labia (outer folds of skin that surround and protect the female genitalia) while providing perineal care. CNA E failed to wipe the inner thigh areas and did not completely wipe the labia (outer folds of skin that surround and protect the female genitalia) of Resident #60 while providing perineal care. These failures could place residents at risk for urinary tract infections due to the provision of improper incontinent care. The findings include: Record review of Resident #11's face sheet, dated 08/20/2026, revealed a [AGE] year-old female with an admission date of 03/04/2020. Diagnoses included hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (brain tissue death due to a lack of blood supply) affecting left non-dominant side, type 2 diabetes mellitus (condition in which the body cannot process sugar correctly so it builds up in the blood) and unspecified dementia (brain disorder affecting memory and thinking skills). Record review of Resident #11's quarterly MDS dated [DATE] section B revealed resident has no speech and rarely/never understands others, therefore the BIMS interview was not conducted (cognitive status was not assessed). Section GG of the MDS revealed that Resident #11 was dependent on staff for all ADL's, including toileting hygiene. Section H revealed that the resident had frequent urinary incontinence and always had bowel incontinence. During an observation of perineal care for Resident #11 on 08/02/2026 at 9:52am, CNA D was observed to wipe the left side of the resident's labia (outer folds of skin that surround and protect the female genitalia), then closed up the newly applied brief. During an interview with CNA D on 08/20/2026 at 10:04am, she stated that Resident #11 could get an infection by not wiping all areas of the labia (outer folds of skin that surround and protect the female genitalia). She stated that she was trained to wipe all the areas of the labia when providing perineal care to a resident. Record review of Resident #60's face sheet, dated 08/20/2026, revealed an [AGE] year-old female with an admission date of 08/03/2026. Diagnoses included acute and chronic respiratory failure with hypoxia (conditions in which the lungs cannot get enough oxygen in to the body or get rid of carbon dioxide which can cause organ failure), chronic obstructive pulmonary disease (long term lung condition that makes breathing difficult) and dysphagia (difficulty swallowing). Record review of Resident #60's admission MDS dated [DATE] section C revealed that the resident had a BIMS score of 12 out of 15, meaning her cognitive status is moderately impaired (mild to moderate forgetfulness). Section GG of the MDS revealed that Resident #51 requires substantial/maximal assistance from staff for toileting hygiene. Section H revealed that the resident had occasional urinary incontinence and always had bowel incontinence. During an observation of perineal care for Resident #60 on 08/20/2026 at 11:25am, CNA E was observed to not wipe the inner thigh areas of the resident while providing incontinent care. In addition, she was observed to only wipe the labia (outer folds of skin that surround and protect the female genitalia) one time, directly along the midline (imaginary line that runs straight down the middle) area. During an interview with CNA E on 08/20/2026 at 11:35am, she stated that she was not aware that she had not wiped Resident #60's inner thigh areas but was aware that she had wiped her labial (outer folds of skin that surround and protect the female genitalia) area once along the midline. She stated that she was trained to wipe once along the midline unless the other areas are visibly dirty. During an interview with the DON on 8/20/2026 at 10:15am, she stated that the CNA's got nervous during the observations which led to the errors with perineal care. During a follow-up interview on 08/21/2026 at 2:45pm, she did not reveal the procedure that staff is to follow when providing perineal care to the residents but stated that she would be doing a check-off on the perineal skills with the staff. Review of facility provided Peri Care - Female skill #10 checklist, step #15 states that (staff is to) Wash genital area, moving from front to back, using a clean part of the washcloth for each stroke or a clean wipe for each stroke. Review of facility provided Policy/Procedure - Nursing Clinical Section: Routine Procedures, Subject: Perineal Care (revised 1/2026) revealed the following procedure for a female without a catheter: 4. Wash pubic area, including upper, inner aspect of both thighs and frontal portion of perineum (area of skin and underlying muscle located between the genitals and anus). A. Use long strokes from the most anterior down to the base of the labia (outer folds of skin that surround and protect the female genitalia). (Wash from the cleanest area to the dirtiest area.)

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #2) reviewed for medication administration. The facility failed to ensure Resident #2 was administered medications used to treat hypertension (high blood pressure) and elevated heart rate as ordered by the physician. This failure could lead to residents not receiving the intended therapeutic effects of medications. Findings included: Record review of Resident #2's Face Sheet dated 8/21/2026 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included essential (primary) hypertension [high blood pressure without a single cause] and sick sinus syndrome [a heart rhythm disorder which can cause abnormal rhythm or rate of the heartbeat]. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 12, which indicated moderately impaired cognition. Record review of Resident #2's Order Summary Report dated 8/21/2026 reflected the following physician's orders:Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet by mouth one time a day for htn Hold FOR sbp less than110 OR PULSE less than 60 Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 12.5 mg by mouth two times a day for HTN Hold FOR sbp less than 110 OR PULSE less than 60 Record review of Resident #2's August 2026 MAR dated 8/21/2026 reflected Resident #2's doses of Lisinopril and Metoprolol were not administered on the following dates by MA O due to Resident #2's vital signs: 8/1/2026, blood pressure 135/588/2/2026, blood pressure 134/448/7/2026, blood pressure 111/508/12/2026, blood pressure 128/448/14/2026, blood pressure 114/59In an interview on 8/21/2026 at 8:11 AM, MA O said the ordered parameters for Resident #2's blood pressure medications (Lisinopril and Metoprolol) were to hold the medications if the blood pressure was less than 110/60 or the heart rate was less than 60. He said if the medication was not administered due to being below the parameters, he would document the vital signs and notify the nurse. He said Resident #2's blood pressure medications were occasionally held due to low blood pressures. After reviewing Resident #2's orders together, MA O said he was not aware Resident #2's medication parameters did not include a specification for the diastolic blood pressure (the bottom number of a blood pressure reading), and the nurse had not informed him of this on any occasion which he had informed him/her that the medications were held, but he had been instructed before by an unknown staff member to hold any blood pressure medication if the diastolic blood pressure was low. He said it was important to give medications per the ordered parameters to ensure residents were receiving the correct medications and the correct dosages. In an interview on 8/21/2026 at 1:35 PM, ADON/RN P said she had been informed by MA O that Resident #2's blood pressure medications did not include parameters regarding the diastolic blood pressure. She said she reached out to Resident #2's physician to request the addition of the parameters, and he said that was fine. RN P was asked if Resident #2's physician intended for the orders to include the diastolic blood pressure parameter from original initiation, and RN P responded he said it was fine, the order didn't change including the dosage and the amount, what is your question? RN P was again asked if the orders should have always included a diastolic blood pressure parameter, and RN P again said he said it was fine, and the order has it now. Record review of the facility policy titled Medication Administration/ Administration of Medication dated June 2022 reflected the following: 2. Medications must be administered in accordance with the written orders of the attendingphysician including following parameter orders - pulse, blood pressure, blood sugar, etc.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 beauty salon reviewed, in that: The facility beauty salon was unlocked and contained potentially harmful materials. This deficient practice could result in residents living within, staff working within, and the public visiting an environment which was potentially unsafe. The findings were: Observation on 08/21/2026 at 1:36 p.m. revealed the facility beauty salon was unlocked and unoccupied. Further observation revealed the cabinets in the salon were unlocked and contained potentially harmful materials including scissors and container of hairspray labeled flammable, hair dye labeled can cause allergic reaction and may cause skin irritation, sanitizing wipes labeled flammable and avoid contact with eyes, and hair setting solution labeled keep out of reach of children. During an interview with the Medical Records Director on 08/21/2026 at 1:36 p.m., the Medical Records Director confirmed the facility beauty salon was unlocked, unoccupied, and contained potentially harmful materials. During an interview with the DON on 08/21/2026 at 2:15 p.m., the DON stated her expectation was that the facility beauty salon remain secured when not in use to protect residents from accessing potentially harmful materials. Record review of the facility policy, Resident Rights, revised 11/2017, revealed, The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 15 (Resident #1) residents in 1 of 1 dining room reviewed for residents rights.The facility failed to promote Resident #1's dignity during lunch when staff did not serve Resident #1 her meal tray with other residents at her table.This failure could affect all residents who eat in the dining room, by contributing to emotional distress and unmet needs. Findings included: Record review of Resident#1's face sheet dated 06/19/2026 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included heart failure, muscle weakness, cognitive communication deficit (problems with communication), macular degeneration (blurred eyes), dementia (memory, thinking, difficulty), and paroxysmal atrial fibrillation (irregular heartbeat that comes and goes). Record review of Resident #1's quarterly MDS dated [DATE] reflected Resident #1 had a BIMS score of 13, which indicated intact cognitive response. The MDS also reflected Resident #1 was independent with eating (resident completes the activity by themself with no assistance from a helper). Record review of Resident #1's care plan dated 06/16/2026 reflected: Focus: [Resident #1] is at risk for nutritional changes. Goal: Will tolerate ordered diet through the review date. Will maintain adequate nutritional status as evidenced by maintaining weight with no signs or symptoms of malnutrition through review date. Interventions: If eats less than 50%, offer meal replacement. Meals in dining room if resident is in agreement. Observation of the lunch meal tray pass on 06/19/2026 at 12:11p.m., revealed Resident #1's tablemates got their lunch trays at 12:11p.m. Resident #1 was the only resident at the table without a meal tray. Observation of the lunch meal tray pass on 06/19/2026 at 12:31p.m., revealed Resident #1 was yelling, I have not gotten my tray! Staff did not acknowledge Resident #1. Resident #1 kept trying to get staff attention without success. During an interview with Resident #1 on 06/19/2026 at 12:36p.m., she said the staff did not give her meal tray to her with her tablemates daily. She said she wanted to eat with her tablemates. She said it upset her that she had to wait so long to get her meal tray. Observation of the lunch meal tray pass on 06/19/2026 at 12:39p.m., revealed Resident #1 got her meal tray. Some of her tablemates were done eating. During an interview with LVN A on 06/19/2026 at 3:53p.m., she said she had been trained on resident rights. She said the policy for meal tray pass was to make sure residents who were sitting at the same table got their meal tray at the same time. She said the CNAs were responsible for putting the meal tickets in order in which they thought the residents would sit. She said the kitchen staff would make the meal trays according to the order of the meal tickets given to them by the CNA. She said residents who were cognitive might not like having to wait for their meal tray after everyone at their table got their tray. She said the nurse monitored to ensure that all residents at the same table got their meal tray at the same time. She said the nurse monitored through observation. She said Resident #1 may not have gotten her meal tray with her tablemates because the CNA may have thought she was eating in her room. During an interview with CNA B on 06/19/2026 at 4:10p.m., she said she had been trained on resident rights. She said the policy for meal tray pass was to make sure residents who were sitting at the same table got their meal tray at the same time. She said the nurse was responsible for putting the meal tickets in order in which the residents sat in the dining room. She said the kitchen staff would make the meal trays according to the order of the meal tickets given to them by the nurse. She said if a resident did not get their meal tray with their tablemates the resident may feel left out. She said the nurse monitored to ensure that all residents at the same table got their meal tray at the same time. She said the nurse monitored through observation. She added that the CNA should alert the nurse if a resident did not get their meal tray. She said she did not know why Resident #1 did not get her meal tray with her tablemates. During an interview with the DON on 06/19/2026 at 4:32p.m., she said she had been trained on resident rights. She said the policy for meal tray pass was to give each resident their meal tray at the same table before moving to the next table. She said the CNA was responsible for putting the meal tickets in order per table. She said if a resident did not get their meal tray with their tablemates the resident may get upset while it may not bother other residents. She said the nurse monitored to ensure that all residents at the same table got their meal tray at the same time. She said the nurse monitored through observation. She said she did not know why Resident #1 did not get her meal tray with her tablemates. During an interview with the ADM on 06/19/2026 at 4:51p.m., he said he had been trained on resident rights. He said the policy for meal tray pass was staff were to pass meal trays per table. He said the nurse was responsible for putting the meal tickets in order per table. He said if a resident did not get their meal tray with their tablemates the resident may feel left out so it was important all residents got their meal tray with their tablemate. He said the nursing department monitored to ensure that all residents at the same table got their meal tray at the same time. He said the nursing department monitored through observation. He added the nursing department should be aware of the policy. He said she did not know why Resident #1 did not get her meal tray with her tablemates. Record review of Serving the Meal Policy dated 05/2024 did not reflect anything about serving the meal trays together. Record review of Resident Rights Dignity and Respect Policy dated 07/2025 reflected It is the policy of this facility that all residents be treated with kindness, dignity, and respect. The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 or 4 residents (Resident #1, Resident #3) reviewed for reporting missing funds. The facility failed to ensure Resident #1's, on 03/13/2026, and Resident #3's, on 12/12/2025, allegation of misappropriation of funds was reported to the SSA .This failure could place all residents at risk for misappropriation and neglect by not immediately reporting allegations of misappropriation to the proper authorities at the facility, other officials, and State Survey Agency.Findings include:Record review of Resident #1's admission Record, dated 05/05/2026, revealed a [AGE] year-old female admitting to the facility on [DATE] with diagnoses including Major Depressive Disorder (serious, common mental health condition characterized by persistent, severe low mood, loss of interest, and low energy, lasting at least two weeks); General Anxiety Disorder (persistent, excessive, and uncontrollable worry about everyday things - such as health, finances, or family - that lasts for at least six months); Type 2 Diabetes(chronic condition where high blood sugar levels result from body's inability to use insulin properly or produce enough of it); and Muscle Weakness (reduced ability to exert force with muscles, often feeling like effort is needed to move arms, legs, or other body parts). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating an intact cognitive response.Record review of Resident #1's Care Plan, revised 04/25/2026, revealed a risk of falls, ADL self-care deficits, psychosocial wellbeing concerns, and impaired mobility.Record review of Resident #1's Progress Notes, dated 05/05/2026, revealed no mention of complaint or grievance related to money missing from resident room.Record review of Resident #1's grievance form, dated 03/13/2026, revealed that the grievance was received on 03/13/2026 and generated by Resident #1. Per grievance form Resident #1 described the concern as she had $52 come missing from her room. Follow-up section of Resident #1's grievance form revealed action taken by ADMIN on 03/14/2026 was that $52 was provided to Resident #1. Response section of grievance form revealed that Resident #1 would be placing her money in a Trust Fund to prevent loss. Record review of Resident#1's financial statements, dated 03/14/2026, revealed that $52 was received in resolution of grievance concerning lost funds.During an interview on 05/06/2026 at 10:56 am with ADMIN surveyor was told by ADMIN that he was unsure if there was a report done regarding Resident #1's missing funds to the SSA. ADMIN would need to check his records.During an interview on 05/06/2026 at 11:29 am, ADMIN stated that there was no self-report submitted to the SSA regarding Resident #1's grievance. During an interview on 05/05/2026 at 2:41 pm, MDS LVN stated that Resident #1 shared with her that $52 was missing from room. Resident #1 inquired about the plan to replace the money. MDS LVN informed Resident #1 that she had completed a grievance form and stated that the ADMIN is going to replace.During an interview and record review on 05/07/2026 at 9:17 am, BOM provided documentation relating to Resident #1's reimbursement of $52 and stated that the reimbursement was pulled from petty cash and that this was approved by ADMIN. BOM stated that $50 was moved into the Trust Fund that Resident #1 opened with them and $2 was kept by Resident #1 for the vending machine. BOM confirmed that the reimbursement happened on 03/14/2026 with print out of Resident #1's Cash Receipt for $52, signed by Resident #1 and ADMIN.Record review of Resident #3's admission Record, dated 05/05/2026, revealed a [AGE] year-old female admitting to the facility on [DATE] with diagnoses including Muscle Weakness (reduced ability to exert force with muscles, often feeling like effort is needed to move arms, legs, or other body parts); Presence of Cardiac Pacemaker (small implantable device placed under skin of the chest to manage irregular or slow heart rhythms, generally due to conditions [NAME] sinus node dysfunction or heart block); Paroxysmal Atrial Fibrillation (type of irregular, rapid heart rhythm that starts and stops suddenly on its own, typically lasting less than seven days); and Hypertension (chronic condition where the force of blood against artery walls is consistently too high).Record review of Resident#3's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating an intact cognitive response.Record review of Resident #3's Care Plan, revised 05/01/2026, revealed a pacemaker in place, fall risk, and a self-care performance deficit. Record review of Resident #3's Progress Notes, dated 05/05/2026, revealed no mention of complaint or grievance related to money missing from resident room.Record review of Resident #3's grievance form, dated 02/23/2026, revealed that the family member placed grievance regarding multiple concerns, including billing and finances.Record review of facility grievance forms, dated 05/06/2026, revealed no grievance listed for Resident #3 in December 2025 or January 2026.During an interview and record review on 05/07/2026 at 9:17 am, BOM stated that Resident #3 has a Trust Fund account with the facility and outside bank usage as well. BOM printed copy of Trust Fund Transaction History for January 1, 20260 - January 21, 2026 that revealed a cash deposit of $145 to Resident #3's Trust Fund account dated 01/21/2026. Petty Cash Box receipt was provided to surveyor dated 01/19/2026 for $145 for Resident #3. BOM stated that ADMIN instructed her to reimburse the $145 to Resident #3 and provided email corroborating statement. During an interview and record review with Resident #3's family member on 05/07/2026 at 9:20am, family member stated that they emailed ADMIN on 02/23/2026 about multiple issues as well as requesting verification of receipt of Trust Fund reimbursement. Resident family member stated the missing money was reported to ADMIN in December. On or around the 12th.During an interview on 05/07/2026 at 10:05 am, ADMIN stated that the normal process to rule out ANE is that they investigate and they report it to SSA if facility suspects funds were stolen. If resident does not state my money was stolen we do not investigate it. We treat it as misplaced funds. ADMIN also stated that there is no way to 100% absolutely ascertain funds were misplaced versus stolen. ADMIN also stated that if facility reports funds as stolen to SSA then it would mean that the facility is admitting to exploitation and that the facility had no grounds to deem that is what happened. ADMIN stated that for Resident #1, Resident #1 never used verbiage of stolen to refer to missing money so it was never reported to SSA. ADMIN also stated that Resident #1 never utilized verbiage of stolen before February email dated 02/23/2026 so it was not reported to SSA till that point.Record review of facility policy for Abuse: Prevention of and Prohibition Against, dated 04/2025, revealed that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Policy also revealed that Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 1 of 1 resident (Resident #2) to meet the needs of the resident, in that: Resident #2's narcotic count log indicated Oxycodone 5mg medication was administered two times on 04/13/2026 without documentation in the MAR.This deficient practice could place residents at risk for injuries by not having an accurate record of medication administration available in the medical record. The findings included:A record review of resident #2's face sheet dated 05/05/2026 revealed an admission date of 04/11/2026 with diagnoses which included dislocation of internal left hip prosthesis (the ball of the hip implant comes out of the socket) and polyneuropathy (nerve damage that may cause weakness, numbness, and burning pain). A record review of resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition.A record review of resident #2's care plan initiated 04/13/2026, revealed: Resident #2 has analteration in musculoskeletal status r/t left hip prothesis dislocation, intervention, Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness, and resident #2 is on pain medication therapy (tylenol, gabapentin, hydrocodone, oxycodone) r/t left hip dislocation, neuropathy, intervention, Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. A record review of resident #2's physician order summary dated 05/05/2026 revealed to administer the following medications: oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl)Give 2 tablet by mouth every 4 hours as needed for severe pain (7-10), with a start date of 04/11/2026. Interview with M Chest pharmacy on 05/07/2026 at 8:21 am confirmed that 108 Oxycodone 5mg tablets were delivered to facility on 04/12/2026 for resident #2. A record review of resident #2's narcotic count sheet for: OXYCODONE TAB 5mg, give 2 tablets (10MG) by mouth every 4 hours as needed, indicated the following doses of medication were administered: 04/13/2026 at 11:30am 2 tablets given, with a remaining count of 106 tabs, and 04/13/2026, no time recorded, 2 tabs given, with a remaining count of 104 tabs. A record review of resident #2's MAR in the electronic medical record revealed no documentation for administration of oxycodone 5mg on 04/13/2026.During an interview with resident #2 on 05/05/2026 at 9:59 am, the resident stated a dose of oxycodone was received on 04/13/2026 at 4:30pm.During an interview on 05/07/2026 at 9:37am with ADON B, she stated confirmation that the oxycodone 5mg was not documented on resident #2's MAR as being administered on 04/13/2026. ADON stated the staff should be documenting all medications on the MAR as they are administered to avoid discrepancies. ADON stated missed documentation was an identified issue that was being addressed through education and pulling the missed documentation report. During an interview on 05/07/2026 at 10:45 am with DON, she stated her expectation is that nursing staff document medication administration in the MAR at the time the medication is given to remain in compliance and avoid medication errors. DON stated she is working on educating staff and the nursing leadership is reviewing documentation daily.A record review of the facility's policy titled, Medication Administration, dated 06/2022, revealed, 3. All current drugs and dosages must be recorded on the resident's medication administration record (MAR). 6. When PRN medications are administered, the nurse must record: B. The date and time administered. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. #6. Right Documentation-Document administration or refusal of the medication after the administration or attempt and note any concerns.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with professional standards for 2 of 8 medication carts (100 Hall nurses medication cart and 100 Hall medication aide cart) reviewed for storage of drugs.The facility failed to ensure the carts for 100 Hall, for both the nurse medication cart and the medication aide cart, were locked and secured on 05/05/2026609 .This failure could place residents at risk of medication misuse, medication errors, drug diversion or harm due to accidental ingestion of unprescribed medications.Findings included:During an observation on 05/06/2026 at 10:03 am, the nurses medication cart on 100 Hall by nurses station was unlocked, the nurse sitting 10 to 15 feet away behind the nurses station. Several unknown residents were ambulating on and around the hall. LVN A stood and exited from nurses station and approached this surveyor when surveyor opened top drawer of nurses medication cart and began rummaging around the drawer while asking whose cart was open.During an interview on 05/06/2026 at 10:03 am, LVN A stated that she never leaves her cart unlocked and she apologized. LVN proceeded to lock medication cart when stating that she knows the cart should be locked at all times. LVN A stated that the negative impact to residents when the cart is left unlocked and unattended is that they could get into medications and take something that they are not supposed to. During an observation on 05/06/2026 at 2:46 pm, the medication aide cart was found unlocked on 100 Hall. Surveyor stood beside cart while looking directly at LVN A. LVN A left nurses station, 10-15 feet away, and jogged to nurses medication cart next to the medication aide cart and reached out to push on the lock. After a second LVN A noticed the medication aide cart next to surveyor was unlocked. LVN A reached over to lock the medication aides medication cart.During an interview on 05/06/2026 at 2:46 pm, LVN A stated that CMA A was on lunch break and she was unsure what time she went to lunch.During an interview on 05/06/2026 at 3:15 pm, CMA A stated that she went to lunch and thought she had locked the cart. CMA A stated that she left the keys to the medication cart with LVN A. CMA A stated that leaving a medication cart unlocked and unattended could negatively impact residents by giving them the opportunity to take medications that are not theirs.During an interview on 05/07/2026 at 10:08 am, ADON A stated that the expectation for all medication carts is that they are locked when unattended. ADON A stated that the negative impact to residents for an open medication cart is that they can be hurt taking things that are not theirs.During an interview on 05/07/2026 at 10:36 am, DON stated that medication carts should be locked when staff steps away from them. Record review of CMA A's time punches on 05/06/2026 revealed CMA A clocked out for lunch at 2:00 pm and clocked back in from lunch at 3:08 pm.Record review of facility's Medication Access and Storage policy, dated 06/2025, revealed that all drugs and biologicals should be stored in locked compartments.

Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) of discharge and the reasons for the move in writing and in a language and manner they understand, as soon as practicable for 1 of 4 residents (Resident #1) reviewed for discharges. The facility failed to ensure Resident #1 received written notice of discharge after he was emergently discharged on 1/10/2026. This failure could result in a violation of residents' rights and improper discharge. Findings included: Record review of Resident #1's admission Record dated 2/04/2026 reflected an [AGE] year-old male admitted to the facility on [DATE] and discharged on 1/10/2026 to an acute care hospital. Relevant diagnoses included unspecified dementia (a cognitive disorder that impacts memory) and anxiety (a mental health disorder characterized by excessive worrying). Record review of Resident #1's admission MDS submitted 12/28/2025 reflected a BIMS score of 06, which indicated severely impaired cognition. Section Q0310 of the MDS reflected the resident's overall goal was 1. Discharge to the community. Section Q0400 reflected the discharge planning was not actively occurring at the time of submission. Record review of Resident #1's Discharge- Return Not Anticipated MDS submitted 1/10/2026 reflected a BIMS score was not assessed. Section E of the MDS reflected the following:E0200 Behavioral Symptom- Presence and FrequencyA. Physical behavioral symptoms directed toward others (1) Behavior of this type occurred 1 to 3 daysB. Verbal behavioral symptoms directed toward others (0) Behavior not exhibitedE0600 not included in assessmentE0800 Rejection of care- Presence and FrequencyDid the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being? (1) Behavior of this type occurred 1 to 3 daysE0900 Wandering Presence and FrequencyHas the resident wandered? (2) Behavior of this type occurred 4 to 6 days, but less than daily Record review of Resident #1's Progress Notes dated 2/04/2026 reflected the following entries:Effective date 1/10/2026 7:01 PM: Verbal aggression Initiated, Resident's room, Nursing Description: 100 Hall Nurse witnessed: @1:47 RESIDENT BECAME AGITATED STAFF ATTEMPTING TO REDIRECT AND REASSURE [family member] WOULD BE COMING TO VISITWHEN HE WAKES UP IN THE MORNING TO NO AVAIL. RESIDENT CONTINUES TO BECOME MORE AGITATED PUNCHED CAREGIVER IN FACE. PROVIDER AND DON AWARE AND BOTH RECOMMEND RESIDENT GO BACK TO THE HOSPITAL FOR HIGHERLEVEL OF CARE FOR EVAL FOR GERI PSYCH RELATED TO BEHAVIORS. RESIDENT MEDICATED WITH CLONAZEPAM ANDDEPAKOTE IN ICE CREAM WITH NO AFFECT. RESIDENT FOUND IN BED WITH ROOMMATE WITH PILLLOW AND LYING ON TOPOFROOMMATE. RESIDENT REMOVED FROM HIS ROOM TO COMMON AREA WHERE RESIDENT FLIPPED OVER COFFEE TABLE,ATTEMPTED TO THROW LAMP THROUGH WINDOW AND BEGAN BANGING ON WINDOW AS WELL RESIDENT SENT TO [Local Hospital Emergency Department} VIAAMBULANCE AND POLICE. PROVIDER CALLED REPORT TO THE ER AS WELL AS NURSE.Effective date 1/10/2026 5:26 PM Physician Progress NoteI was called last evening because [sic] [Resident #1} was severely agitated. He was refusing his medications. He was trying to leave facility. He was aggressive with hitting, biting and kicking staff. He tried to head-butt staff as well. He reportedly attempted to [sic] throw his wheelchair. For the safety of staff and other patients I ordered him to be sent to the ER. He was reportedly fine with no behaviors at the ER and was sent back. No interventions or medications were required. Upon return I spoke with nursing to monitor carefully. I received a call thathe was continued to be agitated [sic] but was a bit more directable. He was given dose of clonazepam and depakote. I called the ER to let them know that we might need to send him back if he continued to be a danger to our staff and other patients. Early this morning I received a call from nursing that he had attempted to smother his roommate with a pillow. I then ordered that he be sent back to the hospital. We are unable to accept him back until he has undergone thorough psychiatric evaluation and has been stable for a couple of days. He has represented aclear risk to the safety of our staff and other residents. In an interview on 2/04/2026 at 3:30 PM, the DON stated Resident #1's behavior was a significant safety risk to himself, other residents, and the facility staff. She said Resident #1 required a level of care that could not be provided by the facility, and the status of his cognition and behaviors was not accurately conveyed to the facility prior to admission. She said the facility was attempting to find alternative placement for Resident #1, and his family member was aware, but he had not yet been accepted for transfer. Due to the nature of the behaviors of 1/10/2026, she said she instructed facility staff to transfer Resident #1 to the local emergency department and to provide the explicit information to the receiving hospital that Resident #1 could not return to the facility for safety reasons. She said Resident #1 had likely not been given a written notice of discharge after the unplanned discharge as the LSW was out of town and it was an unusual circumstance. She said the failure to provide this written notice could a violation of a resident's rights. In an interview with the LSW on 2/04/2026 at 3:38 PM, she said Resident #1 had not been given a written notice of discharge after the unplanned discharge on [DATE] as she was out of town during Resident #1's entire admission. She said all residents receive written notice of discharge and room changes as required by law, but she was unaware Resident #1 had been admitted and discharged in her absence. Record review of the facility policy titled Transfer and Discharge (Involuntary; initiated by the facility, not the resident) undated, received 2/04/2026; reflected the following:The notice must be provided at least 30 days prior to the transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:Health and/or safety of individuals would be endangered due to the clinical or behavioral status of the resident .In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate and the LTC Ombudsman as soon as practicable before the transfer or discharge.

Based on interview and record review, the facility to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for resident assessments. The facility failed to ensure Resident #1's discharge MDS accurately reflected the frequency of the resident's physically aggressive and wandering behaviors at the time of discharge. This failure could lead to improper oversight and care of residents. Findings included: Record review of Resident #1's admission Record dated 2/04/2026 reflected an [AGE] year-old male admitted to the facility on [DATE] and discharged on 1/10/2026 to an acute care hospital. Relevant diagnoses included unspecified dementia (a cognitive disorder that impacts memory) and anxiety (a mental health disorder characterized by excessive worrying). Record review of Resident #1's Discharge- Return Not Anticipated MDS submitted 1/10/2026 reflected a BIMS score was not assessed. Section E of the MDS reflected the following:E0200 Behavioral Symptom- Presence and FrequencyA. Physical behavioral symptoms directed toward others (1) Behavior of this type occurred 1 to 3 daysB. Verbal behavioral symptoms directed toward others (0) Behavior not exhibitedE0600 not included in assessmentE0800 Rejection of care- Presence and FrequencyDid the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being? (1) Behavior of this type occurred 1 to 3 daysE0900 Wandering Presence and FrequencyHas the resident wandered? (2) Behavior of this type occurred 4 to 6 days, but less than daily Record review of Resident #1's Progress Notes dated 2/04/2026 reflected the following entries:Effective date 1/10/2026 7:01 PM: Verbal aggression Initiated, Resident's room, Nursing Description: 100 Hall Nurse witnessed: @1:47 RESIDENT BECAME AGITATED STAFF ATTEMPTING TO REDIRECT AND REASSURE WIFE WOULD BE COMING TO VISITWHEN HE WAKES UP IN THE MORNING TO NO AVAIL. RESIDENT CONTINUES TO BECOME MORE AGITATED PUNCHED CAREGIVER IN FACE. PROVIDER AND DON AWARE AND BOTH RECOMMEND RESIDENT GO BACK TO THE HOSPITAL FOR HIGHERLEVEL OF CARE FOR EVAL FOR GERI PSYCH RELATED TO BEHAVIORS. RESIDENT MEDICATED WITH CLONAZEPAM ANDDEPAKOTE IN ICE CREAM WITH NO AFFECT. RESIDENT FOUND IN BED WITH ROOMMATE WITH PILLLOW AND LYING ON TOPOFROOMMATE. RESIDENT REMOVED FROM HIS ROOM TO COMMON AREA WHERE RESIDENT FLIPPED OVER COFFEE TABLE,ATTEMPTED TO THROW LAMP THROUGH WINDOW AND BEGAN BANGING ON WINDOW AS WELL RESIDENT SENT TO [Local Hospital Emergency Department} VIA AMBULANCE AND POLICE. PROVIDER CALLED REPORT TO THE ER AS WELL AS NURSE.Effective date 1/10/2026 5:26 PM Physician Progress NoteI was called last evening because [sic] [Resident #1} was severely agitated. He was refusing his medications. He was trying to leave facility. He was aggressive with hitting, biting and kicking staff. He tried to head-butt staff as well. He reportedly attempted to throw his wheelchair. For the safety of staff and other patients I ordered him to be sent to the ER. He was reportedly fine with no behaviors at the ER and was sent back. No interventions or medications were required. Upon return I spoke with nursing to monitor carefully. I received a call that he was continued to be agitated [sic] but was a bit more directable. He was given dose of clonazepam and depakote. I called the ER to let them know that we might need to send him back if he continued to be a danger to our staff and other patients. Early this morning I received a call from nursing that he had attempted to smother his roommate with a pillow. I then ordered that he be sent back to the hospital. We are unable to accept him back until he has undergone thorough psychiatric evaluation and has been stable for a couple of days. He has represented a clear risk to the safety of our staff and other residents.Effective date 1/09/2026 7:00 PM Health Status NoteResident continues to attempt to elope facility, staff redirecting resident away from the doors and attempting to engage in alternative activities to distract resident. Wife just left facility as resident had previously been napping when she arrived. @ 1920 [7:20 PM] resident awake and attempting to ambulate without assistance, redirected to his wheelchair. Resident is aggressive hitting, kicking, headbutting staff; resident attempting to throw wheelchair at staff. Staff attempted to medicate for anxiety and resident threw medication across the room. At thistime resident also purposefully put himself on the floor by crawling out of his wheelchair on to the floor.Staff attempted to contact wife multiple times with no answer, on call management notified as well as [sic] provider regarding residents' behavior. Provider gave new order to send resident out for further eval and treatment of behaviors. During this time resident being aggressive to other residents grabbing their wheelchair. EMS contacted to transport patient to hospital, police and fire arrived as well. Resident calmed to some degree with presence of uniformed individuals. Resident sent to [Local Hospital Emergency Department] @ 1933 [7:33 PM] report called to ER, wife notified as well as on call management for facility.Effective date 1/09/2026 10:28 AM Behavior NoteResident continues to try and elope out of the door by nurse's station; unable to be redirected without behaviors such as verbal aggression and or trying to get out of wheelchair and crawl on floor. Received in report that resident was physically aggressive towards staff and sitter last evening during shift. Night nurse had to call spouse to come sit with resident throughout the night. Behaviors continued.Effective 1/08/2026 1:51 PM Health Status NoteResident continues with 1:1 oversight related to behaviors and previous elopement concern. Referral sent to Deer Oaks Services for physch [sic] consult. Pending initial visit. No currents signs of distress or wandering noted.Effective date 1/07/2026 8:52 AM Health Status NoteRESIDENT D 2/3 S/P FALL WITHOUT INJURY, REMAINS ON NEURO'S. RESIDENT CONTINUES TO BE CONFUSED, PLACED ON 1:1 DUE TO BEHAVIORS AND ATTEMPTS TO ELOPE FROM FACILITY. RESIDENT PLEASANT AT THIS TIME, IN COMMON AREA WITH SITTER, APPEARS IN NAD, DENIES PAIN AND OR DISCOMFORT, APPETITE REMAINS INADEQUATE AS WELL AS FLUID INTAKE, SPOUSE MADE AWARE OF CHANGES, WILL CONTINUE TO MONITOR.Effective date 1/06/2026 9:31 PM Health Status NotePatient awake alert and oriented to baseline, patient 1:1 with CNA for wandering and behaviors as per ordered. Patient medicated as per orders refusing vitals for neuro checks. Will Continue to assess for neuros as patient tolerates.Effective date 1/06/2026 1:12 PM Health Status NoteResident refusing to take PRN for anxiety, stating I am not taking anything from you all. Resident continues to be agitated, spouse just returning to facility. Will continue to monitor.Effective date 1/06/2026 11:30 AM Health Status Note Resident attempted to elope out of side door at end of 100 hall; set alarm off. Difficulty redirecting resident, verbally and physicallyaggressive while trying to redirect. In an interview on 2/04/2026 at 2:02 PM, the MDSC said she was responsible for the completion of the completion of Resident #1's admission and Discharge MDS assessments. She said she obtains the information for Section E of the MDS from the progress notes and behavioral notes documented by the nursing staff. After reviewing the discharge MDS together, the MDSC stated Section E did not accurately reflect the behaviors exhibited by Resident #1 in the time period assessed for the discharge MDS. She said an inaccurate MDS could affect proper care and provide an inaccurate reflection of the status of residents. In an interview on 2/04/2026 at 2:31 PM, LVN A said Resident #1 exhibited verbally and physically aggressive behaviors multiple times a day while he was a resident. She said he continuously attempted to elope from the facility on a daily basis, except for the few hours every afternoon when Resident #1's family member was visiting. She said Resident #1 was a danger to himself, other residents, and the staff, and his behaviors could not be properly cared for at the facility. In an interview on 2/04/2026 at 3:30 PM, the DON said Resident #1 exhibited daily behaviors that were physically and verbally aggressive. She said Resident #1 required a constant 1:1 observer due to his behaviors and continuous attempts to elope from the facility. She said Resident #1's discharge MDS should accurately reflect the continuous behaviors that required unplanned, emergent discharge of Resident #1, and the MDSC should have reviewed the progress notes when completing the assessment. Record review of the facility policy titled Comprehensive Assessments (dated 2001, revised March 2022), reflected the following: 8. A significant error is an error in as assessment where:a. the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an appropriate plan of care; andb. the error has not been corrected via submission of a more recent assessment.

Based on interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a residents, the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 10 residents (Resident #1) reviewed for quality of care, in that: The facility failed to transcribe Resident #1's hospital order for insulin glargine on admission according to discharge instructions, and failed to administer the medication for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/7/25. The IJ template was provided to the facility on [DATE] at 5:01 PM. While the IJ was removed on 2/8/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for hyperglycemia related to missing medication doses. Findings include: Record review of Resident #1's face sheet printed 02/06/2025 revealed a [AGE] year-old female admitted on [DATE] after recent hospitalization with a diagnosis of UTI and new on-set CHF exacerbation with co-morbidity of DMII (a long-term condition in which the body does not make enough insulin). Record review of Resident #1's Baseline Care Plan, dated 01/30/2025, revealed resident was a Type II Diabetic and was receiving insulin. Record review of Resident #1's Admission MDS, dated [DATE], reflected it was pending completion and submission. Record review of Resident #1's hospital discharge instructions, dated 01/30/2025, revealed Resident #1 had an order for 17u Insulin Glargine 1x daily. Discharge instructions did not indicate blood glucose level checks. Record review of Resident #1 February 2025 MAR revealed the facility did not transcribe an order for 17u Insulin Glargine until 02/06/2025. Record review of Resident #1's blood glucose levels revealed the following results: 2/5/25 @ 6:21 PM 233 mg/dL, 2/6/25 @ 9:28 AM 446 mg/dL, 2/6/25 @ 4:52 PM 274 md/dL, and 2/6/25 @ 5:13 PM 274 mg/dL. Blood glucose levels were not checked prior to 2/5/25. Record review of Resident #1 blood sugar levels after receiving 17units of insulin glargine revealed 2/7/25 at 10:30 AM blood sugar level of 219 mg/dL. An interview and observation of Resident #1 on 2/6/25 at 3:24 PM revealed Resident #1 sitting up at edge of bed with bedside table in place going thru her mail. The resident was wearing personal clothing items, presented clean, well-groomed, odor free, and wearing prescription glasses in place, that were clean and serviceable. The resident was hard of hearing, but was amiable and accepting of surveyor interaction. Resident #1 stated she told her family member yesterday [02/05/205] that she had not received her insulin like she did at home but did not mention it to facility staff. Resident #1 stated she notified her family member. Resident #1 stated she administers her own insulin at home. Resident #1 verbalized she felt fine today and was pleased that correct orders were now in place. Resident #1 stated she had lived with diabetes for years, did not feel any different. In an interview on 02/05/25 at 4:30 PM with ADON LVN G, the DON, the Regional Nurse, and the Administrator, the DON stated LVN G was notified by Resident#1's family member that the resident was supposed to received daily insulin administration. LVN G confirmed an order for insulin glargine 17u daily was listed on Resident #1's discharge instructions from the hospital, dated 01/30/2025, and contacted physician for insulin orders and administered 17u insulin glargine at 4:27 PM. The Administrator stated this event would be called in to the state as a medication error. In an interview with the DON on 02/06/2025 at 4:45 PM, the DON confirmed that Resident #1 had not received insulin for 6 days from 01/31/25-02/5/25, putting the resident at risk for hyperglycemia (elevated blood sugar levels) with both short-term (hyperglycemia, diabetic ketoacidosis) and long-term (damage to kidneys, eyes and nerves) effects. The DON stated she expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure administration of medications. In an interview with Administrator on 02/06/25 at 5:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per physicians' order. The Administrator stated she expected nursing staff to follow physicians' orders. In an interview with MD #1 on 2/6/255 at 5:45 PM, MD #1 (current physician as of 2/6/25) revealed that when he was notified of Resident #1's BS 446, he advised them to give 4u fast acting and re-check the resident's BS. MD #1 stated he did not like aggressive s/s for geriatric patients and would figure out where she was normally and adjust as needed. MD #1 stated he did not feel more adverse effects as the resident's levels were similar to the hospital levels. MD #1 stated his expectations were, of course are that they follow his orders and is is pleased with the fast action they took with termination of the nurse he spoke to personally regarding the 4u of Lantus administration. In an interview with MD #2 on 2/6/25 at 5:55 PM, MD #2 (admitting physician) stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue hospital orders and he evaluated the resident in person on 1/31/25. MD #2 stated he was not concerned when they told him about the missed Lantus dose of 17u because it is long acting and stays 36-40 hours, so not that damaging. MD #2 stated he had protocols in place for Glucagon and that a s/s for Lantus were not recommended anyway. Record review of the facility policy named, Reconciliation of medications on Admission, revised July 2017, revealed, admitting nurse should reconcile the discharge medications to include dose, route and frequency for all medications, notify physician to verify admitting orders and transcribe them accordingly to the EMR. Record review of the facility policy named, Administering Medications, revised April 2019, revealed, medications are administered in accordance with prescriber orders. This was determined to be an Immediate Jeopardy (IJ) on 2/7/25 at 5:01 PM. The Administrator and the DON were notified and provided the IJ Template on 2/7/25, and a Plan of Removal was requested. [Facility Name] Tag Cited: F684 Alleged Issues: The facility failed to enter and obtain the appropriate prescribed medication for resident upon admission and notify the physician when medication was 'unavailable' or not administered. Plan of Removal 1. Immediate Actions The Medical Director was notified by the Administrator on 2/07/2025 of the Immediate Jeopardy. The DON completed an Admission Drug Regimen review and reconciliation on all new admissions along with the Medical Director date range of 1/30/2025 to current. An Admission drug regimen review and reconciliation tracker was created and put in place by the DON on 2/07/2025, review as completed 2/07/2025. A resident medication administration audit report was conducted by DON and MDS coordinator on 2/08/2025 to ensure medication availability for each resident. Change of condition assessment audit was reviewed on 2/07/2025 for date range of 1/30/2025 to current. Change of condition assessment audit was conducted by the DON on 2/07/2025. Change of condition assessment audit will be monitored in daily clinical meeting Monday through Friday with IDT team conducted by the DON or designee. Saturday and Sunday the change of condition review audit will be performed by the DON or designee. 2. Education DON and ADON in serviced on notifying MD when medications are not transcribed accurately or not available and documenting MD recommendations on 2/07/2025 by VP of Clinical. DON and ADONs were educated on change of condition. When a resident has a change of condition or before sending the resident out, DON must be notified, MD must be notified, and a change of condition must be opened and completed. In service provided by the VP of clinical on 2/07/2025. One on one education provided to nursing staff regarding the Charge Nurse calling the Medical Director and review the hospital discharge medication list, once reconciled enter all orders at the time of admission, complete admission note, ensure that drug regimen review is completed, and all assessments completed. Education completed by DON and ADON's on 2/07/2025. One on one education provided to nursing staff in regard to notifying MD when medications are not available and to provide a progress note with MD recommendations when medications are not available. Education provided by DON and ADONs on 2/07/2025. Staff that were not physically present in the facility were contacted via phone and education reviewed with them by the DON and ADONs on 2/07/2025. 3. Monitoring The Admission Drug Regimen Review and Reconciliation tracker on new admissions will be reviewed daily in morning clinical meeting by the IDT Team Monday through Friday. Saturday and Sunday, the Admission Drug Regimen Review and Reconciliation will be completed by the DON or designee. An audit of every MAR will be conducted Monday through Friday in the clinical meeting by the DON or designee to ensure medication availability for all residents. Saturday and Sunday, the medication administration audit will be completed by the DON or designee. The Admission Drug Regiment Review and Reconciliation tracker will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting for a minimum of three months. 4. QAPI Committee Review: An Ad Hoc QAPI committee meeting was completed 2/07/2025. 5. Plan of Removal date: 2/07/2025 The Plan of Removal was accepted on 02/08/2025 at 5:29 p.m., and the verification of the POR included the following: 1. Interview with Medical Director on 2/07/2025 at 4:45 PM verified he was notified of IJ. Interview with DON and Administrator on 2/08/2025 verified the Admissions Drug Regimen Review and Reconciliation was completed for all residents admitted since 1/20/2025. This surveyor completed 7 of 7 admissions reviews from 1/30/2025-2/7/2025 with no errors noted. Record review on 2/08/2025 verified medication administration audit report was conducted by MDS Coordinator and DON. Verified Change of Condition assessment audit was completed by DON 2/8/2025 and verified Change of Condition assessment audit in place with Administrator. 2. Interviews on 2/08/2025 between hours of 7:30 AM - 7:00 PM with 17 of 27 FT/PRN Nurses: LVN H stated aware of how to complete a change of condition and understands importance of accurate medication reconciliation for new admissions. RN I stated understanding of how to input orders into EMR, identify and report change of condition and need to clarify admitting orders with MD. LVN J stated understanding of importance of verifying admitting orders and confirming with MD as well as date input in EMR. LVN C stated inservices received for change of condition, medication reconciliation and understands importance. LVN K stated understands process of medication reconciliation for admissions and need to take time in reviewing discharge instructions, verbalized understanding of change of condition notifications. LVN L stated understanding of change of condition and understands need to clarify all discharge instructions for admissions and verify with MD. LVN M stated received inservices for change of condition and clarification of medication reconciliation for discharge instructions on new admissions. LVN N stated understanding of importance of completing new admissions and discharge instructions / medication reconciliation on all new admissions and notifying MD for change of conditions. LVN AE stated received inservices on identify and reporting change of condition and importance of completing accurate medication reconciliation on all admissions. LVN O stated received inservices for change of condition and new admissions. Stated understands how to complete medication reconciliations and date input in EMR. LVN Q stated understands how to complete new admission assessments, change of condition assessments and medication reconciliation according to discharge instructions. LVN S stated understanding of need for clarification and accuracy for new admissions and following discharge instructions, notifying MD and completed change of condition assessments. LVN T stated received inservices for change of condition and understands importance of notifying MD and verify new admission orders. LVN U stated understanding of process for new admissions and need to ensure accurate transcription and notification of MD to verify orders. LVN V stated received inservices for change of condition, medication reconciliation for new admissions and understands how to input into EMR. LVN X stated understands need to accuracy when completing new admission medication reconciliation and notifying MD of change of condition. 4 of 4 Agency Nurses on duty 2/08/2025 (LVN Z, LVN Y, LVN AI, LVN B) verified they received in-services and training from DON or ADON (RN DON AG, LVN ADON G, LVN ADON R, Admin LVN P) regarding completing a Change of Condition assessment, completing new and re-admission medication reconciliation and admission assessments according to Admission Checklist to include verifying orders (all orders, but specifically insulin orders) and transcribing orders in EMR. Inservice Training and Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interview on 2/08/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication reconciliation process for admissions. Inservice Training and Training log for 27 of 27 FT/PRN Staff review and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interviews on 2/8/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication availability, who to contact and how to access Emergency medication system. Inservice Training & Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN nurses with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Record review on 2/08/2025 of In-service log and training provided reviewed. All nurses interviewed were able to identify how to complete a Change of Condition assessment, how to verify orders for new admissions according to discharge instructions by transcribing and verbalizing to physician (or designee) to include how to input information in EMR including parameters and sliding scale needs for insulin orders. Through interview and observation, staff members were able to demonstrate they received identified inservices and demonstrated knowledge of subject matter through surveyor questions. 3. Record review on 2/08/2025 of Admission Drug Regimen and Reconciliation Tracker that will be kept by the Administrator and/or DON during clinical meeting. DON verbalized she will review MAR in clinical meetings to ensure medication availability. On 2/08/2025, Administrator confirmed Admission Drug Regimen Review and Reconciliation tracker will be reviewed at least quarterly in QAPI meeting. 4. On 2/08/2025, Administrator confirmed QAPI meeting was completed 2/07/2025. The Administrator was informed the Immediate Jeopardy was removed on 2/08/2025 at 7:37 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to provide pharmacological services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to acquire, receive, dispense, and administer Resident #1's scheduled insulin 17u Insulin Glargine daily as ordered for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on [DATE] at 5:01 PM. While the IJ was removed on 2/08/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This deficient practice could place resident at risk for adverse side effects of hyperglycemia. Findings include: Record review of Resident #1's face sheet printed 02/06/2025 revealed a [AGE] year-old female admitted on [DATE] after recent hospitalization with a diagnosis of UTI and new on-set CHF exacerbation with co-morbidity of DMII (a long-term condition in which the body does not make enough insulin). Record review of Resident #1's Baseline Care Plan, dated 01/30/2025, revealed resident was a Type II Diabetic and was receiving insulin. Record review of Resident #1's hospital discharge instructions dated 01/30/2025 revealed Resident #1 had an order for 17units Insulin Glargine 1 x daily. Hospital discharge instructions dated 01/30/2025 did not include orders to check blood glucose levels. Record review of Resident #1's February 2025 MAR dated 02/06/2025 revealed the facility failed to transcribe orders for daily insulin until 02/05/2025. Record review of Resident #1's blood glucose levels revealed the following results: 2/5/25 @ 6:21 PM 233 mg/dL, 2/6/25 @ 9:28 AM 446 mg/dL, 2/6/25 @ 4:52 PM 274 md/dL, and 2/6/25 @ 5:13 PM 274 mg/dL. Blood glucose levels were not checked prior to 2/5/25. Record review of Resident #1 blood sugar levels after receiving 17units of insulin glargine revealed 2/7/25 at 10:30 AM blood sugar level of 219 mg/dL. In an interview with LVN G on 2/5/25 at 4:30: PM, LVN G stated she was notified by Resident #1's family member that Resident #1 received daily insulin. LVN G stated she confirmed the hospital discharge medication listing and that the admitting nurse had failed to transcribe the order for 17units Insulin Glargine daily. An interview and observation of Resident #1 on 2/6/25 at 3:24 PM revealed Resident #1 sitting up at edge of bed with bedside table in place going thru her mail. The resident was wearing personal clothing items, presented clean, well-groomed, odor free, and wearing prescription glasses in place, that were clean and serviceable. The resident was hard of hearing, but was amiable and accepting of surveyor interaction. Resident #1 stated she told her family member yesterday [02/05/205] that she had not received her insulin like she did at home but did not mention it to facility staff. Resident #1 stated she notified her family member. Resident #1 stated she administers her own insulin at home. Resident #1 verbalized she felt fine today and was pleased that correct orders were now in place. Resident #1 stated she had lived with diabetes for years, did not feel any different. In an interview with DON on 02/06/25 at 4:45 PM, the DON stated she was informed by LVN G of the missed order for daily insulin Glargine on Resident #1's admission 01/30/2025. The DON confirmed LVN G notified the resident's physician on 2/025/2025 at 4:30 PM and obtained orders for 17units Insulin glargine daily. The DON confirmed the resident had not received insulin for 6 days from 01/31//25-02/5/25, putting her at risk for hyperglycemia (elevated blood sugar levels) with both short-term and long-term effects. The DON stated she expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure administration of medications. In an interview with Administrator on 02/06/25 at 5:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per physicians' order. The Administrator stated she expected nursing staff to follow physicians' orders. In an interview with MD #1 on 2/6/255 at 5:45 PM, MD #1 (current physician as of 2/6/25) revealed that when he was notified of Resident #1's BS 446, he advised them to give 4u fast acting and re-check the resident's BS. MD #1 stated he did not like aggressive s/s for geriatric patients and would figure out where she was normally and adjust as needed. MD #1 stated he did not feel more adverse effects as the resident's levels were similar to the hospital levels. MD #1 stated his expectations were, of course are that they follow his orders and is is pleased with the fast action they took with termination of the nurse he spoke to personally regarding the 4u of Lantus administration. In an interview with MD #2 on 2/6/25 at 5:55 PM, MD #2 (admitting physician) stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue hospital orders and he evaluated the resident in person on 1/31/25. MD #2 stated he was not concerned when they told him about the missed Lantus dose of 17u because it is long acting and stays 36-40 hours, so not that damaging. MD #2 stated he had protocols in place for Glucagon and that a s/s for Lantus were not recommended anyway. Record review of the facility policy named, Reconciliation of medications on Admission, revised July 2017, revealed, admitting nurse should reconcile the discharge medications to include dose, route and frequency for all medications, notify physician to verify admitting orders and transcribe them accordingly to the EMR. Record review of the facility policy named, Administering Medications, revised April 2019, revealed, medications are administered in accordance with prescriber orders. This was determined to be an Immediate Jeopardy (IJ) on 2/7/25 at 5:01 PM. The Administrator and the DON were notified and provided the IJ Template on 2/7/25, and a Plan of Removal was requested. [facility] Tag Cited: F755 Alleged issues: The facility failed to provide pharmacological services to meet the needs of Resident #1 when admitting nurse did not reconcile Insulin Glargine to Resident #1's medication record as per hospital discharge instructions. Plan of Removal 1. Immediate Actions The Medical Director was notified by the Administrator on 2/07/2025 of the Immediate Jeopardy. The DON completed a chart audit on all residents receiving insulin on 2/07/2025 with audit date beginning 1/30/2025. An insulin tracker reconciliation process was put in place for an audit to be completed daily by DON or designee to ensure insulin is administered correctly and in a timely manner. Insulin Tracker will be monitored by DON or ADON daily in clinical meeting with the IDT Team Monday thru Friday. On weekends, Insulin Tracker will be monitored by DON or designee. The DON completed an Admission Drug Regimen review and reconciliation on all new admissions with the Medical Director with a date range of 1/20/2025-current. An Admission Drug Regimen Review and Reconciliation tracker was created and put in place by the DON on 2/07/2025 and review was completed 2/07/2025. 2. Education An inservice was conducted for the DON and ADONs by the VP of Clinical on 2/07/2025 on reconciliation of medications for all admissions. One on one education provided to clinical staff that upon admission, discharge medication list will be reconciled with MD via phone (verbal), or in person with charge nurse. Once the charge nurse has completed the medication reconciliation, the DON or designee will review the reconciliation to confirm accuracy. The DON or designee will track the reconciliation on the admission drug regimen/reconciliation log. Tracking began on 1/30/2025, conducted by the DON. DON and designee will educate nursing staff before the next shift and newly hired nurses. IDT Team were educated on the importance of timely insulin administration provided by DON on 2/07/2025. Staff that were not physically present in the facility were contacted via phone and education provided to them by the DON and/or ADONs on 2/07/2025. DON and ADONs will educate nursing staff before the next shift. 3. Monitoring The reconciliation of medications with MD will be monitored by the DON or ADONs by using the Admission Drug Regimen Review and Reconciliation tracker. The tracker log consists of signing off on the MD reconciliation review of discharge medications list and reviewing the order listing in daily clinical meeting Monday-Friday by the DON or designee and IDT Team. Saturday and Sunday, tracker will be monitored by the DON or designee. Reconciliation tracking log was initiated for new admissions beginning 1/30/2025 to current by the DON. The insulin monitoring tracker will be presented at the monthly Quality Assurance Performance meeting. 4. QAPI Committee Review: Ad Ad Hoc QAPI committee meeting was completed on 2/07/2025. The Plan of Removal was accepted on 02/08/2025 at 5:29 p.m., and the verification of the POR included the following: 1. Interview with Medical Director on 2/07/2025 at 4:45 PM verified he was notified of IJ. Record review on 2/8/25 for 12 of 12 residents with insulin orders (chart audit), insulin tracker and drug regimen review completed. Verified available insulin medication matched order for 3 of 3 residents [Resident #1, Resident #3, Resident 4] on 2/8/25 at 11:30 a.m Record review on 2/08/2025 verified in-service and education was completed for 28 of 28 FT / PRN staff [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON] and 8 of 8 Agency staff on 2/07/2025. 2. Interviews on 2/08/2025 between hours of 7:30 AM - 7:00 PM with 17 of 27 FT/PRN Nurses: LVN H stated aware of how to complete a change of condition and understands importance of accurate medication reconciliation for new admissions. RN I stated understanding of how to input orders into EMR, identify and report change of condition and need to clarify admitting orders with MD. LVN J stated understanding of importance of verifying admitting orders and confirming with MD as well as date input in EMR. LVN C stated inservices received for change of condition, medication reconciliation and understands importance. LVN K stated understands process of medication reconciliation for admissions and need to take time in reviewing discharge instructions, verbalized understanding of change of condition notifications. LVN L stated understanding of change of condition and understands need to clarify all discharge instructions for admissions and verify with MD. LVN M stated received inservices for change of condition and clarification of medication reconciliation for discharge instructions on new admissions. LVN N stated understanding of importance of completing new admissions and discharge instructions / medication reconciliation on all new admissions and notifying MD for change of conditions. LVN AE stated received inservices on identify and reporting change of condition and importance of completing accurate medication reconciliation on all admissions. LVN O stated received inservices for change of condition and new admissions. Stated understands how to complete medication reconciliations and date input in EMR. LVN Q stated understands how to complete new admission assessments, change of condition assessments and medication reconciliation according to discharge instructions. LVN S stated understanding of need for clarification and accuracy for new admissions and following discharge instructions, notifying MD and completed change of condition assessments. LVN T stated received inservices for change of condition and understands importance of notifying MD and verify new admission orders. LVN U stated understanding of process for new admissions and need to ensure accurate transcription and notification of MD to verify orders. LVN V stated received inservices for change of condition, medication reconciliation for new admissions and understands how to input into EMR. LVN X stated understands need to accuracy when completing new admission medication reconciliation and notifying MD of change of condition. 4 of 4 Agency Nurses on duty 2/08/2025 (LVN Z, LVN Y, LVN AI, LVN B) verified they received in-services and training from DON or ADON (RN DON AG, LVN ADON G, LVN ADON R, Admin LVN P) regarding completing a Change of Condition assessment, completing new and re-admission medication reconciliation and admission assessments according to Admission Checklist to include verifying orders (all orders, but specifically insulin orders) and transcribing orders in EMR. Inservice Training and Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interview on 2/08/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication reconciliation process for admissions. Inservice Training and Training log for 27 of 27 FT/PRN Staff review and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interviews on 2/8/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication availability, who to contact and how to access Emergency medication system. Inservice Training & Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN nurses with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Record review on 2/08/2025 of In-service log and training provided reviewed. All nurses interviewed were able to identify how to complete a Change of Condition assessment, how to verify orders for new admissions according to discharge instructions by transcribing and verbalizing to physician (or designee) to include how to input information in EMR including parameters and sliding scale needs for insulin orders. Through interview and observation, staff members were able to demonstrate they received identified inservices and demonstrated knowledge of subject matter through surveyor questions. 3. Record review on 2/08/2025 of facility initiated tracker that will be reviewed in clinical meetings. Confirmed monitoring process by Administrator and DON. Completed record review on 2/08/2025 of facility tracking form. Observation on 2/08/2025 at 11:45 AM of insulin administration for 1 of 1 residents (Resident #3) completed with no errors. Confirmed with 11 of 21 FT/PRN Nurses that they received competency training for insulin administration and order implementation. 1 PRN nurse LVN Q had not received competency training and has not worked since November 2025. LVN Q is aware that he will need to complete competency training prior to start of next scheduled shift (no shift identified at this time). [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. 4. Interview with Administrator on 2/08/2025 confirmed that tracking system will be reviewed at least quarterly during QAPI meeting. The Administrator was informed the Immediate Jeopardy was removed on 2/08/2025 at 7:37 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure Resident #1 was administered Insulin Glargine 17units daily for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on [DATE] at 5:01 PM. The IJ was removed on 2/08/2025. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective actions. This failure placed resident at risk for adverse side effects to include increase in blood glucose levels and life-threatening complication of Diabetic ketoacidosis. Findings include: Record review of Resident #1's face sheet, dated 02/06/2025, revealed a [AGE] year-old female admitted [DATE] with diagnoses of UTI and new on-set CHF with co-morbidity of DMII (a long-term condition in which the body does not make enough insulin). Record review of Resident #1's hospital discharge instructions, dated 01/30/2025, revealed an order for 17u Insulin Glargine 1x daily. Hospital discharge instructions did not include monitoring of blood glucose levels. Record review of Resident #1's blood glucose levels revealed the following results: 2/5/25 @ 6:21 PM 233 mg/dL, 2/6/25 @ 9:28 AM 446 mg/dL, 2/6/25 @ 4:52 PM 274 md/dL, and 2/6/25 @ 5:13 PM 274 mg/dL. Blood glucose levels were not checked prior to 2/5/25. Record review of Resident #1's Baseline Care Plan, dated 01/30/2025, revealed resident was a Type II Diabetic and was receiving insulin. Record review of Resident #1's Admission MDS, dated [DATE], revealed the MDS was pending completion and submission. Record review of Resident #1's February 2025 MAR revealed the facility did not transcribe an order for 17u Insulin Glargine until 02/06/2025. In an interview with LVN G on 2/5/25 at 4:30: PM, LVN G stated she was notified by Resident #1's family member that Resident #1 received daily insulin. LVN G stated she confirmed the hospital discharge medication listing and that the admitting nurse had failed to transcribe the order for 17units Insulin Glargine daily. An interview and observation of Resident #1 on 2/6/25 at 3:24 PM revealed Resident #1 sitting up at edge of bed with bedside table in place going thru her mail. The resident was wearing personal clothing items, presented clean, well-groomed, odor free, and wearing prescription glasses in place, that were clean and serviceable. The resident was hard of hearing, but was amiable and accepting of surveyor interaction. Resident #1 stated she told her family member yesterday [02/05/205] that she had not received her insulin like she did at home but did not mention it to facility staff. Resident #1 stated she notified her family member. Resident #1 stated she administers her own insulin at home. Resident #1 verbalized she felt fine today and was pleased that correct orders were now in place. Resident #1 stated she had lived with diabetes for years, did not feel any different. In an interview with DON on 02/06/25 at 4:45 PM, the DON stated she was informed by LVN G of the missed order for daily insulin Glargine on Resident #1's admission 01/30/2025. The DON confirmed LVN G notified the resident's physician on 2/025/2025 at 4:30 PM and obtained orders for 17units Insulin glargine daily. The DON confirmed the resident had not received insulin for 6 days from 01/31//25-02/5/25, putting her at risk for hyperglycemia (elevated blood sugar levels) with both short-term and long-term effects. The DON stated she expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure administration of medications. In an interview with Administrator on 02/06/25 at 5:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per physicians' order. The Administrator stated she expected nursing staff to follow physicians' orders. In an interview with MD #1 on 2/6/255 at 5:45 PM, MD #1 (current physician as of 2/6/25) revealed that when he was notified of Resident #1's BS 446, he advised them to give 4u fast acting and re-check the resident's BS. MD #1 stated he did not like aggressive s/s for geriatric patients and would figure out where she was normally and adjust as needed. MD #1 stated he did not feel more adverse effects as the resident's levels were similar to the hospital levels. MD #1 stated his expectations were, of course are that they follow his orders and is is pleased with the fast action they took with termination of the nurse he spoke to personally regarding the 4u of Lantus administration. In an interview with MD #2 on 2/6/25 at 5:55 PM, MD #2 (admitting physician) stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue hospital orders and he evaluated the resident in person on 1/31/25. MD #2 stated he was not concerned when they told him about the missed Lantus dose of 17u because it is long acting and stays 36-40 hours, so not that damaging. MD #2 stated he had protocols in place for Glucagon and that a s/s for Lantus were not recommended anyway. Record review of the facility policy named, Reconciliation of medications on Admission, revised July 2017, revealed, admitting nurse should reconcile the discharge medications to include dose, route and frequency for all medications, notify physician to verify admitting orders and transcribe them accordingly to the EMR. Record review of the facility policy named, Administering Medications, revised April 2019, revealed, medications are administered in accordance with prescriber orders. This was determined to be an Immediate Jeopardy (IJ) on 2/7/25 at 5:01 PM. The Administrator and the DON were notified and provided the IJ Template on 2/7/25, and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 2/8/2025 at 5:29 PM. [facility Name] Tag Cited: F760 Alleged Issues: The facility failed to ensure Resident #1 was free from significant medication errors when the facility failed to administer Insulin Glargine medication according to hospital discharge instructions and fast acting insulin as ordered by the physician. Plan of Removal 1. Immediate Actions The Medical Director was notified by the Administrator on 2/07/2025 of the Immediate Jeopardy. The DON completed a chart audit on all residents receiving insulin on 2/07/2025. An insulin tracker was implemented for an audit to be completed daily to assure insulin is administered correctly and in a timely manner. Audit completed by DON on 2/07/2025. Insulin Tracker will be monitored by DON or ADON daily in clinical meeting with IDT Team Monday thru Friday. On Saturday and Sunday Insulin tracker will be monitored by the DON or designee. The DON completed an insulin audit on 2/07/2025 to confirm insulin orders were in place and transcribed correctly. 2. Education An in-service was conducted with DON and ADONs by the VP of Clinical on 2/07/2025 in regard to the insulin order audit and educating staff on administration competency and glucometer use check off. One on one education to clinical staff regarding physician's orders for insulin administration are to be followed accurately and on time. Blood glucose monitoring orders are to be followed accurately an on time. Date will be documents in the residents' chart at time of administration. Completed by DON and ADON's on 2/07/2025. DON will educate nursing staff before their next shift and new hire nurses before they begin working. IDT Team members were educated on the importance of timely insulin administration. DON or designee will verify daily insulin tracker in clinical meeting (Monday through Friday, DON or designee Saturday and Sunday) on new admissions an insulin dependent residents by reviewing the MAR daily. Staff that were not physically present in the facility were contacted via phone and education reviewed with them by the DON and ADON's on 2/07/2025. DON and ADONs will have nursing staff educated before their next shift. 3. Monitoring The order listing will be reviewed daily in the morning clinical meeting by the IDT Team Monday through Friday. Saturday and Sunday, the order listing will be reviewed by the DON or designee and tracked on the insulin log. Interventions will be implemented with the insulin tracker log Monday through Friday in the clinical meeting with the IDT Members and monitored by the DON or designee on Saturday and Sunday. Insulin tracker will be monitored by the DON and Administrator for completion. The insulin monitoring tracker will be presented at the monthly QAPI meeting for a minimum of three months. Insulin / glucose administration competencies was observed and conducted by the DON and ADONs on 2/08/2025. Insulin / glucose competencies will be completed for new hire nurses during on boarding with DON or designee. 4. QAPI Committee An Ad Hoc QAPI committee meeting was completed 2/07/2025. The Plan of Removal was accepted on 02/08/2025, and the verification of the POR included the following: 1. Interview with Medical Director on 2/07/2025 at 4:45 PM verified he was notified of IJ. Record review of facility created tracker audit of all residents receiving insulin on 2/08/2025. Reviewed process of on-going monitoring with DON. Review for 12 of 12 residents with insulin orders to verify orders are in EMR system was completed on 2/0/2025 with no errors. Verification of administration of 3 of 3 residents insulin per MAR and observation of 1 of 1 residents (Resident #3) insulin administration was completed on 2/08/2025 with no errors. 2. Interview on 2/08/2025 with 11 of 27 FT/PRN Nursing Staff and 4 of 4 Agency staff on duty 2/08/2025 to confirm that they received in-service on administration of insulin. Observation completed on 2/08/2025 at 12:00 PM for 1 of 1 residents (Resident #3) insulin administration for accuracy of order and medication available. Verified with each nurse interview that they understood how to input orders into the EMR system, understood the process for following insulin orders and recording data accurately and timely. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interviews on 2/08/2025 between hours of 7:30 AM - 7:00 PM with 17 of 27 FT/PRN Nurses: LVN H stated understands how to input insulin orders in EMR and complete change of condition assessments. RN I stated understand insulin parameters, how to input into EMR and notify MD for change of condition. LVN J stated understands how to input insulin parameters in EMR and how to complete change of condition assessments. LVN C stated understands how to complete orders for insulin with accurate parameters and need to notify physician of change of condition. LVN K stated understands change of condition assessments, need to notify MD and how to data input insulin parameters in EMR. LVN L stated understands how to complete insulin orders and change of condition assessment. LVN M stated understands how to put insulin orders in EMR per physicians orders and to notify MD of change of condition. LVN N stated understands how to input insulin orders in EMR and how to complete change of condition assessments. LVN AE stated understands how to recognize and report change of condition assessments and need to notify MD and understands how to input insulin orders and parameters in EMR. LVN O stated understands how to input insulin orders in EMR and understands what assessments / notifications are needed for change of conditions. LVN Q stated receives inservices on insulin orders and change of conditions. LVN S stated understands training on insulin orders administration and data input and change of condition notifications. LVN T stated understands need to notify MD for change of condition and understands how to input insulin orders in EMR, LVN U stated received inservices on insulin orders and identifying / reporting change of condition. LVN V stated understands how to complete insulin administration orders and input parameters in EMR and understands how to complete change of condition assessments. LVN X stated received inservices on insulin orders administration and date input in EMR and inservice on completing and recognizing change of condition 4 of 4 Agency Nurses on duty 2/08/2025 (LVN Z, LVN Y, LVN AI, LVN B) verified they received in-services and training from DON or ADON (RN DON AG, LVN ADON G, LVN ADON R, Admin LVN P) on competency for insulin administration, how to enter insulin parameters in EMR, insulin documentation and change of condition notifications. Reviewed / copied facility created insulin tracker that will be reviewed in clinical meeting. [6 Ft 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. All nurses interviewed were able to verbalize how to transcribe and date input insulin orders including blood sugar monitoring parameters in the EMR. All nurses interviewed verbalized understanding of need to notify physician of change of condition related to blood sugar levels. Verification of administration of 3 of 3 residents insulin per MAR on 2/8/25 at 11:30 AM [Resident #1, Resident #3, Resident #4] and observation of 1 of 1 residents (Resident #3) insulin administration was completed on 2/08/2025 at 11:45 AM with no errors. 3. Record review on 2/08/2025 of facility initiated tracker that will be reviewed in clinical meetings. Confirmed monitoring process by Administrator and DON. Completed record review on 2/08/2025 of facility tracking form. Observation on 2/08/2025 at 11:45 AM of insulin administration for 1 of 1 residents (Resident #3) completed with no errors. Confirmed with 11 of 21 FT/PRN Nurses that they received competency training for insulin administration and order implementation. 1 PRN nurse LVN Q had not received competency training and has not worked since November 2025. LVN Q is aware that he will need to complete competency training prior to start of next scheduled shift (no shift identified at this time). [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. 4. Administrator verified QAPI meeting was completed with PIP in place in conjunction with this Plan of Removal. The Administrator was informed the Immediate Jeopardy was removed on 2/08/2025 at 7:37 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 had adequate interventions and supervision in place to prevent accidents for Resident #1. Resident #1 had seven falls in 1 month (11/19/24, 11/25/24, 11/27/24 x2, 12/11/24 x2, and 12/13/24), the last of which resulted in injuries and hospitalization . An IJ was identified on 12/19/24. The IJ template was provided to the facility on [DATE] at 7:15 pm. While the IJ was removed on 12/21/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to monitor the implementation of the plan of removal. These failures placed the resident at risk for accidents and serious injuries. Findings included: Record review of Resident #1's Admission Record, dated 11/14/24, revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included: malignant melanoma of skin (skin cancer), osteoporosis (weak/brittle bones), muscle weakness, gait/mobility abnormality, lack of coordination, cognitive communication deficit (difficulty with thinking and language), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), memory deficit, frontal lobe and executive function deficit (damage to the frontal lobe of the brain causing impairment in executive function), hypertension (high blood pressure), cerebral infarction (stroke - disrupted blood flow to the brain), and syncope (fainting/passing out) and collapse. Record review of Resident #1's Comprehensive MDS assessment, dated 11/18/24, revealed Resident #1 had a BIMS score of 11, suggesting moderate cognitive impairment. Further review revealed Resident #1 had an impairment to a lower extremity, required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds. Or supports trunk or limbs) toileting hygiene, sit to stand, chair/bed-to-chair transfer, and toilet transfer; and was dependent (Helper does all the effort) to walk ten feet and picking up objects; required supervision/touch assistance to wheel 50 feet with two turns. Record review of Resident #1's Baseline Care Plan, dated 11/18/24, revealed Resident #1 had a history of falls. Record review of Resident #1's Order Summary, dated 12/15/24, revealed: Duloxetine 60 Mg once a day (used to treat Depression), Losartan Potassium 100 Mg once a day (used to treat high blood pressure), Metoprolol 100 Mg once a day (used to treat high blood pressure), and Tramadol 50 Mg as PRN (used to treat pain). Record review of Resident #1's Care Plan, dated 12/15/24, revealed: [Resident #1] has had an actual fall with no injury r/t Poor Balance and Unsteady gait 11/27/24 11/28/24, initiated on 11/28/24 and revised on 12/6/24. Interventions/Tasks for the focus included: Call don't fall signs in room initiated 12/6/24, Continue interventions on the at-risk plan, initiated 11/28/24, fall mat at bedside, initiated 12/6/24, Fall mat beside residents [sic] bed to help prevent injury due to falls out of bed, initiated 11/28/24, and PT consult for strength and mobility, initiated 11/28/24. Record review of the facility's incident log, dated 12/15/24, revealed Resident #1 had falls on 11/19/24, 11/25/24, two falls on 11/27/24, 12/11/24, and 12/13/24. Record review of Resident #1's Fall Risk Evaluation, dated 11/14/24, revealed a score of 2. Further review of the evaluation revealed it was incomplete. Further review of the evaluations revealed .If the total score is ten or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . Record review of Resident #1's Fall Risk Evaluation, dated 11/14/24 and completed on 12/15/24, revealed a score of 19. Fall Risk Evaluation, dated 11/19/24, revealed a score of 13; 11/25/24, revealed a score of 20; 11/28/24, revealed a score of 22; 12/11/24, revealed a score of 20; and 12/13/24, revealed a score of 17. Further review of the evaluations revealed .If the total score is ten or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . Record review of Resident #1's Therapy Screen, dated 11/25/24, revealed: fall screen; patient educated on calling nursing staff for assistance with obtaining clothing as pt reports she fell out of her chair trying to get clothes. She reports she slid out of her char [sic]. Per nursing pt found sitting on floor in front of her closet and in front of w/c .will continue to educate and monitor for any falls. Record review of Resident #1's Therapy Screen, dated 11/29/24, revealed: Fall screen .reported to have multiple falls recently. Pt educated on transfer training from w/c-toilet-w/c and w/c-bed-w/c with use of .grab bar. Pt given constant reminders to always call for assistance with all transfers. Record review of Resident #1's Therapy Screen, dated 12/11/24, revealed: Fall screen-Pt had 2 falls today, one in the morning when attempting to pick up a small piece of paper from the floor and Pt fell later in day when attempting to gather items from bedside with falling out of w/c. Nursing, therapy, and aides in room educating and reminding pt to use call light prior to standing or reaching for items. Pt is very unsafe and does not recall safety techniques .We will continue to educate pt on safety and precautions. Record review of Resident #1's Therapy Screen, dated 11/21/24, revealed: Patient sustained a fall from attempting to stand up from WC using the end of the bed rail for assistance and walk into the bathroom, patient ending up falling to the floor landing on her buttocks .educated on importance of asking for assistance and using call light. Record review of Resident #1's Progress Notes revealed: 11/19/24 - No progress notes regarding Resident #1's fall. 11/25/24 at 2:18 pm - This nurse called to room by CNA after resident was found on the floor. Upon entering room resident found in sitting position with legs out in front of her, non-skid socks in place. Resident in front of closet. Wheelchair with seat cushion upright, brakesunlocked [sic], positioned behind resident .Author: [LVN E] . 11/27/24 at 7:00 pm - Resident had unwitnessed fall in the bathroom. Resident stated she was trying to get up to wipe after using the bathroom. Resident stated that her surgical shoe, is what made her fall. Resident was found in the shower on her left side/back .Educated resident on using call light system for help and to not get up on her own .Author: [LVN D] . 11/27/24 at 11:35 pm - .SBAR .RESIDENT NOTED LYING ON RT SIDE ON FLOOR, NEXT TO BED, STATED I WAS TRYING TO ANSWER MY PHONE IT WAS RINGING, RESIDENT ASSESSED, VS TAKEN, NEURO CHECKS INITIATED PER FACILITY PROTOCOL, SKIN ASSESSMENT HEAD TO TOE DONE .FALL PRECAUTIONS INITIATED FLOOR MATTS [sic] IN PLACE, WILL CONTINUE TO MONITOR . 12/11/24 at 5:11 am - RESIDENT CONTINUES MONITORING UNWITNESSED FALL DAY 1/3 /C NEURO CHECKS, NO S/S ACUTE DISTRESS, NO C/O PAIN OR DISCOMFORT VOICED .WILL CONTINUE TO MONITOR. Author: [LVN F] . 12/13/24 at 1:53 pm - S/P Fall day 3/3 Resident continues to try and self-transfer. Resident needs constant monitoring and reorientation. Resident utilizes call light but does not wait for assistance. Resident educated on importance of waiting for staff assistance with transfers. Neuros assessed per protocol. Author: [LVN E] . 12/13/24 at 6:20 pm - .head to Toe assessment performed. resident unconscious, and resident breathing. Unable to arouse resident and assess pain. Awaiting EMS arrival. Author: [LVN D] . 12/13/24 at 6:25 pm - Awaiting EMS arrival. This nurse by residents [sic] side, reassuring resident that staff is with her. Resident still unconscious. Resident is still breathing. Author: [LVN D] . 12/13/24 at 6:33 pm - .at approximately [6:15 pm] [MA A] the medication aide alerted this nurse that our resident [Resident #1] was on the floor from an unwitnessed fall. resident was found on the floor face down, left arm underneath her body. Resident was unconscious. Blood evident on the [sic] floor. Residents nose was bleeding, Unsure from the way resident was laying if head laceration occured [sic]. Resident unable to respond to questions. Vitals 98.6 T, 159/95 BP, 80 Heart rate. EMS immediately called. resident finally able to respond to pain. Resident unable to tell us what hurt. EMS arrived on scene and assessed resident. Resident put in C-collar by Ems and taken out to hospital. ADON [LVN L] notified once resident was taken by EMS. MD notified as well. Residents' [sic] roommate said resident got upeven [sic] though she told her to call but resident did not listen to her. Roommate was the one who initiated and called for help. Author: [LVN D] . Record review of the facility's incident reports revealed: 11/19/24 at 10:51 pm - .Per CNA [CNA O], resident had witnessed fall. CNA [CNA O] stated that the resident was in her wheelchair and tried holding onto the edge of the bed to stand up to go to the bathroom. Upon trying to stand, [CNA O] stated she witness [sic] the resident slide down onto the ground from wheelchair. Per [CNA O] CNA, and resident, resident did not hit her head and landed strictly on bottom. No skin tears or bruising or pain present . 11/25/24 at 1:28 pm - .This nurse called to room by CNA after resident was found on the floor. Upon entering room resident found in sitting position with legs out in front of her, non-skid socks in place. Resident in front of closet. Wheelchair with seat cushion upright, brakes unlocked, positioned behind resident. Resident alert and oriented x3, respirations even and unlabored, denies pain. I was sitting on the edge of my wheelchair trying to reach in the closet when I jut plopped down straight on my but [sic] . 11/27/24 at 11:15 pm - .Resident was found lying on the bathroom floor in shower. Resident stated she tried to stand up and wipe herself. Resident stated that her surgical shoe is what caused her to fall. Resident was found lying on her left side/back. Resident denied pain at initial assessment. Neurological asssessment [sic], and pain assessment completed at this time .Resident stated she did not hit her head . 11/27/24 at 11:35 pm - .RESIDENT NOTED LYING ON RT SIDE ON FLOOR, NEXT TO BED, STATED I WAS TRYING TO ANSWER MY PHONE IT WAS RINGING, RESIDENT ASSESSED, VS TAKEN, NEURO CHECKS INITIATED PER FACILITY PROTOCOL, SKIN ASSESSMENT HEAD TO TOE DONE, HEAD NORMOCEPHALIC, NO S/S ACUTE DISTRESS, RESIDENT ABLE TO MOVE ALL EXTREMITITES, NO C/O PAIN OR DISCOMFORT, NON-SKID SOCKS ON AT TIME OF INCIDENT, RESIDENT NON COMPLIANT CONTINUES TO ATTEMPT TRANSFERS WITHOUT ASSITANCE, POOR SAFETY AWARENESS, BED AT LOWEST POSITION. CALL LIGHT WITHIN REACH, REITERATED IMPORTANCE OF USING CALL LIGHT FOR ASSISTANCE, RESIDENT ACKNOWLEGES UNDERSTANDING STATING I KNOW ,I KNOW I SHOULD CALL, YOU ALL WILL BE HAPPY WHEN I LEAVE THIS PLACE, BLAME MY FALL TO THE PERSON CALLING MY PHONE AT THIS TIME . 12/11/24 at 4:35 am - .RESIDENT UNWITNESSED FALL , NOTED SITTING ON BUTTOCKS IN FRONT OF RECLINER, RESIDENT ASSESSED, HEAD TO TOE DONE, NO VISIBLE INJURIES NOTED, VS TAKEN, NEURO CHECKS INITITATED PER FACILITY PROTOCOL, NON-SKID SOCKS ON AT TIME OF INICIDENT, RESIDENT STATED I WAS TRYING TO PICK UP MY REMOTE TO WATCH TV, IT fell RESIDENT REITERATED THE IMPORTANCE OF USING CALL LIGHT FOR ASSISTANCE, STATED YES , I KNOW, I DID NOT FALL I JUST SLID OFF MY CHAIR, NO NOTHING HURTS AND NO I DID NOT HIT MY HEAD, IM SORRY RESIDENT ASSISTED ONTO W/C AND IS NOW IN COMMON AREA WATCHING TV, WILL CONTINUE TO MONITOR, MD, AND ADON NOTIFIED, RESIDENT SELF RP. RESIDENT STATED I WAS TRYING TO PICK UP MY REMOTE TO WATCH TV, IT fell STATED YES, I KNOW, YOU DONT HAVE TO TELL ANYONE I JUST SLID OF MY CHAIR, NO NOTHING HURTS AND NO I DID NOT HIT MY HEAD, IM SORRY . 12/11/24 at 2:55 pm - .CNA came to grab this nurse to let her know resident had un-witnessed fall. Resident observed on her left hip in front of wheelchair. Resident stated no pain, and that she knows she is supposed to call for help transferring but just didn't call. Neuro assessment done and resident at neurological baseline. Resident able to move bilateral upper and lower extremities. Re educated resident on call light use . 12/13/24 at 6:15 pm - .At approximately 18:15 [6:15 pm] the medication aide alerted this nurse that our resident [Resident #1] was observed on the floor from an un witnessed fall by the CNA on the hall, however fall witnessed by resident's roommate. Resident was observed with her face down on the floor, and left arm underneath her body. Resident was unconscious, respiration noted, but unable to respond or answer any of my questions that were asked. Blood was evident on the floor underneath resident's face, nose noted to be bleeding at this time. Unable to move resident due to a possible neck or back Injury. Unsure from the way resident was laying if head laceration occurred. EMS immediately notified. This nurse continued to reassure resident that there was staff with her. this nurse stayed with resident until EMS arrived on scene. EMS then arrived on scene, where they also performed a head to toe assessment, at this time resident still unconscious. EMS then put resident into a C-Collar and resident began to respond and answer questions from EMS regarding her pain level and stated she hurt all over her body EMS immediately transported her out. ADON notified at 18:25 [6:25 pm] once resident was safe with EMS. [MD] notified at 18:40 [6:40 pm]. Resident Unable to give Description . Record review of Resident #1's Hospital B documentation, dated 12/17/24, revealed Dementia and diagnostic report on a CT scan of Resident #1's brain/head without contrast. The report, dated 12/13/24, revealed IMPRESSION: .subarachnoid hemorrhage .Left frontal scalp hematoma . During a telephone interview on 12/15/24 at 2:45 pm, LVN D said Resident #1 had fallen on 12/13/24 and was found on the floor in her room face down with her left arm under her body, there was blood on the floor, and blood was coming from her nose. LVN D said she was unsure if Resident #1 had a head laceration and was not moved because they were unsure if she had a neck injury. LVN D said Resident #1 was breathing but snoring and her vitals were normal. EMS was called, LVN D said Resident #1 did not wake up at all. LVN D said Resident #1 did not respond to questions from EMS but did open her eyes when EMS turned her over. LVN D further stated Resident #1 said she hurt all over. LVN D said the fall was unwitnessed by staff but Resident #1's roommate said Resident #1 was getting up out of her wheelchair and her roommate told her not to get up and to use the call light. LVN D said Resident #1 did not like to use her call light. LVN D further stated Resident #1 had been educated about using the call light. LVN D said Resident #1 would apologize for not using the call light to ask for assistance. LVN D said Resident #1 had sustained other falls with no injuries. LVN D said there were signs in each resident's room, reminding them to use the call light, especially if they have fallen, but could not recall if Resident #1 had or not. LVN D said she did not remember if the fall mat was next to Resident #1's bed. During a telephone interview on 12/15/25 at 2:53 pm, CMA A said on 12/23/24 she was preparing medications when she heard someone yelling for help. CMA A saw Resident #1 on the floor, checked to see if she was okay, and told the nurse. CMA A further stated Resident #1 was fast asleep that hit knocked her out, staff called EMS. CMA A said she had walked by earlier and Resident #1 was sitting in her wheelchair by her bed, facing the door. CMA A said Resident #1 was able to use the call light and was coherent to use it. CMA A said she had caught Resident #1 transferring from the bed to the chair and told her to use the light when she wanted to transfer. CMA A further stated she would remind Resident #1 to use the call light when she saw her. During a telephone interview on 12/15/24 at 3:05 pm, CNA B said on 12/13/24 Resident #1 fell within 20 minutes after the start of her shift. CNA B said she and the CNA from the previous shift just completed a hall walk to ensure her residents were safe. CNA B said she was assisting another resident across the hall in the restroom when she heard someone start to yell so she asked CMA A to see what was going. CNA B said she was told by CMA A that Resident #1 was on the floor. CNA B said Resident #1 had knocked herself out and she was snoring. CNA B said Resident #1 had to be in a state of unconsciousness when she landed because the position she was in was not natural. CNA B said during her round Resident #1 was sitting in her wheelchair. CNA B said this was only the second shift she worked on the skilled hall but had heard Resident #1 was a huge fall risk. CNA B said she saw Resident #1 trying to get up a few times on the shift prior and staff went in to redirect her, made sure the call light was in reach, and asked her to use it. CNA B said Resident #1 tried to get out of bed or her wheelchair without assistance. CNA B further stated she was not sure if Resident #1 had dementia, but staff had to reiterate. Interview on 12/15/24 at 2:15 pm, Resident #1's roommate said she was sitting in the room when she saw Resident #1 standing on12/13/24 but was unsure why she got up. Resident #1's roommate said she did not actually see her fall because it was dark. The state investigator did not observe a Call don't fall or fall mat in Resident #1's room. During an interview and observation on 12/16/24 at 4:45 pm, LVN D said Resident #1 was unsteady and had a surgical shoe that made her more unsteady. LVN D further stated Resident #1 could bare weight with assistance and was not able to walk on her own. LVN D said the fall mat in Resident #1's room might have contributed to the fall on 12/13/24 because of the surgical shoe. LVN D said Resident #1 was not on a toileting schedule and was able to tell staff when she needed to use the restroom. LVN D said she did not know how often Resident #1 was checked on the other shifts but on her shift the aides went up and down the hall about every thirty minutes and so did she. Resident #1's room was observed to be in the middle of the hallway with a table and two empty chairs outside the door. During an interview on 12/16/24 at 5:02 pm, CNA C said Resident #1 was asked her every 2 hours if she needed to use the restroom or she would let the staff know when she needed to use the restroom. CNA C said she tried to get to know her residents as much as possible or would find out from the therapy department the level of care residents required. CNA C said she did not know how to access the Kardex (document used to view the residents' level of need/care) and did think CNAs could have access to them. CNA C said Resident #1 was able to use the call light to call for assistance. CNA C further stated Resident #1 had started getting up more without help but was not sure when this started. CNA C said Resident #1 did not have a fall mat. CNA C said the staff told Resident #1 not to get up alone and Resident #1 would say yeah I know but she still got up without calling for help. CNA C said she had seen Resident #1 trying to stand at times and went in her room to assist her. CNA C said Resident #1 did not have special supervision and did not know how often the nurses went into her room. CNA C said she did not know what the facility's At risk plan or Fall protocol were. CNA C said if a resident fell staff were required to notify the nurse immediately and the nurses followed up with interventions. During an interview on 12/18/24 at 12:27 pm, LVN E said she did not think Resident #1 fell on [DATE] but remembered LVN F said Resident #1 had fallen on her shift. LVN E said Resident #1 did fall on 11/25/24 while looking for clothes in her closet. LVN E said she told Resident #1 not to get up and to use her call light. LVN E further stated she did not think Resident #1 had new interventions after 11/28/24. LVN E said Resident #1 never had a fall mat in her room and thought the fall mat would have put Resident #1 at a higher risk for falls. She stated she was never really in bed during the day, she was usually in the wheelchair or recliner, and she would self-transfer so she thought the mat would have tripped her. LVN E said the facility's fall protocol was to initiate neuro checks and make sure the residents' call light was within reach. LVN E said she did not think Resident #1 refused to use the call light but just forgot. LVN E further stated Resident #1 was forgetful and was confused at times, adding she thought Resident #1 had dementia. LVN E said she did not review resident care plans, did not know where to find them, and had not heard of any expectations regarding reviewing care plans. LVN E said she learned about the residents' level of care through the hospital paperwork, what the CNAs saw, shift report, and if the residents needed a higher level of care, therapy would usually let the staff know. LVN E said Resident #1's room was in the middle of the hallway where the CNAs sat to complete their documentation. LVN E further stated the CNAs sat at the table outside Resident #1's room from time to time. During an interview on 12/18/24 at 1:42 pm, the PTA said Resident #1 had had multiple falls during self-attempted transfers since her admission despite repeated education reminding her not to self-transfer. The PTA said she educated Resident #1 every day and she demonstrated no carry over between sessions, there was poor cognitive insight to her own deficits. The PTA said Resident #1's poor cognition was communicated to the nursing staff and documented in the daily notes that Resident #1 was a very high fall risk. The PTA said Resident #1 did not have a floor mat because she was not falling off the bed but fell during self-transfers, during functional tasks. The PTA said a fall mat would have probably put Resident #1 at a higher risk for falls and if staff had added a fall mat to Resident #1's care plan it was not communicated to her. The PTA said Resident #1's cognitive status was very poor since her admission, she had significant safety awareness deficits, and needed constant reminders. During an interview on 12/18/24 at 1:55 pm COTA K said Resident #1 was working on cognitive things during therapy, she was very forgetful, easily distracted, her problem solving and sequencing were bad. COTA K said she focused on the call light with Resident #1, because she had a lot of falls and just was not safe. COTA K said she thought Resident #1's cognition had gotten worse. COTA K said their main goal was to keep Resident #1 safe because her balance was poor. COTA K said Resident #1's condition had been communicated to the nursing staff. COTA K said the staff reminded Resident #1 to use the call light but it was about her remembering to use it. COTA K said Resident #1 did not have increased supervision other than her room door was kept open. COTA K said she had to repeat instructions to Resident #1 during therapy sessions because she forgot the task they were working on during the same session. During a telephone interview on 12/18/24 at 2:14 pm, Resident #1's family member said Resident #1's medical/surgical history had taken a toll on her cognitively. Resident #1's family member said Resident #1 had been feeling dizzy. Resident #1's family member further stated Resident #1's cognitive decline had been more than normal in the last couple of months and she got confused. Resident #1's family member said she did not know if Resident #1 remembered to use the call light and wait for assistance. During an interview on 12/18/24 at 2:31 pm, LVN L said she did not know if Resident #1 was falling due to lack of memory, but she kept trying to get up and would fall, and she had a surgical shoe and she would try to walk with that shoe. LVN L further stated Resident #1 was forgetful. LVN L said she did not think Resident #1 was not purposefully non-complaint. LVN L said Resident #1 had call don't fall sign, a fall mat, and verbal redirection on her care plan. LVN L said she could not say how long Resident #1 retained information regarding using the call light. LVN L said Resident #1's room was located by the CNAs table and there was a CNA at the table a lot of times. LVN L said Resident #1 was off balance because of the surgical shoe and did not start falling until after she got the surgical shoe. LVN L said she did not know why Resident #1 had not been moved closer to the nurses' station yet but thought it was because her room was close to the CNAs documentation station and there was always someone sitting there. LVN L said the MDS nurse was responsible for updating care plans and the care plans were reviewed during the morning meetings. LVN L further stated since she was assigned to the skilled hall, she also met with the therapy department on Tuesdays and Thursdays to review the residents' needs and goals. LVN L said nurses were expected to review resident care plans but did not know when or how often they were required to review them. LVN L said her expectation as a ADON was for nurses to review care plans if they notice a change in condition. Attempted interview on 12/19/24 at 9:45 am with the Physician was unsuccessful. During an interview on 12/19/24 at 10:54 am, LVN H said the facility's at-risk plan meant residents were at risk for falls and standard interventions were added to the care plans. LVN H further stated interventions included: monitoring the residents for falls and if they had an actual fall it was added to the care plan along with interventions. LVN H said according to therapy Resident #1 was impulsive and tried to be independent. LVN H further stated therapy worked on reminding Resident #1 to use the call light, adding Resident #1 did well for a while, but then returned to not using it. LVN H said a sign was put in Resident #1's room because visual reminders were more effective. LVN H said reminders to use the call light was added to Resident #1's care plan but no other interventions had been added. LVN H said moving Resident #1 closer to the nurses' station had not been discussed prior to the 12/13/24 fall. LVN H said she did not know if Resident #1's surgical boot had been discussed because she did not always work at the facility. LVN H said other interventions should have been put in place for Resident #1 if she continued to fall. LVN H further stated each fall should have been reviewed but she was not in the facility during some the days Resident #1 sustained falls. LVN H said incidents and related documentation were reviewed during the morning meetings as well as what the residents were doing prior to the incident. LVN H said interventions were then put in place depending on the action that caused the incident. LVN H said she did not know why this was not done after each of Resident #1's falls. LVN H said the facility policy regarding care plans was that they be reviewed quarterly and annually and updated if necessary. LVN H said as the MDS coordinator, she was responsible for ensuring care plans were updated. LVN H said she was not aware that the interventions on Resident #1's care plan had not been implemented and management was responsible for ensuring interventions were implemented. LVN H further stated she could not say whether additional interventions would have prevented additional falls for Resident #1. During an interview and observation on 12/19/24 at 3:20 pm, Resident #1 was sitting in the chair in her hospital room, green/purple discoloration was noted to the left temple, area around her left eye, and left hand. Resident#1 said she had gotten in an accident but did not remember how. Resident #1 said she fell at home on 12/13/24 on the floor, hit her head and put a hole in the paneling in the kitchen. Resident #1 said she was trying to cook. Resident #1 said she fell like four times while at the facility. Resident #1 said she understood that not calling for help was a safety issue and she needed to pay attention to that. Resident #1 said she had been feeling light-headed a lot lately and thought she had mentioned this to the doctor. Resident #1 said she mentioned feeling dizzy to the facility staff and was told to sit down if she felt like she was falling. Resident #1 said she did not remember what she was doing or where she was going when she fell on [DATE]. Resident #1 further stated she told them I would get there when I get there. Resident #1 said she was sure the surgical shoe caused her to fall because it slipped, and she told them that it was slipping and making her fall. Resident #1 said she ended up falling and was unable to get up. Resident #1 said at times when she put her feet down, she got confused about them moving or not. Resident #1 further stated she did not know how she got to the hospital. During an interview on 12/19/24 at 3:50 pm, the Hospital B LVN said Resident #1's memory was good in the morning but started getting confused around 2 pm. The Hospital B LVN said Resident #1 had a hemorrhage which was now stable and a rib fracture. The Hospital B LVN said Resident #1 had not fallen at the hospital, she was checked every hour, and asked if she needed anything during that time. Interview attempts with LVN F on 12/19/24 at 5:30 pm and 12/21/24 at 6:28 pm were unsuccessful. During an interview on 12/21/24 at 5:43 pm, CMA A said she did not remember seeing a call don't fall sign on Resident #1's wall or a fall mat. CMA A further stated she never saw anything in front of Resident #1's bed, never. CMA A said she had overheard Resident #1 had several falls. CMA A further stated Resident #1's interventions had not been communicated to her. CMA A said before Resident #1 fell on [DATE] she had not heard about a Kardex (document used to view the residents' level of need/care) or how to access it. CMA A further stated that Resident #1 did not have any additional interventions in place prior to 12/13/24. CMA A said Resident #1 always had her call light and was reminded to use it, but she did not use it. CMA A said she thought Resident #1 forgot to use the call light sometimes. During a telephone interview on 12/21/24 at 5:56 pm, LVN D said she did not remember if Resident #1 had a fall on 11/19/24 during her shift. LVN D said if Resident #1 had fallen on her shift, she would have documented it. When we give report, we say whether they have fallen, and what interventions were in place and document it in the report book. She stated, We did not deal with the care plans, us nurses on the floor. I am new, I have only been there for two months, so I would not even know, we just informed each other during report. She remembered to use the call light, she says I know, I know. I have to use the red button when I need something. During an interview on 12/21/24 at 7:12 pm, LVN M said she worked on the long-term side but if Resident #1's interventions were not preventing her falls then they were not working. LVN M said the ADONs were responsible for ensuring care plan interventions were implemented and LVN L was responsible for the skilled hall were Resident #1 resided. During a telephone interview on 12/19/24 at 12:27 pm, the CVP (Interim DON) said based on interviews with Resident #1 she either did not think to use the call light for assistance or forgot. The CVP said if Resident #1 was forgetting to use the call light for assistance, then the reminders to use the call light were not effective. The CVP said the facility's goal was to keep re-educating Resident #1 and she would use the call light after the reminders. The CVP said Resident #1'a surgical shoe was di [TRUNCATED]

Based on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 (Resident #1) of 5 residents reviewed for a change of condition. The facility failed to notify the physician and follow up on a change in condition for Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on [DATE]. Resident #1 expired at the hospital on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 7:35 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1's diagnoses included: atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), cognitive communication deficit, muscle weakness, hyperlipidemia (high cholesterol), hypertension (high blood pressure), atherosclerotic heart disease (damage in the heart's major blood vessels), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's MDS assessment, dated [DATE], revealed Resident #1 had a BIMS score of 3 (suggesting severe impairment) and active diagnoses of debility, cardiorespiratory conditions. Record review of Resident #1's orders included: Aspirin EC Tablet Delayed Release 81 MG; Give 1 tablet by mouth one time a day for Heart health, Clopidogrel Bisulfate Oral Tablet 75 MG; Give 1 tablet by mouth one time a day for CHF, Lisinopril Oral Tablet 10 MG; Give 1 tablet by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW ,d+[DATE] or 60, Maalox Max Oral Suspension [DATE] MG/5ML; Give 30 ml by mouth every 4 hours as needed for Indigestion; Metoprolol Succinate Oral Tablet Extended Release 24 Hour 25 MG; Give 12.5 mg by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW ,d+[DATE] OR PULSE BELOW 60. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was at risk for complications related to atrial fibrillation/flutter with interventions of: Assess, document and report to physician as needed for the s/s of irregular heartrate (fast, slow, pounding), feelings of syncope (loss of consciousness for a short period of time) or collapse. Resident #1 had coronary artery disease (CAD) r/t atrial fibrillation, hyperlipidemia, and hypertension with interventions of: Monitor/document/report PRN any s/s of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating. Resident #1 had anemia with interventions of: Monitor/document/report PRN following s/s of anemia: pallor and syncope. Record review of Resident #1's ER record, dated [DATE], revealed Resident #1 was seen by provider at 9:24 am, chief complaint was AMS. According to review of electronic health records, Resident #1 had a history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (damage or disease in the heart's major blood vessels with history of stent x3), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and congestive heart failure (condition in which the heart can't pump blood well enough to meet the body's needs). Resident #1 presented to the emergency department from nursing home by EMS due to shortness of breath and had become unresponsive. Initial vital signs at 9:38 am were T 97 F, P 48, R 4, BP ,d+[DATE]. Resident #1's general appearance was lethargic (diminished energy, mental capacity, and motivation) with agonal (abnormal pattern) breathing, dazed look, and bradycardia (week pulse). Resident #1 was actively dying, and family confirmed no CPR. Time of death was 9:31 am. Record review of nurse progress note written by LVN B, dated [DATE] at 9:16 am, revealed: Note Text: this nurse called to shower room. resident noted to be unresponsive and noted stool on floor. resident placed back in bed legs elevated. ,d+[DATE] 92%ra 70 stat cbc cmp ordered. res alert at this time. no distress noted. family aware. No further assessment was completed. Record review of a nurse progress note written by LVN A, dated [DATE] at 11:17 pm , revealed: Messages: Subject: Abdominal pain [[DATE] 19:31 :22 CST] [LVN A]: Resident has had complaints of nausea and abdominal pain. No emesis observed. Maalox 30ml administered and [slightly] effective. Resident now primarily has complaint of abdominal pain, tender on palpation. Bowel sounds present. CNAs report loose stools x 2 days with a sour smell. Resident has had very small amount of po fluids and food. Grunting and moaning observed. Baseline orientation is x 1. Last reported VS at [7:00 pm]-,d+[DATE], HR 74, T 97.8, RR 18 even and unlabored. Please advise. Participants: [LVN A] Additional notes: Awaiting provider orders. Report given to oncoming nurse for monitoring and follow up. Record review of Resident #1's EMR revealed there was no follow up communication from the NP and there were no progress notes for [DATE] and [DATE]. Record review of Resident #1's vital signs, dated [DATE] at 7:18 am, revealed BP ,d+[DATE] and P 92. Record review of a nurse progress note written by LVN B, dated [DATE] at 7:20 am, revealed: . Skin warm & dry, skin color WNL and turgor is normal . No further assessment was completed. Record review of a nurse progress note written by LVN B, dated [DATE] at 9:00 am, revealed: NOTED SOB AND INCREASED CONFUSION. 02 SATS NOT REGISTERING. RESIDENT STATED GET HOSPICE FAST. I FEEL SICK I WANT TO GO TO HOSPITAL. ORDERS TO SEND TO ER FOR EVAL. FAMILY NOTIFIED. Record review of a nurse progress note written by LVN B, dated [DATE] at 10:07 am, revealed: RESIDENT EXPIRED IN THE ER. Record review of a nurse progress note, dated [DATE] at 8:29 am, written by LVN B: late entry [DATE] vital signs ,d+[DATE] 92 97.5 22 lung sounds clear in all lobes. upon arrival of ems o2 placed on resident but still unable to get 02 sat reading. report called to [hospital staff] in er. During an interview on [DATE] at 1:18 pm, the DON said she requested report from LVN C who worked on [DATE] 10 pm - 6 am and requested a late entry be completed in Resident #1's record. The DON said she did not ask LVN C if she followed up with the physician regarding Resident #1's complaints of abdominal pain and nausea. During an interview on [DATE] at 1:39 pm, LVN B said she only completed a skin assessment on Resident #1 on [DATE] at 7:20 am because he was fine. LVN B said she went back later to check on him and tried to obtain an SpO2 but did not get a reading. She added she took a set of vital signs and Resident #1 said he was not feeling well, and the resident was sent to the hospital. LVN B said she was not aware of Resident #1's complaints of abdominal pain and nausea during the prior shift. She added they were required to give report and she did receive report from LVN C; however, LVN C did not mention anything about Resident #1's complaints. During an interview on [DATE] at 1:58 pm, LVN A said she had documented the communication with the provider and had given report to LVN C regarding Resident #1's complaint on [DATE]. She said she was sure she obtained vital signs but did not document it because she was so busy, she added his vital signs were low, but he was also not eating or drinking. LVN A said Resident #1 had not eaten since lunch and his family said he had complained of an upset stomach. She added his abdomen was a bit tender when she touched him on [DATE]. LVN A said Resident #1 was given chicken noodle soup for lunch and dinner, and he took a couple of bites. During an interview on [DATE] at 3:49 pm, RN A said she worked on [DATE] overnight shift as a CNA and Resident #1 did not complain of abdominal pain or nausea during her shift. She added, he did have a small amount of loose BM about the size of my palm and this was reported to the nurse. RN A said Resident #1 did not complain of any cramping or other issues, she added that he was usually confused. During an interview on [DATE] at 5:02 pm the physician said facility knew that, if a resident was unresponsive, they needed to call 911 so that more definitive care could be provided. The physician said the vital signs documented on [DATE] at 9:16 am looked fine, but if the Resident #1 went unresponsive, he expected the facility to have called 911. The physician said he would have expected the facility to monitor Resident #1's status for 72 hours following the incident. During an interview on [DATE] at 5:08 pm, the physician said he did not see any communication to him from the facility on [DATE] regarding Resident #1's condition and the communication was between LVN A and the NP per the progress notes. The physician said he did not see any response from the NP regarding Resident #1's complaint of abdominal pain and nausea and did not know if the NP responded in a timely manner. The physician added the facility knew he could be contacted if needed but that he did not have any missed calls from the facility. During an interview on [DATE] at 4:07 pm LVN C said she worked the night shift on [DATE] and was updated on Resident #1's condition and added that LVN A said to keep a close eye on Resident #1 and that LVN A contacted the NP on [DATE] and was waiting for a response. LVN C said she did not document on [DATE] and was asked to complete a late entry. She said she did communicate Resident #1's complaints of abdominal pain and nausea to the morning shift. LVN C said she did not see a response from the NP regarding Resident #1's complaint and let the morning shift know that it was pending. LVN C said that they normally waited for a response from the NP, she added they waited unless it was an issue that could not wait or the resident's condition worsened. During an interview on [DATE] at 6:24 pm, the NP said he had to look at his notes to see if he had been notified of Resident #1's complaints of abdominal pain and nausea. He added Resident #1 was not someone to look out for because he was pretty stable. At 6:31 pm the NP read the progress note dated [DATE] at 11:17 pm, he said he did note Resident #1's BP and said this was not the first time the resident had these s/s. The NP said, I guess there was a decline. The NP said he did not recall if he responded to the notification but if he had, he would not be able to prove it. During an interview on [DATE] at 7:45 pm, the DON said Resident #1's BP fluctuated a lot. She added that the physician was not notified of Resident #1's hypotensive episodes because he asked to be notified after 3 consecutive days, this was not in writing but was a verbal understanding. Record review of an email, dated [DATE] at 11:53 am, from the DON to LVN C read : Phone conversation with [LVN C] charge nurse ,d+[DATE]-,d+[DATE], verbal report via phone [LVN C] stated no change in resident's condition reported on shift, VS taken and stable, resident at baseline with no complaints verbalized or noted with any abdominal pain. Record review of the facility policy, dated February 2021, titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . Record review of the facility clinical protocol, dated [DATE], titled Acute Condition Changes revealed .9. The attending physician, NP, or designee (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the medical director for additional guidance and consultation if d1ey do not receive a timely or appropriate response. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:35 pm and were provided with the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 8:28 pm and reflected the following: 1. Corrective Action: Administrator immediately ensured changes of condition are reported to DON, physician, NP or designee with documentation of attempts. The administrator immediately ensured that secured conversation via PCC and clinical phone numbers are available to all staff. Reeducated LVN, CNA, and RNs on the need for communication follow up with a change of condition with physician, NP or designee and document attempts. If unable to get contact will D/C resident to ER. Reeducation provided on procedure of reporting a change of condition immediately. Reeducation completed on [DATE]. 2. Resident with potential to be Affected: The alleged deficient practice had the potential to affect Resident #1 who may have had a change of condition and failed to notify physician, NP or designee and all residents who have a change in condition. 3. Measures of Systemic Changes: RN, LVN, CNA and DON have been re- educated [DATE] on reporting change of condition immediately. Completion of training [DATE] by administrator and DON provided to in-house staff and agency. For those unable to attend a teams meeting link was provided to watch what was discussed. Prior to the start of shift staff member will sign a reeducation form stating they watched and understood the information. Reeducation provided during shift change prior to starting shift. Reeducated on reporting change in condition to physician, NP or designee and documenting attempts to contact. Reeducated to escalate to next contact immediately if no response and D/C to ER if no contact is made. DON or designee to monitor daily via secure conversation review or as deemed necessary. As documented in the citation, will continue to contact appropriate clinical staff with a change of condition and escalate as necessary. Physician, NP or designee will be notified by the facility staff of residents who have a change of condition immediately and escalate to next contact until communication is obtained with a physician, NP or designee or D/C to ER. Monitoring: DON or designee will follow up on change of condition and orders will be reviewed daily or as designated necessary via UDA and 24-hour report review. DON or designee will report change of conditions in daily Stand-Up Meeting, and immediately correct any abnormal findings, and report those findings to the Administrator, DON, or assigned designee, and Physician, NP or designee. The administrator or assigned designee will report findings to the QAPI Committee for 3 months or until deemed no longer necessary. DON or designee will monitor daily 24-hour report to ensure that change of condition is followed up immediately and documented during shift change. DON or designee will monitor communication daily or as deemed necessary to ensure timely communication with physician, NP or designee and to escalate as required or D/C to ER. Verification of Plan of Removal: Record review of the Resident Roster dated [DATE] revealed Resident #1 no longer resided in the facility. During an interview on [DATE] at 3:00 pm the DON stated Resident #1 was deceased on [DATE], cause of death unknown. During an interview on [DATE] at 8:52 am, the DON stated change of conditions were determined every day by reviewing the 24-hour report. She checks that the MD and RP were notified of the change of condition and documented in the clinical chart. The DON stated she follows up on physician recommendations, if applicable. From the time [DATE] to [DATE] at 9:00 am, Resident #6 had a change of condition ([DATE] in early morning). The DON stated Resident #6 had episodes of diarrhea. Interventions included: PRN anti-diarrhea medication, hydration at 125 cc per hour, and notified the RP; vitals taken and would be taken Q shift. During an interview on [DATE] at 9:10 am, the Administrator stated changes of condition were monitored and captured in the 24-hour report. The Administrator stated he follows-up by checking with the DON that the RP and MD were notified of the change of condition. The Administrator stated that he inquired at morning reports that physician recommendations were implemented, and documentation was made in the clinical chart. During an interview on [DATE] at 11:09 am, the ADON stated she attended the morning administrative and clinical meetings and one resident [Resident#7] had a change of condition on [DATE]; sent to ER, positive of flu. Based on the facility's clinical procedures, assessment was completed and documented as a change of condition, MD and RP notified, and clinical record was documented. During a joint interview on [DATE] at 12:02 pm the Administrator and the DON stated changes of condition were discussed at morning meetings - administrative meeting at 9:00 am Monday to Friday and the clinical meeting at 9:30 am. Attendees at the administrative meetings were department heads, the DON, the ADON and the Administrator. Attendees at the clinical meeting usually included the DON, the ADON, the Administrator, the Wound Care Nurse, the Director of Rehab and the MDS Nurse. The Administrator stated two residents [Resident #6 and Resident #7] had changes of condition from the timeframe of [DATE] to the present [DATE]. The Administrator stated that for Resident #6 and Resident #7, the MD and RP were notified of the changes of condition; and the clinical record was documented. The Administrator stated the next QAPI meeting was for [DATE] at 10:00 am and the required attendees would be the Administrator, the DON, the MD, and a Pharmacy Rep by telephone. The DON concurred that Resident #6 and Resident #7 had changes of condition and the facility followed its policy: assessment, vitals, notify RP and MD, documentation and continued monitoring for up to 72 hours. Interviews on [DATE] from 8:28 am to 3:00 pm, with 5 day shift (6 am to 2 pm) nursing staff (2 LVNs, 3 CNAs, 2 MAs), 5 evening shift (2 pm to 10 pm) ( 2 LVNs, 2 CNAs, 1 MA), and 2 night shift (10 pm to 6 am) nursing staff (2 LVNs) they said they had been in-serviced on how to communicate changes of condition between shifts, documentation for 72 hours, and notification to MD and RP. Record review of the facility's sign-in sheets on of [DATE] revealed 65 nursing signatures for a completion rate of 96% (nursing staff=65). Record review of the facility's Acute Condition Changes-Clinical Protocol, dated revised [DATE], revealed one was present and in effect. Record review of the facility's Charting and Documentation policy, dated revised [DATE], revealed one was present and in effect. Record review of the facility's Resident Examination and Assessment policy, dated revised February 2014, revealed one was present and in effect. Record review of the facility's Change in a Resident's Condition or Status policy, dated revised February 2021, revealed one was present and in effect. Record review of the facility's Transfer or Discharge, Emergency policy, dated revised [DATE], revealed one was present and in effect. Record review of facility's Abuse and Neglect policy, dated revised [DATE], revealed one was present and in effect. On [DATE] at 5:00 pm, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to monitor Resident #1 following an episode during which he became unresponsive with low blood pressure on [DATE] and failed to notify the physician related to Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on [DATE]. Resident #1 expired at the hospital on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 7:35 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy because due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1's diagnoses included: atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), cognitive communication deficit,?muscle weakness,?hyperlipidemia (high cholesterol),?hypertension (high blood pressure),?atherosclerotic heart disease (damage in the heart's major blood vessels), and?peripheral vascular disease (circulatory condition in which?narrowed blood vessels reduce blood flow to the limbs).? Record review of Resident #1's MDS assessment, dated [DATE], revealed Resident #1 had a BIMS score of 3 (suggesting severe impairment) and active diagnoses of debility, cardiorespiratory conditions. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was at risk for complications related to atrial fibrillation/flutter with interventions of: Assess, document and report to physician as needed for the s/s of irregular heartrate (fast, slow, pounding), feelings of syncope (loss of consciousness for a short period of time) or collapse. Resident #1 had coronary artery disease (CAD) r/t atrial fibrillation, hyperlipidemia, and hypertension with interventions of: Monitor/document/report PRN any s/s of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating. Resident #1 had anemia with interventions of: Monitor/document/report PRN following s/s of anemia: pallor and syncope. Record review of Resident #1's orders included: Aspirin EC Tablet Delayed Release 81 MG; Give 1 tablet by mouth one time a day for Heart health, Clopidogrel Bisulfate Oral Tablet 75 MG; Give 1 tablet by mouth one time a day for CHF, Lisinopril Oral Tablet 10 MG; Give 1 tablet by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW ,d+[DATE] or 60, Maalox Max Oral Suspension [DATE] MG/5ML; Give 30 ml by mouth every 4 hours as needed for Indigestion; Metoprolol Succinate Oral Tablet Extended Release 24 Hour 25 MG; Give 12.5 mg by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW ,d+[DATE] OR PULSE BELOW 60. Record review of Resident #1's ER record, dated [DATE], revealed Resident #1 was seen by provider at 9:24 am, chief complaint was AMS. According to review of electronic health records, Resident #1 had a history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (damage or disease in the heart's major blood vessels with history of stent x3), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and congestive heart failure (condition in which the heart can't pump blood well enough to meet the body's needs). Resident #1 presented to the emergency department from nursing home by EMS due to shortness of breath and had become unresponsive. Initial vital signs at 9:38 am were T 97 F, P 48, R 4, BP ,d+[DATE]. Resident #1's general appearance was lethargic (diminished energy, mental capacity, and motivation) with agonal (abnormal pattern) breathing, dazed look, and bradycardia (week pulse). Resident #1 was actively dying, and family confirmed no CPR. Time of death was 9:31 am. Record review of Resident #1's Blood Pressure Log revealed a blood pressure of ,d+[DATE] on [DATE] at 7:12 am. Record review of nurse progress note written by LVN B, dated [DATE] at 9:16 am, revealed: Note Text: this nurse called to shower room. resident noted to be unresponsive (what did they mean, how was it described) and noted stool on floor. resident placed back in bed legs elevated. ,d+[DATE] 92%ra 70 stat cbc cmp ordered. res alert at this time. no distress noted. family aware. No further assessment was completed. Record review of Resident #1' EMR revealed there was no documentation of assessments/monitoring for [DATE] and [DATE]. During an interview on [DATE] at 1:18 pm the DON said that Resident #1 becoming unresponsive in the shower room on [DATE], he was taken back to his room and his feet were elevated. She said the physician ordered stat CBC and CMP. Record review of Resident #1's Clinical Laboratory Report, dated [DATE], revealed: Glucose 140, Total Protein 5.8, Albumin 2.8, RBC 3.09, and H/H 9XXX,d+[DATE].5, During an interview on [DATE] at 1:39 pm LVN B said she had notified the physician after Resident #1 became unresponsive on [DATE] and he ordered labs. She said she obtained a set of vital signs (BP ,d+[DATE], P 70, SpO2 (percentage of oxygen in the blood) 92% RA), put the resident back in bed and lifted his legs up, and Resident #1 returned to baseline (oriented x1). LVN B said she did not assess further because Resident #1 was not in distress and was at baseline (alert and oriented to self). She added there were no other issues during the rest of her shift. During an interview on [DATE] at 5:02 pm the physician said he did not see any communication to him from the facility on [DATE] regarding Resident #1's condition and added the facility might have reached out to the NP and the orders for the labs might have come from the NP. The physician said he did not recall being notified by the NP of Resident #1's condition. He added the facility knew that, if a resident was unresponsive, they needed to call 911 so that more definitive care could be provided. The physician said the vital signs documented on [DATE] at 9:16 am looked fine, but if the Resident #1 went unresponsive, he expected the facility to have called 911. The physician said he would have expected the facility to monitor Resident #1's status for 72 hours following the incident. During an interview on [DATE] at 5:53 pm CNA D said when they tried to get him up for a shower on [DATE] Resident #1 was not looking good but was awake, he was laid back down after the shower because he was not feeling well and was not himself. She added Resident #1 usually helped a little, but he was not doing that. CNA D said they were in the shower room when Resident #1 became unresponsive, adding he closed his eyes and was not responding to his name or rubbing of his chest. CNA D said the DON came into the shower room and said to get vital signs. She said it was decided to lay him back down and do an evaluation. CNA D said she remembered the nurse took his vitals and elevated his feet above his heart to see if that helped. CNA D said she then went on break and could not say if the interventions helped, but when she left the room approximately 5 minutes later, Resident #1 was still unresponsive. During an interview on [DATE] at 6:06 pm CNA C said she had walked into the shower room on [DATE] and her partner CNA D was trying to undress Resident #1 and she said hey, he doesn't look good. She went to get LVN B who wasn't available, so she grabbed the DON and was told by the DON to get vital signs. She said when she walked back to Resident #1's room, the nurse was already in there and was trying to get his BP but was unable to, so the DON tried and could not get it. They put Resident #1 in bed and the nurse was still doing the blood pressure. CNA C said she was in Resident #1's room approximately 10 minutes and Resident #1 was not doing anything. She added when she arrived at the shower room Resident #1's arms were limp and his eyes looked glazed over, she said he did not look good, he looked pale. CNA C said she was calling his name and there was no response. During an interview on [DATE] at 6:17 pm LVN B said Resident #1 was passed out in the shower chair and he was white. She said she called his name and shook him, but he did not respond. During an interview on [DATE] at 12:55 pm, the DON said training was not provided after Resident #1 became unresponsive on [DATE] because she felt the nurses assessed well. She added she did not see a need for further intervention because she felt that the interventions (lying him down, obtaining vital signs, notifying the NP and obtaining labs) were appropriate. The DON said Resident #1 was not sent out sooner because in her clinical opinion as soon as his feet were elevated, he went back to baseline. The DON said Resident #1 did have a BM while in the shower room that did not require struggle. During an interview on [DATE] at 6:24 pm the NP said Resident #1 fainted in the shower. He instructed staff to elevate the head of the bed, hydrate, obtain vital signs and labs. During an interview on [DATE] at 7:45 pm the DON said she was aware of Resident #1's hypotensive episode on [DATE] at 7:12 am and that he should have been ok to be showered because there was a 2-hour gap between when the BP was taken and when he was taken to the shower and the showers didn't get that hot. She added that Resident #1's BP fluctuated a lot. The DON said the physician was not notified of Resident #1's hypotensive episodes because he asked to be notified after 3 consecutive days, but this was not in writing. The DON said the facility process for monitoring included shift-to-shift communication and assessment of the situation that was reported by the previous shift. Record review of facility policy, dated February 2021, titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition . Record review of the facility clinical protocol, dated [DATE], titled Acute Condition Changes revealed Monitoring and Follow-Up . The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician, NP or designee will adjust treatment accordingly for 72 hours . The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:35 pm and were provided with the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 8:28 pm and reflected the following: 1. Corrective Action: Administrator and DON immediately ensured that changes in condition are monitored and assessed every shift for 72 hours. If a change in condition is noted staff is to report change in condition immediately to charge nurse, DON and physician, NP or designee and provide intervention as directed. 2. Resident with potential to be Affected: The alleged deficient practice had the potential to affect Resident #1 who may have had change of condition episode in shower on [DATE] with staff assistance in shower and all residents who have a change in condition. 3. Measures of Systemic Changes: RN, LVN, DON have been re- educated on [DATE], Completion of training [DATE] by DON and administrator included in-house staff and agency. For those unavailable to attend, a team's call was recorded discussing the topics and provided a link via text and respond stating they listened and understood the information provided. Staff will then sign a reeducation form stating they watched the meeting prior to start of shift. Reeducation provided on changes in condition and monitoring length of time for nursing staff to follow. Staff reeducation on procedure of reporting change in condition. As documented will continue to monitor change of condition and asses' residents with a change of condition. Monitoring: DON or designee will follow up on change of conditions using 24-hour report and medication parameter monitoring tool daily by DON or designee. Any change of condition will be reported to DON or designee and followed up with physician, NP or designee daily and between staff during shift change. If unable to get a response staff will reach out to the backup physician. If unable to get contact will send resident to ER. Changes in condition will be reviewed in Daily Stand-Up Meeting, and immediately correct any abnormal findings, and report those findings to the Administrator, DON, or assigned designee, and Physician, NP or designee. The administrator or assigned designee will report findings to the QAPI Committee for 3 months or until deemed no longer necessary. Verification of Plan of Removal: Record review of the Resident Roster dated [DATE] revealed Resident #1 no longer resided in the facility. During an interview on [DATE] at 3:00 pm the DON stated Resident #1 was deceased on [DATE], cause of death unknown. During an interview on [DATE] at 8:52 am the DON stated change of conditions were determined every day by reviewing the 24-hour report. She checks that the MD and RP were notified of the change of condition and documented in the clinical chart. The DON stated she follows up on physician recommendations, if applicable. From the time [DATE] to [DATE] at 9:00 am, Resident #6 had a change of condition ([DATE] in early morning). The DON stated Resident #6 had episodes of diarrhea. Interventions included: PRN anti-diarrhea medication, hydration at 125 cc per hour, and notified the RP; vitals taken and would be taken Q shift. During an interview on [DATE] at 9:10 am the Administrator stated changes of condition were monitored and captured in the 24-hour report. The Administrator stated he follows-up by checking with the DON that the RP and MD were notified of the change of condition. The Administrator stated that he inquired at morning reports that physician recommendations were implemented, and documentation was made in the clinical chart. During an interview on [DATE] at 11:09 am the ADON stated she attended the morning administrative and clinical meetings and one resident [Resident#7] had a change of condition on [DATE]; sent to ER, positive of flu. Based on the facility's clinical procedures, assessment was completed and documented as a change of condition, MD and RP notified, and clinical record was documented. During a joint interview on [DATE] at 12:02 pm the Administrator stated changes of condition were discussed at morning meetings - administrative meeting at 9:00 am Monday to Friday and the clinical meeting at 9:30 am. Attendees at the administrative meetings were department heads, the DON, the ADON and the Administrator. Attendees at the clinical meeting usually included the DON, the ADON, the Administrator, the Wound Care Nurse, the Director of Rehab and the MDS Nurse. The Administrator stated two residents [Resident #6 and Resident #7] had changes of condition from the timeframe of [DATE] to the present [DATE]. The Administrator stated that for Resident #6 and Resident #7, the MD and RP were notified of the changes of condition; and the clinical record was documented. The Administrator stated the next QAPI meeting was for [DATE] at 10:00 am and the required attendees would be the Administrator, the DON, the MD, and a Pharmacy Rep by telephone. The DON concurred that Resident #6 and Resident #7 had changes of condition and the facility followed its policy: assessment, vitals, notify RP and MD, documentation and continued monitoring for up to 72 hours. In interviews on [DATE] from 8:28 am to 3:00 pm, with 5 day shift (6 am to 2 pm) nursing staff (2 LVNs, 3 CNAs, 2 CMAs), 5 evening shift (2 pm to 10 pm) ( 2 LVNs, 2 CNAs, 1 CMAs), and 2 night shift (10 pm to 6 am) nursing staff (2 LVNs) they said they had been in-serviced on how to communicate changes of condition between shifts, documentation for 72 hours, and notification to MD and RP. Record review of facility's sign-in sheets on of [DATE] revealed 65 nursing signatures for a completion rate of 96% (nursing staff=65). Record review of facility's Acute Condition Changes-Clinical Protocol, dated revised [DATE], revealed one was present and in effect. Record review of facility's Charting and Documentation policy, dated revised [DATE], revealed one was present and in effect. Record review of facility's Resident Examination and Assessment policy, dated revised February 2014, revealed one was present and in effect. Record review of facility's Change in a Resident's Condition or Status policy, dated revised February 2021, revealed one was present and in effect. Record review of facility's Transfer or Discharge, Emergency policy, dated revised [DATE], revealed one was present and in effect. Record review of facility's Abuse and Neglect policy, dated revised [DATE], revealed one was present and in effect. On [DATE] at 5:00 pm, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.