Every finding on record at Rosewood Center

Based on record review and interviews, the facility failed to employ a qualified social worker to provide and oversee social services from 10/14/25 through the time of survey, resulting in a failure to ensure appropriate follow-up, documentation, and resident support related to an allegation of misappropriation of property, abuse, neglect, reporting, and investigation. Resident identifiers: #54, #36, #32, #30, #3. Facility census: 67. Findings Include: a) Resident #32 Record review and staff interview revealed the facility did not employ a qualified social worker from 10/14/25 through the time of survey. During an interview on 03/25/26, facility administration confirmed there had been no qualified social worker employed during this time period. Record review of an allegation of misappropriation involving Resident #32 revealed the facility failed to ensure ongoing social service follow-up and oversight. On 09/10/25, Resident #32 reported unauthorized use of her debit card. Although the allegation was reported and initially investigated, the facility failed to maintain documentation of the resident's bank records, determine the total amount of funds misappropriated, or track the outcome of the investigation. Further review revealed a Grand [NAME] subpoena dated 01/14/26 related to the incident; however, the facility was unable to provide additional follow-up documentation at the time of survey. During an interview on 03/23/26 at 3:45 PM , Resident #32 stated she had not received updates regarding the situation. During interviews on 03/25/26, at 3:30 PM the Business Office Manager confirmed the facility did not maintain copies of the resident's financial records. Resident #32 confirmed the facility had not requested or reviewed her bank statements until the time of survey An interview completed on 03/25/26 at approximately 4:15 PM with the facility administrator who stated they have not had a full time social worker at the facility since 10/14/25. The Administrator also stated we did have a contract Social Worker who would come twice a week. Confirming the facility with a census above 60 did not obtain a social worker full time. b) Resident #3 During an interview on 03/22/26 at 1:15 PM, Resident #3 who has a Brief Interview for Mental Status (BIMS) of 15, stated, There are (2) two nurses that work Monday thru Thursday. They are always sleeping. I told the administration and I guess the (2) two nurses were mad at me. I have a recording of the one calling me a Jerk. Resident #15 then let the State Agency (SA) listened to recording with a date of 3-11-26, which in fact revealed the voice of a staff member say, You are a jerk Resident #3 says, So, your calling me a jerk staff member says because you are a jerk. Resident #15 identified the (2) two staff members as Registered Nurse (RN) # 1, and Licensed Practical Nurse (LPN) #2. The one speaking on the phone is RN #1. Resident #15 further stated, I told (LPN #3 named) and she reported it to (Registered Nurse, Infection Preventionist RNIP #4 named) During a telephone interview on 03/22/26 at 1:46 PM, RNIP #4 stated, I do not know entirely what went on. He has a conversation on his phone and in that conversation someone is calling him a jerk I think it might have been brought up in a care plan meeting. During an interview on 03/22/26 at 2:00 PM, The administrator said she was unaware of the entire situation. She immediately reported the incident and started an investigation. The investigation was ongoing at the end of survey. Video evidence is attached During an interview on 03/24/26 at 11:00 AM, The State Agency (SA) asked the Administrator, What did you find out with the reportable? The Administrator replied, During my resident interviews, I found a few more things and now have three (3) more reportables. c) Facilities interview with residents A review of the above investigation revealed the following (5) five questions asked to residents: Have you eve heard or seen (Licensed Practical Nurse (LPN) #2 name) or (Registered Nurse (RN) #1 name) (Monday-Thursday Night Shift Nurses) sleep during work hours or while not on break? Have you ever heard or seen (Licensed Practical Nurse (LPN) #2 name) or (Registered Nurse (RN) #1 name) (Monday-Thursday Night Shift Nurses) be loud with or speak inappropriately to another staff member? Have you ever heard or seen (Licensed Practical Nurse (LPN) #2 name) or (Registered Nurse (RN) #1 name) (Monday-Thursday Night Shift Nurses) be loud with or speak inappropriately to a resident? Do you have any concerns with any staff member in the facility sleeping or speaking inappropriately to a resident or another staff member? Do you feel comfortable reporting concerns to administration ( Administrator or Director of Nursing (DON)? Resident #36 reported yes to question #4 and named Nursing Assistant (NA) #14. The administrator started an investigation. Resident #54 answered yes to question #4 and named NA #14. The administrator started an investigation. Resident #30 answered yes to question #4 and named NA#14. The administrator stared an investigation. During an interview on 03/25/26 at 10:00 AM, The State Agency (SA) asked Resident #36 who has a Brief interview for Mental Status (BIMS) of 15, Do you feel if you had a social worker, that these allegations would of been easier to report? Resident #36 replied I feel like I would be able to tell someone, yes. During an interview on 03/25/26 at 10:05 AM, The SA asked Resident #30 who has a BIMS of 10, Do you feel if you had a social worker, that these allegations would of been easier to report? Resident #30 replied, Yes. During an interview on 03/25/26 at 11:00 AM, The SA asked Resident #3 who has a BIMS of 15, Do you feel if you had a social worker, that these allegation would of been easier to report? Resident #3 replied, Yes, I think it would of already been taken care of. d) Director of Social Services Job Description A review of the Job Description on 03/25/26 at 3:00 PM under (ADVOCACY) reads as follows: Works with Social Services staff, interprofessional team, and administration to promote and protect patient/resident rights and psychosocial well-being of all patients/residents. Prevents, addresses, and reports patient/resident abuse as mandated by law and professional licensure. Active contributor in Center's grievance/concern investigation and resolution process. Identifies and monitors community changes and opportunities such a legislation, regulations, and programs that impact nursing home patients/residents. Works with patients/residents, families, and significant others to provide support and information for taking a more proactive role in self-advocacy to improve the quality of life/care for individual patients/residents Responds to issues identified by patient/resident and families to determine satisfaction with services. With the above allegations that would not have been discovered without Surveyor intervention, combined with the Advocacy role of a Social Worker the State Agency determined that this had the potential to effect all 67 residents currently residing in the facility.

Based on observation, record review, and staff interviews, the facility failed to establish and 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 with regards to the resident's personal products. This failed practice was a random opportunity for discovery. Resident identifiers: #12, #7, #39, and #68. Facility Census: 68.Findings Included:a) Resident #12During an interview with Resident #12, on 03/22/26 at 12:08 PM, a wheelchair near the resident's bed had rips and holes in the plastic cover on the left side of the head rest, and both of the arm rests covering and plastic trim, exposing the inner padding. b) Resident #17During entrance interview, on 03/22/26 at approximately 12:25 PM, it was observed that resident #17's Geri-chair had cracks and tears down the right of the back rest and on both arm rests exposing the inner padding.c) Resident #39An observation of Resident #39's wheel chair, on 03/22/26 at 2:45 PM, found cracks and tears in both armrests and tears on the front and back edges on the corner of his foot pad, with exposed inner padding. d) Resident #68During an interview with Resident #68, on 03/23/26 at 3:18 PM, it was observed her wheel chair's plastic covering was worn off from the edge halfway up the right armrest with exposed inner padding.e) 100 hall wheel chair outside room [ROOM NUMBER]An observation of a wheel chair sitting outside room [ROOM NUMBER], on 03/23/26 at 12:45 PM, found tears in both arm rests and open broken zipper in the leg padding, with exposed inner padding.f) Staff InterviewDuring a facility walk through and interview with the Director of Nursing, on 03/23/2026 at 3:23 PM, she acknowledged the above listed Resident wheelchairs and one Geri-chair had areas with exposed inner padding and stated they would be reported to the maintenance department for repairs or replacement.

Based on observation and interview, the facility failed to ensure that medications were disposed of in accordance with professional standards of practice for one (1) of one (1) medication storage rooms observed. The facility failed to remove and properly dispose of 11 discontinued medications that remained in the storage room in various random drawers. This failure created a potential for medication errors or unauthorized access to medications. Facility Census: 67 Findings include:The facility's policy titled Medication Storage Storage of Medications, revised 01/26, indicated that discontinued medications must be removed from the active storage area immediately and documented for disposal to prevent accidental administration.On 03/24/26 at 9:30 AM, during a review of the medication storage room, 11 different medications were found stored in random drawers rather than being sequestered for destruction or returned to the pharmacy. The following medications were observed:-Carvedilol 3.125 MG -Tamsulosin HCL 0,4-Clopidogrel 75 MG-Dapagliflozin 10 MG-Prednisolone 20 MG-6 vials of Haloperidol lactate 5MG with expiration date of October 2025 In an interview, on 03/24/26 at 10:00 AM, the Director of Nursing (DON) confirmed that these medications were no longer in use. The DON stated that the medications should have been pulled and processed for disposal according to facility policy but were left in the drawers.

Based on observation, resident and staff interviews, the facility failed to ensure resident call lights were within reach. This was a random opportunity for discovery resident identifier: #27. Facility Census: 67. Findings Included: a) Resident #27 During an interview with Resident #27, on 03/23/2026 at 11:50 AM, he stated he couldn't find his call button. The staff forgot to put it back after my bed bath today. They usually clip it to my shirt. Surveyor pushed the roommate's call button. Employee #84 came into the room to answer the call light. She found the call bell behind the back of the bed and reclipped it to his shirt. b) Staff Interviews In an interview with Employee #84, on 03/23/26 at 12:02 PM, she acknowledged the call bell was not within resident's reach and clipped it to his shirt. During an interview on 03/23/26 at approximately 2:25 PM, the Director of Nursing stated she had been made aware of the call button not being within resident's reach.

Based on record review and staff interview the facility failed to ensure staff was educated/ informed on the Covid Vaccine. The facility failed to provide education on the benefits, risks, and potential side effects of the COVID-19 vaccine to staff. This was true for one (1) of one (1) staff members selected. Census: 67. Findings include: a) Record Review Certified Nursing Assistant (CNA) #18 was randomly selected to verify if Covid-19 vaccine education/information was given as well as if the vaccine was offered. No record existed. b) Staff Interview Interview with Nursing Home Administrator (NHA), on 03/24/2026 2:25 PM, confirmed CNA #18 was not educated on the Covid-19 vaccine. No documentation existed showing any employee was offered or educated on Covid-19 vaccinations.

Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record related to intellectual disability. This failed practice was found true for one (1)of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #8. Facility census: 67.Findings Include: a) Resident #8 A record review, on 03/23/26 at 2:25 PM, revealed Resident #8's most recent Pre-admission Screening and Resident Review (PASARR) dated 03/06/26, indicated Resident #8 has a diagnosis of Mental Retardation (intellectual disability). Further record review revealed a History and Physical (H&P), dated 01/28/26, under the History of Present illness section, the last sentence read, Patient has underlying mental retardation unable to communicate much. There was no diagnosis of Mental Retardation (intellectual disability) listed in Resident #8's medical record. During an interview on 03/23/25 at 3:35 PM, the Administrator confirmed that Mental Retardation (intellectual disability) was not listed on Resident #8's medical record as a diagnosis.

Based on observation, record review, and staff interviews, the facility failed to ensure Medicaid residents receive routine dental services. This deficient practice was found for (1) one of (1) one residents reviewed for dental services during the Long-Term Care Survey Process. Resident identifier: #70. Facility census: 67. Findings Include: The facility policy titled, Dental Services, directs: Center will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. The policy defined routine dental services as follows: An annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. a) Resident #70 The initial observation on 03/22/26 at 12:15 PM, revealed Resident #70 in the dining room, waiting for her lunch tray. Resident #70's teeth were covered in debris and had a thick white substance around her gum lines. An observation on 03/24/25 at 2:30 PM, revealed Resident #70 in her bed. Resident's teeth were covered in debris and had a thick white substance around her gum lines. A record review on 03/24/25 at 2:40 PM, revealed an oral health care plan that included the following intervention, revised 03/19/25:Provide oral hygiene/mouth care twice per day and as needed. Further record review had an admission date for Resident #70 for 2022. No dental consults could be found since admission. A general patient note dated for 01/09/26 read as follows:A dentist appt. was scheduled for 8:30 AM, however when she arrived she could not be seen because her MPOA was not present to sign the forms so this appt. needs to be reschedules at a convenient time for the MPOA to be present. The dental appointment was rescheduled for 03/26/26. During an interview on 03/24/25 at 3:45 PM, The Director of Nursing (DON) said that she could not find any dental consults in the medical record. The State Agency (SA) asked the DON, Is there no record since her admission in 2022 that any dental services had been provided? DON replied, You are correct.

Based on record review and staff interview the facility failed to ensure the daily Nurse Staff Posting had the correct date. This failed practice was a random opportunity for discovery and the potential to effect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 67.Findings Included:a) Nurse staff posting:Upon facility entrance, on 03/22/26 at 11:30 AM, a review of the Nurse Staff Posting found the posting had the incorrect date of 03/20/26, revealing it had not been updated for two (2) days.During an interview on 03/22/26 at 11:39 AM, The Nurse Manager on staff stated, Yes, we had a call off and I haven't gotten to that yet.

Based on record review and staff interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Physician orders related to medications changes and instructions for Atorvastatin, Digoxin, and Lidocaine patches were not found in the electronic record. This was a random opportunity for discovery. Resident Identifier: #4. Facility Census: 67.Findings Included: a)Resident #4's Record Review Atorvastatin:On 03/24/2026 at 12:29 PM, during Resident #4's record review, the Medical Regimen Review, dated 07/25/25, recommended Atorvastatin 40mg HS to be discontinued. The physician agreed and signed off on the discontinuation. On 03/24/2026, it was found this order still active in the electronic record. Digoxin:On 03/24/2026 at 12:29 PM, during Resident #4's record review, the Medical Regimen Review, dated 12/30/25, recommended ordering daily apical pulse readings prior to Digoxin administration along with hold parameters if pulse is less that 60, to monitor for rhythm and rate. The physician agreed and signed off on the recommendation. On 03/24/2026, it was found the instructions for Digoxin had not been added in the electronic physician orders. Lidocaine Patch:On 03/24/2026 at 12:29 PM, during Resident #4's record review, the Medical Regimen Review, dated 02/25/26, found Pharmacist recommended instructions for resident #4's Lidocaine Patch. The physician agreed and signed off on the recommendation noting, Lidocaine patch to shoulders - Please add removal time of 2200 to med order. On 03/24/2026, it was found the recommended Lidocaine patch instructions had not been added in the electronic physician orders record. b) Staff interview: During an interview, 03/24/2026 at 2:33 PM, the Administrator verified the physician order for discontinuing Atorvastatin and the recommended instructions for Digoxin and the Lidocaine Patches were not added to Resident #4's electronic record and stated she could not explain why they were overlooked.

Based on record review, surveyor observation and intervention, as well as resident and staff interviews, the facility failed to provide necessary care and services to maintain or improve resident's ability to perform activities of daily living (ADL), such as mobility for one (1) of one (1) residents reviewed (Resident #60). The facility failed to follow up on the outcome of the resident receiving new custom made Hip Knee Ankle Foot Orthosis to resume Physical Therapy, placing resident at risk for continued decline in mobility. Resident Identifier: #60. Facility Census: 67.Findings include: a) Observation and Resident Interview During an initial tour of Resident #60's room, it was observed there was a brand new custom Hip Knee Ankle Foot Orthosis (HKAFO) against the wall by the bed. When resident was asked how long he had the device, he stated, A few weeks now. When asked if the resident went to Physical Therapy (PT), the answer was, Not anymore. This conversation took place on 03/23/2026 at 10:10 AM in resident's room. b) Record Review Record review, completed on 03/24/2026, showed Resident # 60 was discharged from Physical Therapy (PT) on 11/10/2025 with the intentions of picking resident back up for Physical Therapy once his new Hip Knee Ankle Foot Orthosis (HKAFO) arrived. Record review indicated that the resident was at risk for decreased ability to perform ADL(s) due to decreased mobility and increased weakness related to paraplegia and spina bifida. No documentation existed in PT showing when the resident went to be measured/casted for his HKAFO. In Resident #60's PT Discharge Summary, a note stated, awaiting arrival of new orthotics (arriving in 2 days). In the Patient Progress section of the Discharge Summary, it is quoted, Will address therapy services again when new orthotics arrive. A Patient Document Receipt from [Name and location of the company which supplied the HKAFO] showed the HKAFO was received on 02/24/2026 at the resident's appointment at 8:30 AM. Resident was discharged from PT on 11/10/2025 with the goal of picking resident back up on PT when the new orthotics arrived. The new orthotic was received on 2/24/2026 but as of 3/24/26 the resident has not been picked back up for therapy services b) Interviews with Resident and Staff An interview with the Director of Rehab, on 03/24/26 at 8:55 AM, revealed the therapy department was not aware Resident #60 had received the new HKAFO, nor had they followed up with resident to see if new item had been received. This situation was also discussed with the Nursing Home Administrator (NHA) on 03/24/2026 at 9:35 AM. It was acknowledged that a month had transpired from the time Resident #60 had received the new HKAFO and Surveyor intervention.

Based on record review, resident interview, and staff interview the facility failed to implement a care plan related to oral hygiene. This failed practice was found true for (1) one of (1) one residents reviewed under the dental pathway during the Long-Term Care Survey Process. Resident identifier: #70. Facility census: 67.Findings Included: a) Resident #70 The initial observation, on 03/22/26 at 12:15 PM, revealed Resident #70 in the dining room, waiting for her lunch tray. Resident #70's teeth were covered in debris and had a thick white substance around her gum lines. An observation, on 03/24/25 at 2:30 PM, revealed Resident #70 in her bed. Resident's teeth were covered in debris and had a thick white substance around her gum lines. A record review, completed on 03/24/25 at 2:40 PM, revealed an oral health care plan that included the following intervention, revised 03/19/25: Provide oral hygiene/mouth care twice per day and as needed. During an interview on 03/24/25 at 3:45 PM, the Director of Nursing (DON) confirmed that Resident #70 did not appear to have had oral hygiene completed. No further information was given prior to facility exit.

Based on record review, resident interview, and staff interview, the facility failed to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one (1) of one (1) resident reviewed (Resident #32). The facility failed to maintain sufficient documentation to determine the extent of the alleged financial exploitation and failed to follow up on the outcome of the investigation, potentially placing residents at risk for continued or unaddressed misappropriation of property. Resident Identifier: #32. Facility Census: 67.Findings Included:a) Record ReviewA record review was completed on 03/24/26. The record review revealed that on 09/10/25, Resident #32 reported unknown charges on her debit card. The facility initiated an investigation and reported the allegation to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Ombudsman, and local law enforcement.Progress notes documented the following actions:-09/12/25: Law enforcement interviewed Resident #32 at the facility. The resident had cancelled her debit card and planned to obtain additional information from her bank.-09/15/25: Resident #32 was scheduled to go to the bank for further information, with plans to update law enforcement.-09/18/25: Resident #32 obtained bank statements; attempts were made to contact the investigating officer.-09/19/25: Law enforcement returned to the facility, obtained the resident's banking information, and asked additional questions.Review of the facility's 5-day investigation report indicated the Administrator and Director of Nursing reported the allegation as required. The facility assisted the resident in obtaining bank statements and reviewed charges with her. The report noted the alleged perpetrator was the resident's former roommate. The investigation was determined to be inconclusive, with law enforcement continuing the investigation. The residents were separated, and the resident's debit card was deactivated.Further review revealed a January 14, 2026, Grand [NAME] subpoena for Resident #32 related to the alleged fraudulent use of her debit card.However, at the time of survey, the facility was unable to provide any additional documentation or evidence of follow-up regarding the alleged misappropriation, including the total amount of funds involved, outcomes of the investigation, or ongoing tracking of the allegation, until requested by the State Agency.b) Resident and Staff InterviewsDuring an interview, on 03/23/26 at approximately 11:00 AM, Resident #32 stated her former roommate used her debit card without permission and estimated that approximately $800-$900 had been spent. The resident stated she had not received any updates regarding the situation.During an interview, on 03/25/26 at approximately 3:00 PM, the Business Office Manager (BOM) stated the facility did not have copies of the resident's bank statements, as they had been turned over to law enforcement. The BOM reported that law enforcement would not release information due to an ongoing investigation.In a follow-up interview, on 03/25/26 at approximately 3:45 PM, Resident #32 stated that no one from the facility had requested copies of her bank statements or attempted to review them, aside from law enforcement, until shortly before the interview when the BOM inquired. This indicated the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation.On 03/25/26 at 4:00 PM, Staff #43 provided a written statement indicating they accompanied Resident #32 to a Grand [NAME] proceeding, on January 20, 2026, related to fraudulent use of the resident's debit card. The statement noted the prosecutor obtained an indictment without the resident's testimony.

Based on resident interview, staff interviews, and policy review, the facility failed to report a resident allegation of verbal abuse within two (2) hours of facility staff being aware of the allegation. Additionally, the facility failed to complete and/or submit a 5-day follow-up for an allegation of abuse for Resident #77. This failed practice was found true for two (2) of two (2) residents reviewed for abuse during the Long-Term Care Survey Process. Resident identifier #3. Facility census: 67. Findings Included:A review of the policy titled, OPS300 Abuse Prohibition, revealed verbal abuse defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.Additionally, the policy directs, immediately upon identification of a concern, a report of suspected or alleged abuse, mistreatment, or neglect, the administrator or designee will report allegations involving abuse (physical, verbal, sexual, mental) no later than two (2) hours after the allegation is made. a) Resident #3During an interview on 03/22/26 at 1:15 PM, Resident #3 who had a Brief Interview for Mental Status (BIMS) of 15, stated, There are (2) two nurses that work Monday thru Thursday. They are always sleeping. I told the administration and I guess the (2) two nurses were mad at me. I have a recording of the one calling me a jerk. Resident #15 then let the State Agency (SA) listen to the recording, with a date of 03/11/26, which in fact revealed the voice of a staff member saying, You are a jerk. Resident #3 then asked, So, your calling me a jerk?. The staff member could be heard replying, Because you are a jerk. A BIMS score of 15 indicates Resident #3 was cognitively intact. Resident #15 identified the two (2) staff members as Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2. The one speaking on the recording was identified as RN #1.Resident #15 further stated, I told (LPN #3's Name) and she reported it to (Registered Nurse, Infection Preventionist RNIP #4's Name).During a telephone interview, on 03/22/26 at 1:46 PM, RNIP #4 stated, I do not know entirely what went on. He has a conversation on his phone and in that conversation someone is calling him a jerk. I think it might have been brought up in a care plan meeting.During an interview on 03/22/26 at 2:00 PM, the Administrator said she was unaware of the entire situation. She immediately reported the incident and started an investigation.The investigation was ongoing at the end of survey.Audio evidence was attached to the survey in the iQUIES program.b) Resident #77A record review on 03/25/26 at 9:30 AM, revealed that Resident #77 was admitted on [DATE] and was discharged to the hospital on [DATE].A review of reportable #238789 led the state agency (SA) to review the facility's list of reportable incidents for (1) year. This review was completed on 03/25/26 at 10:00 AM.Resident #77 had a reportable incident of verbal abuse reported to the SA on 04/15/25. There was no evidence that a five-day follow-up report was sent.During an interview on 03/25/26 at 11:30 AM, the Administrator stated, We do not have a record of that reportable. There is no five-day follow-up.

Based on resident interview, staff interview, and policy review, the facility failed to ensure residents were free of verbal abuse from staff. This failed practice was true for (1) one of (2) two residents reviewed for abuse during the Long-Term Care Survey Process. Resident identifier #3. Facility census: 67.Findings Included: A review of the policy titled, OPS300 Abuse Prohibition, revealed verbal abuse defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Additionally, the policy directs, immediately upon identification of a concern, a report of suspected or alleged abuse, mistreatment, or neglect, the administrator or designee will report allegations involving abuse (physical, verbal, sexual, mental) no later than two (2) hours after the allegation is made. a) Resident #3 During an interview on 03/22/26 at 1:15 PM, Resident #3 who had a Brief Interview for Mental Status (BIMS) of 15, stated, There are (2) two nurses that work Monday thru Thursday. They are always sleeping. I told the administration and I guess the (2) two nurses were mad at me. I have a recording of the one calling me a jerk. Resident #15 then let the State Agency (SA) listen to the recording, with a date of 03/11/26, which in fact revealed the voice of a staff member saying, You are a jerk. Resident #3 then asked, So, you're calling me a jerk? The staff member could be heard replying, Because you are a jerk. A BIMS score of 15 indicates Resident #3 was cognitively intact. Resident #15 identified the two (2) staff members as Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2. The one speaking on the phone was identified as RN #1.Resident #15 further stated, I told (LPN #3's Name) and she reported it to (Registered Nurse, Infection Preventionist RNIP #4's Name).During a telephone interview, on 03/22/26 at 1:46 PM, RNIP #4 stated, I do not know entirely what went on. He has a conversation on his phone and in that conversation someone is calling him a jerk. I think it might have been brought up in a care plan meeting.During an interview on 03/22/26 at 2:00 PM, the Administrator said she was unaware of the entire situation. She immediately reported the incident and started an investigation. The investigation was ongoing at the end of survey. Audio evidence was attached to the survey in the iQIES program.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of two (2) residents reviewed during the annual survey process. Additionally, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of two (2) residents reviewed during the annual survey process. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #218, #317, and #318. Facility census: 64. Findings Included: a) SNF ABN On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for two (2) residents who remained at the facility. - Resident #218 began Medicare Part A skilled services on 09/05/24. The last covered day of Part A service was 10/16/24. There was no evidence that a SNF ABN form was provided. - Resident #317 began Medicare Part A skilled services on 10/17/24. The last covered day of Part A service was 10/22/24. There was no evidence that a SNF ABN form was provided. In an interview on 02/19/25 at 2:55 PM, the Interim Administrator confirmed the facility could not provide evidence a SNF ABN form was given to residents # 218 and # 317 who had remained in the facility. b) NOMNC On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following resident: - Resident #318 began Medicare Part A skilled services on 01/17/22. The last covered day of Part A service was 02/05/25. There was no evidence that a NOMNC form was provided. In an interview on 02/20/25 at approximately 10:30 AM, the Interim Administrator stated the facility was unable to provide verification the NOMNC form was given to Resident #318.

Based on record review and staff interview, the facility failed to complete their self-identified corrective action which was intended to protect residents following an investigation into a resident-to-resident physical altercation that was verified as abuse. The facility failed to oversee the complete implementation of staff being retrained on the facility's 1:1 Supervision policy. This failed practice had the potential to affect more than a limited number of residents in the building. Facility Census: 64 Findings included: a) Resident #54 A record review, completed on 02/20/25 at 5:07 PM, revealed there was a physical resident-to-resident altercation on 12/28/24 at 1:19 PM. The facility reportable and investigation revealed staff reported Resident #54 was in the dining room for the communal lunch program. There were approximately 6-7 resident remaining in the dining room at the time of the incident. The Activities Assistant was about 20 feet away from Resident #54 when Resident #218 returned to the dining room. Resident #54 got up and walked over to Resident #218 and kicked him in the right shin. The Activities Assistant immediately removed the victim from the dining room and asked for Nurse Aide (NA) assistance with Resident #54 and he was redirected. Resident #54 had been placed on 1:1 observation due to a previously reported incident on 12/26/24 with a different resident. Throughout their investigation process, the facility identified the need to retrain staff on the 1:1 Supervision policy because there had been a communication breakdown when the assigned NA had gone on break. Resident #54 ended up in the dining room without 1:1 supervision for the 12/28/24 resident-to-resident incident. Review of the facilities credible evidence for training staff revealed the following staff members had not been retrained on the 1:1 Supervision policy: -Nurse Aide (NA) #17 -Registered Nurse (RN) #27 -NA #16 -NA #29 -NA #9 -NA #6 -RN #36 -MDS Nurse #25 -Director of Social Services -RN #51 -NA#60 -LPN #59 -NA #42 -NA #56 -RN #71 -NA #55 During an interview on 02/24/25 at 3:45 PM, the former Interim Administrator (FIA) stated the facility shared what they had found regarding the staff re-education. The FIA stated there had been a binder that had evidence of all staff receiving the training, but it could not be found. It was acknowledged that the above-mentioned staff had not received the re-training regarding the facility's 1:1 Supervision policy and they had all been assigned 1:1 Supervision of Resident #54 since the 12/28/24 incident.

Based on record review and staff interview, the facility failed to ensure residents were free from resident-to-resident abuse. This was true for six (6) of six (6) facility reported incidents reviewed. Resident identifiers: #54, #30, #216, #48, #218, #32, and #12. Facility census: 64. Findings included: a) A record review, completed 02/19/25 at 6:30 PM, revealed there was a resident-to-resident altercation on 11/27/24 at 12:00 PM. The facility reportable and investigation revealed that staff observed Resident #54 pushing Resident #30 in his wheelchair down the hallway. Resident #54 aggressively shoved the wheelchair forward causing Resident #30 to fall to the floor. Resident #30 had an abrasion on his head and some skin tears on his right hand. A record review, completed on 02/19/25 at 7:15 PM, revealed there was a resident-to-resident altercation on 12/01/24 at 4:15 PM. The facility reportable and investigation revealed that staff were notified by the family of Resident #216 that Resident #54 was yelling at them and becoming hostile while they were trying to visit. Resident #54 began making verbal threats when staff attempted to redirect. A record review, completed on 02/19/25 at 8:04 PM, revealed there was a resident-to-resident altercation on 12/10/24 at 4:30 PM. The facility reportable and investigation revealed staff reported that Resident #54 was trying to hit Resident #48. Resident #48 reported Resident #54 threatened to kill him. Resident #48 reported he blocked the hits with his arm. Resident #48 had red marks on his arm where Resident #54 grabbed him and hit him. The two residents were separated. Resident #48 was assessed for emotional/physical injury. The resident had red marks on his arm but did not require medical intervention. Resident #48 denied any emotional harm. A record review, completed on 02/20/25 at 4:38 PM, revealed there was a resident-to-resident altercation on 12/26/24 at 4:30 PM. The facility reportable and investigation revealed staff reported the nurse on duty heard staff telling Resident #54 to stop hitting. When the nurse walked into the hall, Resident #48 was asked about what happened and he stated that Resident #54 was already upset and came up to him and hit him on the right shoulder. The residents were separated, and Resident #48 was assessed for injuries. The resident's shoulder was red from the blow but did not require medical attention. Resident #48 denied any emotional harm. A record review, completed on 02/20/25 at 5:07 PM, revealed there was a resident-to-resident altercation on 12/28/24 at 1:19 PM. The facility reportable and investigation revealed staff reported Resident #54 was in the dining room for the communal lunch program. There were approximately 6-7 resident remaining in the dining room at the time of the incident. The Activities Assistant was about 20 feet away from Resident #54 when Resident #218 returned to the dining room. Resident #54 got up and walked over to Resident #218 and kicked him in the right shin. The Activities Assistant immediately removed the victim from the dining room and asked for Nurse Aide assistance with Resident #54 and he was redirected. Resident #218 was assessed for injuries and no injuries were noted. Both residents were started on a change in condition to continue to monitor. A record review, completed on 02/24/25 at 7:27 PM, revealed there was a resident-to-resident altercation on 02/11/24 at 6:35 PM. The facility reportable and investigation revealed staff reported Resident #54 hit Resident #32 on the head while in the hallway. The residents were immediately separated. A head-to-toe assessment was completed on Resident #32. He denied pain or injury. Resident #54 then went further up the hallway and started to hit Resident #12, but his son intervened and prevented it from happening. Resident #54 was redirected by staff. During an interview on 02/24/25 at 3:45 PM, the former Interim Administrator (FIA) acknowledged Resident #54 had experienced numerous resident-to-resident altercations which had been substantiated by the facility as either verbal or physical abuse.

Based on resident interview, observation, and staff interview, the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business. This was a random opportunity for discovery. Resident identifiers: #9, #18, #22, #26, #31, #32, #38, #40, #48, and #51. Facility census: 64. Findings included: a) During a resident council meeting, on 02/19/25 at 11:00 AM, the residents stated they knew they were able to file a grievance with the social worker, but did not know how or where to file an anonymous grievance or complaint. During a facility walk-through with the Administrator, on 02/20/25 at approximately 12:30 PM, the Administrator acknowledged there were no grievance forms available nor were there any posted signs stating residents were able to file a grievance anonymously. b) On 02/20/25 at approximately 12:30 PM, During an interview/walk through with the facility Administrator, She acknowledged there weren't any posted signs where residents were able to file a grievance anonymously.

Based on review of the resident council minutes, resident council meeting, and staff interview, the facility failed to inform residents both orally and in writing in a language that the residents understood of their rights and all rules and regulations governing resident conduct and responsibilities on a yearly basis. Resident identifiers: #9, #18, #22, #26, #31, #38, #40, #48, and #51. Census: 64. Findings included: a) On 02/19/25 at 10:38 AM, a review of the past 12 months of Resident Council meeting minutes was completed. Resident rights were not listed in the discussions during the Resident Council meeting minutes. During a Resident Council meeting, on 02/20/25 at 11:00 AM, the residents stated resident rights were not talked about during previous meetings. They could not remember staff discussing them in any fashion since the day of admission. During an interview on 02/20/25 at 11:55 AM, the Director of Social Services (DoSS) the DoSS stated, other than upon admission, she had not discussed resident rights with the residents since she started this facility as a social worker and was not aware of it being done prior to her employment. d) During an interview on 02/20/2024 at 12:00 PM, the Director of Nursing (DON) acknowledged she had worked in the facility for multiple years and did not remember staff members discussing rights with the residents.

Based on the resident council meeting, observation, and staff interviews, the facility failed to post notice of the availability of the most recent survey results in areas of the facility that were prominent and accessible to the public. This was a random opportunity for discovery. Facility census: 64. Findings included: a) During the resident council meeting on 02/19/2024 at 11:00 AM, the residents stated they were unaware they had the right to see the most recent state survey results and did not know where the results were in the building. During a facility walk-through on 02/20/25 at 12:30 PM, it was observed that the facility did not post signage regarding the availability of the most recent survey results. During an interview on 02/20/25 at approximately 12:38 PM, the former Interim Administrator (FIA) acknowledged the absence of a posted notice regarding the availability of the most recent survey results for residents and/or visitors to review.

Based on record review, facility reported incident review, and staff interview the facility delayed initiating Cardiopulmonary Resuscitation (CPR) to Resident #63 after staff identified he did not have a heart beat or breath sounds but was still warm to the touch. The residents record contained no documentation to indicate if he did or did not want to have CPR. The standard of care is when there is an absence of an advance directive CPR should be given. Resident #63 was found unresponsive with no pulse or respirations by facility staff at approximately 6:45 am on [DATE]. CPR was no initiated until 7:19 am which was approximately 34 minutes after he was round unresponsive with no pulse or respirations. The emergency medical squad arrived at 7:30 am and assumed care of the code. They received authorization to call the time of death around 7:55 am on [DATE]. The state agency on [DATE] entered the facility to initiate an investigation into this situation which was self-reported by the facility. On [DATE] the SA determined on [DATE] an immediate jeopardy (IJ) situation was present in the facility. The facility initiated a plan of correction on [DATE] and completed their plan as of [DATE]. Therefore, this IJ will be cited as past noncompliance with a start date of [DATE] and an end date of [DATE]. This was true for one (1) of eight (8) residents who expired at the facility from [DATE] to [DATE]. Resident identifier: #63. Facility Census: 62. Findings included: On [DATE] the state agency received a five (5) day follow-up report regarding an incident that took place on [DATE] involving Resident #63. The five (5) day follow-up report read as follows: [DATE] FIVE DAY FOLLOW UP REPORT Alleged Perpetrator: (First and Last Name of RN #2), RN Alleged Victim: (First and Last Name of Resident #63) , resident On [DATE], (First name of Resident #63) was found unresponsive with no pulse or respirations by staff around 6:45 AM. (First and last name of Resident #63) was admitted to (Name of Facility on [DATE] for a skilled stay. His pertinent diagnoses include: noninfective gastroenteritis and colitis, unspecified; diarrhea, unspecified; enterocolitis due to clostridium difficile, not specified as recurrent; type 2 diabetes mellitus without complications; gastrostomy status; dysphagia, unspecified; malignant neoplasm of esophagus, unspecified; ulcer of esophagus with bleeding; and hypoglycemia, unspecified. (First name of Resident #63) scored an ,d+[DATE] on his most recent BIMS on [DATE]. His level of staff assistance varied from partial to dependent assistance for bathing, bed mobility, dressing, hygiene, and transfers. (First name of RN #2) reported she administered 30 mL of water through (First name of Resident #63)'s peg tube around 0530. He refused the Jevity 1.5 feeding citing complaints of feeling full. She advised he was pleasant and talkative, and denied being in any distress or discomfort. She reportedly obtained a finger stick at 6 AM of 124. The documented fingerstick is listed at 117. Based on statements obtained from all staff working on [DATE], (First name of Resident #63) was found unresponsive by a CNA while completing her round upon entering his room around 0645. The description she provided indicated that he wasn't breathing, his eyes and mouth were open. At this time, (First name of Resident #63) was still warm to touch per her statement. She ran to the door and called for the registered nurse, (First and last name of RN #2). Upon being informed that Mr. (Last name of Resident #63) was not responsive, (First and last name of RN #2) entered the room and completed an assessment. She was unable to discern a heartbeat, or breath sounds with her stethoscope. She was also unable to locate a pulse. She notified the physician and attempted to contact the patient's next of kin. The oncoming shift of nurses arrived at the center around 7 AM and started receiving report from (First name of RN #2) . Upon hearing that the patient had passed away, (First and last name of RN #3), RN asked (First name of RN #2) if she knew what his code status was and (First name of RN #2) replied I don't know but it isn't going to do him much good now. (First name of RN #2) advised she wasn't doing anything until I talk to (First name of the Director of Nursing (DON). (First and last name of the DON) , RN, DON spoke with staff at the center around 0719 and instructed them to begin CPR and call 911 and advised them the center was running an active code. (Name of Local emergency squad) arrived at the center around 0730 and assumed care of the code. They received authorization to call the time of death around 0755. The facility completed an audit on [DATE] for all residents to ensure they had a code status listed in the Physician Orders. Re-educations was provided by the DON/Designee to all licensed nurses to ensure if there is no order for code status in the resident chart; the resident is considered a full code and CPR is to be initiated and documented on the CPR/AED flowsheet with a posttest to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test upon the beginning of the next shift to work. New licensed nurses will be provided education, including post-test during orientation by the DON/designee. The Unit Managers/designee will monitor starting on [DATE] new admission/readmissions and/or change in resident advance directives order to ensure the resident has an order for code status. The Nurse Practice Educator/designee will conduct mock code drills starting on [DATE] daily across all shifts for 3 days, then weekly for 2 weeks, then monthly for 3 months and randomly thereafter. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved; then randomly thereafter as determined by the QIC committee. (First and last name of RN #2) was suspended pending investigation. An initial report was made to the WV RN Board. Neglect will be substantiated due to the delay in care. (First Name of Resident #2) has been terminated effective [DATE]. The state agency initiated an on - site investigation into this facility reported incident on [DATE]. During the investigation the reportable incident was reviewed and the above referenced Five (5) day follow-up was contained in the reportable. There were staff statements which supported the statements in the five day follow- up report. The following are the staff statements which were contained in the reportable record which was provided to the surveyor: Statement from Registered Nurse (RN) #3 (typed as written) dated [DATE]: After clocking into my shift at 7am [DATE], I approached the nurses station where the night nurse (first and last name of RN #2), RN was sitting at her computer charting. I gathered my materials form shift and a report sheet. The nurse then said to me Mr. (Last name of Resident #63) just passed away. I asked the nurse when, and she stated probably between 6:,d+[DATE]:45 am because he was still warm. I then asked if he was a DNR of Full Code. She stated, I don't know, but it isn't going to do him much good now. I'm not doing anything until I talk to (First name of the DON). I then explained to her that his POST form should have been verified upon discovering he was unresponsive and that vital signs have ceased, and if no POST form was available we should have began CPR and attempted to contact MPOA. I then immediately searched the resident's chart for a POST form, which was not available and called a code blue. (Initials of RN #2), RN then called the DON (First and Last name of the DON), RN while dayshift staff members responded to the code. Upon entering the room, resident was observed to be laying flat in bed, warm to touch, and Pale in color. Vital signs ceased. CPR was initiated by (First and last name of RN #7), RN while (First and last name of Nurse Aide (NA) #10), CNA obtained an AED, and I began pulling needed supplies from the crash cart. Once other staff members responded to assist, I went to the nurses station where, (Initials of RN #2), RN was sitting at her computer and asked her if she had called 911. She then picked up the phone and dialed 911. I began printing appropriate paperwork needed for EMS to give them upon arrival. EMS responded and entered the facility. As they approached the resident's room, I gave them the needed documents and report on the patient. When asked when the last time the resident was seen stable, (Initials of RN #2), RN responded with around 3am when she flushed his PEG tube with water and that was the last time she had laid eyes on the resident. As I assisted EMS and staff wit the code, I obtained a FS (finger stick) on the resident due to HX (history of) DM (Diabetes Mellitus) and the FS read 42. EMS staff asked when the last FS was obtained, and I then asked (initials of RN #2), RN because the resident had an order for 6am FS. She responded with 127. I obtained the history from both glucometers and could not find a FS reading 127 and the last FS obtained from the A hall glucometer was timed shortly after 1am. I then called the DON and attempted to reach the president's wife/emergency contact. I explained to the wife that the resident's vitals had ceased, and we were actively running a code with EMS. Due to not having a signed POST form on file and having to perform CPR I then asked the wife whether she wished for us to continue with CPR and she responded with yes. While speaking with the wife, EMS staff had called time of death. At this time the DON had arrived to the resident's room and spoke with EMS staff. I then assisted staff and EMS with transferring the patient back to the bed and cleaning him up. I went back up to the nurses station where (Initials of RN #2), RN was still sitting at her computer charting . She then said to me, I don't care if I get fired, I have a job at (Initials of Local Hospital). Statement from RN #7 dated [DATE] (typed as written) : I arrived to the facility at 7:03 (AM) and proceeded to the nurses station to receive a report from the off going nurse of A hall. She proceeded to give me report after having made the statement that they had found a patient expired in his bed prior to my arrival. She had stated that she was waiting on the DON to call her back to find out what she wanted to do . During that time while she was waiting for the phone call she was giving me report on A hall patients and about 5 minutes later she received the phone call from and individual I assumed was either the DON, Aministrator, or MD (Medical Doctor). It was while she was on the phone call that I became aware that the patient did not of a DNR. Promptly after that statement made by the off going nurse, she instructed me to head down to the patients room and start CPR. Staff were alerted of the Code Blue, announced by, (First and last name of RN #3), and everyone immediately responded to the code. Upon reaching the patients room, I quickly performed a rapid assessment and determined the patient was indeed unresponsive and I started CPR/compression. AED pads were applied after the first round of compression/during ventilation. Compressions and ventilation were not interrupted during this transition. CPR had been underway for about ,d+[DATE] round of compressions/2 AED rhythm checks before EMS had arrived with no shockable rhythm found. Once EMS arrived they assumed care and took over CPR and compressions vis mechanical compressions unit. This statement is to the best of my knowledge and I am unable to provide any more exact times than what is contained in this statement. Statement from RN #2 dated [DATE] (typed as written): Regarding (First and Last Name of Resident #63) This nurse rounded on this resident at 0530 (5:30 am) in room (Room number redacted to maintain confidentiality). He allowed me to give him 30 ml of water through his peg tube but refused his jevity 1.5 cal feeding c/o of feeling full. He was pleasant, talkative, and denied being in any distress or discomfort. I performed his 6 am finger stick which was 124. We talked for a about fie more minutes about the importance of keeping hydrated and I left his room. The resident was stable at this time. Sometime later was notified by the NA making her rounds that this resident appeared to not be breathing. I entered the room with my stethoscope at 0645 (6:45 am) and found Mr. (Last name of Resident #63) unresponsive and not breathing. I was unable to discern a heartbeat or pulse. I found no mottling or any other areas of concern to the residents body. Dr. (last name of the attending physician) was notified at 0705 (7:05 am) at which time he told me he was on his way to the (Name of Facility). I attempted to call the resident wife but was unable to talk with her personally. I brought up the residents documents online but was unable to find a POST form that documented his wishes regarding end of life care. I immediately called my DON and recounted the above events. (Name of local EMS Service) was notified at 0726 (7:26 am) that we were actively starting CPR in lieu of no advance directives. Crash care was brought to the door of the residents room and the AED was utilized while awaiting the emergency squad. (Initials of Local EMS service) arrived at 0737 (7:37 am) and took over care of Mr. (Last name of resident #63) at this time. These statements are true to the best of my knowledge and recollection. Statement from Nurse Aide (NA) #17 this statement is not dated (Typed as written): I was maken [sic] our last round go to (first and last name of Resident #63) room I turn on light and see he wasn't breathen [sic} his eyes and mouth were open. I ran to the door and yelled for the nurse , (First name of RN #2). She came in also (First Name of Licensed Practical Nurse (LPN) #16) and (First name of NA #21) came in the nurse (First name of RN #2) listen to him breathe and said he was gone, we touch him and he was still warm. She said he hasn't been gone too long and she said something about his tube feeding that he was full up to or to full not sure she left. (First name of NA #21) and I washed him up. We was about done and (First Name of NA #18) came in and asked if we needed help. She help us put the flat sheet under him we got done and left next thing I new [sic] (First name of RN #3) asked (First name of NA #10) to help her because we half [sic] to do CPR on him. Coed [sic] blue. When I got to the room (First Name of RN #7) and (First name of Na #10) was doing CPR on him. (Nick Name of Activity Director) out of activities was In there too. I left and told them I would wait on the ambulance. Time I got to the door they was here and I showed them the way. Statement from NA #10 dated [DATE] (Typed as written): This morning Friday [DATE], upon arriving at the nurses station to get shift report and begin my day. I asked (First name of NA in Training #23) where the rest of the staff was. She informed me that (NA #17) was performing post-mortem care on Mr. (Last name of Resident #63). I went to his door, Room (room number redacted to maintain confidentiality), and knocked on his door to see if (First name of NA #17) needed any assistance as I was under the impression she was in the room by herself. After learning (First and Last Name of NA #21) was also in the room, I collected my necessary materials for my shift and began filling the ice chest go a water pass in the nutrition room. After coming out of the nutrition room, I overheard discussion as to whether or not Mr. (Last name of Resident #63) was a full code or a DNR and went behind the desk at the nurse's station to see if I could be of any help. (First and Last Name of RN #2), RN was sitting at the computer and stated, I don't know if he is full code or not but it wont do him any good now. (First and Last Name of RN #3) , RN replied with, Do we have a signed POST form stating yes or no? With no reply from (First name of RN #2), (First Name of RN #3) walked over to the computer and began to see if he had one scanned into his chart and I pulled his paper chart off of the shelf and began to flip through finding no POST form. (First name of RN #2) then made the comment that was not doing anything until she talked to (First Name of the DON), the DON. I then walked down B hall and began my day with ice water pass while I waited for further instructions as to what was happening. (First and last Name of NA #18) and I got shift report from (First and Last name of NA #21) and began an Ice pass. We made it about ,d+[DATE] of the way down the hallway when, (First name of RN #3) called code blue. I went to (First name of NA #18) and told her there was a code blue in room (Room number redacted to maintain confidentiality). I observed (First name of RN #3) and (First and last name of RN #7) retrieving the crash cart and oxygen tank from the clean utility room so I got the AED and made my way to Room (Room Number redacted to maintain confidentiality). Upon arriving to the room, (First name if RN #7) was adjusting the bed to an appropriate lever for CPR and (First Name of RN #3) obtained necessary materials from the crash cart. I then opened the AED and followed prompts while (First Name of RN #7) began compressions. ( First Name of RN #3) then received a phone call from (First Name of DON) so she handed me the ambu bag and told me she would be right back. I went to the head of the bed, connected the oxygen to the bag and began giving the resident rescue breaths in accordance with the guidelines of CPR. While assisting in the code, I observed the resident being pale and warm to the touch. I continued aiding in CPR switching off between providing Rescue breaths and performing compressions until (Initials of local emergency squad) arrived on scene. I then followed orders of the medics as they took over the code. We lowered the resident to the floor to provide more adequate CPR and EMS attached the LUCAS machine. Once they no longer needed my assistance, I went back to B hall to finish the ICE water pass. After we completed the ice pass, I put the supplies away and went back to Room (Room number redacted to protect confidentiality) where I found (First name of RN #2) talking to the medics while they performed the code. While I was in the room the female medic asked what time was he last seen alive, when (First name of RN #2) replied with around 3 am I flushed is peg tube with 30 cc of water and he declined his feed and pain pill at that time. Resident was talking and was free of pan at that time. I asked the medics I they needed any further assistance to which they replied no and I left the room to pass breakfast trays. After passing the trays I noticed squad was still here so again I went to the room to see if they were in need of any assistance to which the female medic told me no but asked if I knew what time he was found to which I replied I was not on shift yet but I believe it was sometime between 0630 and 0700 Se expressed gratitude for my honesty as she could not get a straightforward answer from the night shift nurse. That was the end of our interactions, and I went back to b hall. Statement from NA #18 this statement does not have a date (typed as written): I came in this morning and the new girl asked me If I was a nurse or an aide. I told her aide she said they're down there in (Room number redacted to maintain confidentiality) cleaning him up and they might need help. So I went down and ask [sic] them if they needed help. They [sic] 2 aides said can you help roll him so I did and I helped put a sheet under him. We then covered him up. I went back down B hall. Oh yea I forgot he was still warm. I also tried to close his mouth which it wouldn't close. My self and (First name of NA #10) went to pass water down b hall then (First name of NA #10 said that (First name of RN #3) called Code Blue but told her Code Blue so we went down to (Room number redacted to maintain confidentiality) (First name of NA #10) grabbed the AED and put pads on his chest and her and (First Name of RN #7) started doing compressions. (First Name of RN #3) called 911. Ambulance Came and they took the man off the bed and place him in the floor and proceeded to continue CPR After Ambulance came I came out of room I was just standing there. Statement from LPN #16 dated [DATE] (typed as written): On [DATE] at 645 am this nurse pulled scheduled medications and tube feed for Room (Room number redacted to maintain confidentiality). Upon entering room, resident was repositioned blood pressure obtained and tube fed site was cleaned and dressing applied. While administering meds and tube fed this nurse heard someone say something but could not make out what was said. Then heard someone say he's gone. As soon as feeding syringe was empty, I capped feeding tube and went to check. I entered room (room number redacted to maintain confidentiality) and CNA stated he's gone. Resident noted to be very pale with mouth open. Turned to get the other nurse who was walking into room. Returned to Room (room number redacted to maintain confidentiality) to ensure no medications were left unattended. Statement from NA #19 dated [DATE] (typed as written): We checked resident in (room number redacted to maintain confidentiality) around ,d+[DATE] (am) he was not wet an no BM, he couldn't find his TV remote so we helped him find it (in his bed) and I talked to him a little about watching, The wheel of fortune and asked if he was okay and needed anything else, he said he was fine and we left the room. Statement from Activity Director #20 dated [DATE] (typed as written): On Friday Morning I was in activity room and I heard them call a code blue. When I gotin the room a nurse was in there performing CPR and A SNA was using ambu bag giving breaths. I asked if the nurse needed a break at this time and the nurse and CNA just switched jobs and when I notice CAN getting tired I jumped in and did one round of compressions and then the squad came and took over. Resident was not responsive to CPR. When I got in the room he was pale in color. Statement from NA #21 dated [DATE] (typed as written): We had been in room (room number redacted to maintain confidentiality) between 3:30 am and 4:00 am. Resident was dry and ok. Was talking about watching Wheel of Fortune. That room was the last one to check on the 5 am round. (First name of NA #17) had gowned up and went in ahead of me. She came to the door and said we need a nurse Upon entering the room the resident had a waxy color and did not appear to be breathing but was warm to the touch. (First name of RN #2) entered the room just after me with a stethoscope. She listened to him and checked for a pulse and told us he was gone. (First name of NA #17) and I started cleaning him up and (First Name of NA #18) came in to help us finish him up. The final two statements in the investigation were from NA #12 and NA #15 both of whom stated they had no interaction with the resident until after the code was over and they helped to get the resident back into the bed. A review of the medical record for Resident #63 found there was no documentation in his medical record pertaining to this incident. The only documentation in the record to indicate the resident had expired was a death in facility minimum data set with an assessment reference date of [DATE] and four (4) e-mar notes which indicated, PT (patient) expired as a reason why the medication was not administered. An interview with the Nursing Home Administrator (NHA) at 9:04 am on [DATE] confirmed there was no documentation in the medical record regarding this incident. She indicated they found that during the end of their investigation. Their training does incorporate making sure the code and the steps of the code are documented in the medical record. Further review of the medical record found Resident #63's care plan was void of any information pertaining to his code status. There was not a physician order or a Physician order for Scope of Treatment (POST) form in the record. An interview with the Nursing Home administrator on the afternoon of [DATE] confirmed there was no post for or code status order. She stated, it is usually addressed by the admitting nurse, but they missed his and there was not one. The facility initiated a plan of correction on [DATE] which read as follows: F678 Resident #(First and last initial of Resident #63) no longer resides in the facility. All residents of the facility have the potential to be affected. The Director of Nursing (DON/Designee) conducted an audit on [DATE] for all residents to ensure all residents had a code status listed in the Physician Orders. The DON conducted an audit on [DATE] for all licensed nursing staff including any non licensed nursing personnel to validate their current Cardiopulmonary Resuscitation (CPR) certification with corrective action immediately upon discovery. Re-education was provided by the DON/Designee to all licensed nurses on [DATE] to ensure if there is no order for code status in the resident chart the resident is considered a full code and CPR to be initiated and documented on the CPR/AED flow sheet with a posttest to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post test during orientation by the DON/Designee. The unit managers (UM)/designee will monitor starting [DATE] new admission/readmissions and/or change in resident advance directives order to ensure the resident has an order for code status and the CPR/AED flowsheet is utilized for all CPR daily for 2 weeks including weekends and holidays, then five times a week for four (4) weeks , then three (3) times a week for 4 weeks then randomly thereafter. The nurse Practice Educator (NPE)/designee will conduct mock code drill starting [DATE] daily across all shifts X 3 days, then weekly for 2 weeks , then monthly for 3 months, then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or in servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. An interview with the Director of Nursing (DON) around 10:00 am on [DATE] confirmed she and the nurse practice educator (NPE) conduct the mock CPR drills she explained the process as follows: We take the CPR dummy to different places in the facility and have the staff run a code. She stated, we observe to make sure they are completing all steps of the CPR process correctly and that everyone is knowledgeable about what they need to do an when. She stated, if we identify staff that may need a little extra help we will focus the next drill on them to ensure they are getting the training they need. Licensed Practical Nurse (LPN) #4, LPN #5, and LPN #6 were interviewed on [DATE] and [DATE] they were knowledgeable about the education they received and were able to accurately describe the steps they would follow in initiating or not initiating CPR. They were asked questions about different scenarios and was able to accurately answer all questions. A review of the training and audits provided by the facility found all the training and audits they mentioned in their Plan of correction were completed with the last trainings taking place on [DATE]. The audits remain ongoing to ensure continued compliance. Any nurses who have not been educated have not worked since the incident and will be educated when they return to work. All residents who expired in the facility from [DATE] were reviewed. There were eight (8) total including Resident #63. Resident #64, 65, 66, 67, 68, 69 and 70. The seven (7) residents excluding Resident #63 all had orders for Do Not Resuscitate: New admissions the facility was also reviewed to ensure there were no issues with the code status and/or orders for such. The Findings of the review are below: -- Resident #6 admitted on [DATE] is a full code and it is identified accurately throughout her medical record. --Resident #11 admitted on [DATE] is a DNR which was established by the facility on [DATE] and is identified accurately throughout the medical record. -- Resident #12 admitted on [DATE] is a DNR which was established by the facility on [DATE] and is identified accurately throughout the medical record. -- Resident #16 admitted on [DATE] is a full code and it is identified accurately throughout his medical record. -- Resident #25 admitted on [DATE] is a full code and it is identified accurately throughout her medical record. --Resident #34 admitted on [DATE] is a full code and it is identified accurately throughout his medical record. -- Resident #40 admitted on [DATE] is a DNR and this is identified accurately throughout her medical record. -- Resident #50 was admitted on [DATE] and is a full code and it is identified accurately throughout her medical record. -- Resident #59 was admitted on [DATE] and is a full code and it is identified accurately throughout her medical record. All CPR certifications were reviewed by the SA and all licensed nursing staff have current CPR certifications. All posttests completed by the facility was also reviewed and all staff had completed the training and the post test.

Based on observation, record review, and staff interview, the facility failed to assess and treat Resident #210's pain stemming from an unstageable pressure ulcer to his left heel resulting in actual physical and psychosocial harm. The resident rated his pain as a 8 (very strong pain) on 01/30/23. The surveyor notified the resident's nurse of his pain. The resident again rated his pain as a 10 (worst pain possible) on 02/01/23 during his pressure ulcer treatment. The facility failed to provide any pain medication on 01/30/23 despite surveyor intervention. Pain medication was not provided until the surveyor again alerted staff on 02/01/23. The facility failed to monitor the effectiveness of the pain medication administered within one (1) hour after administration on 02/01/23. This practice caused unnecessary suffering for the resident. This was true for one (1) of two (2) residents reviewed for the care area of pain. Resident identifier: #210. Facility census: 64. Findings included: a) Resident #210 During initial screening on 01/30/23 at 12:16 PM, Resident #210 stated he had pain level of 8 on a 1-10 pain scale with 10 being the worst. Resident indicated it was in his left heel, it hurt him all the time as he lifted his leg up and stated, It hurts bad, it's too far gone now to do anything. Surveyor informed Resident's nurse, Licensed Practical Nurse (LPN) #44 that Resident was reporting pain. LPN #44 stated she would check into it. Record review on 02/01/23 at 10:00 AM showed an order to cleanse Left heel with wound cleanser and apply skin prep to unstageable pressure injury every shift. No orders for pain medication or pain assessment were present. Observation on 02/01/23 at 10:40 showed Resident #210 to be holding his left leg in the air, cradled by his hands for support, up off the mattress of his bed when surveyor and RN #54 entered the room for wound care. Resident stated, It hurts, can't stand to lay it down and wiggled his left foot. As RN #54 initiated wound care and gently wiped the left heel with wound cleaner, the Resident jerked his heel out of RN #54's hand and yelled oh, oh I can't stand that it hurts. When RN #54 resumed wound care, Resident #210 grunted, the Resident's face turned red, and he grimaced with his jaw clinched. RN #54 stated, No denying that's painful. Resident #210 was asked by Surveyor for a pain level on a 1-10 pain scale with 10 being the worst, and he replied Ten. Resident #210 stated no one had done anything for the pain, and he needed to get out of there because he had pain medication at home he could take. RN #54 was asked if the Resident had been medicated for pain prior to wound care and RN #54 stated' No I don't think he has an order for pain medication. He [resident #210] done this yesterday when I was working on his heel, and I just thought he was ticklish. On 02/01/23 at 10:56 AM, the Director of Nursing (DON) and Administrator were informed of the Resident #210's complaint of severe pain during wound care. The Administrator stated, Ok the doctor is here today I'll let him know. The DON then stated, He does not have anything ordered for pain? He was very sick when he came here. On 02/02/23 at 1:57 PM LPN #44 was asked if the doctor was able to address the resident's pain? LPN #44 stated that she just sent that script over to pharmacy so she can now pull that from the Omnicell. LPN #44 further stated, I was just in there, he said he was feeling ok. On 02/01/23 at 2:00 PM Resident #210 stated they still had not gave him anything for pain, and the heel still hurts bad. Resident stated Pain level 8 on a 1-10 pain scale with 10 being the worst. On 02/01/23 at 2:03 PM, when the surveyor exited the Resident's room, LPN #44 yelled down the hallway, I'm getting it now. LPN #44 then stated, I just clarified that order, and I can get it out of the Omnicell. He [resident #210] said he wasn't having pain. Surveyor Reported to LPN #44 that Resident's pain level was just reported as an 8 out of 10 and Resident begged, Please see if they can give me something. On 02/01/23 at 3:00 PM record review showed Pain medication was administered at 2:44 PM by LPN #44. Medication Administration note stated, Ultram Oral Tablet 50 MG Give 50 mg via G-Tube every 8 hours as needed for Pain. Resident rates pain 8/10. Ultram given per order. Will continue to monitor. Record review on 02/01/23 at 3:05 PM showed an order for Ultram Oral Tablet 50 MG (Tramadol HCl), Controlled Drug, give 50 mg via G-Tube every 8 hours as needed for Pain was entered by LPN #44 at 2:00 PM on 02/01/23. Record review indicated as of 4:52 PM on 02/01/23, the pain assessment to monitor the effectiveness of the PRN (as needed) pain medication that was administered to Resident #210 on 02/01/23 at 2:44 PM had not been completed. During an interview on 02/01/23 at 4:55 PM, the DON verified PRN pain medication should be monitored for effectiveness within one hour of administration. The DON agreed Resident #210's pain should have been better managed and not let go that long before intervention.

Based on record review and staff interview, the facility failed to notify the physician of a deterioration in a resident's health status with a need to alter treatment, in a timely manner. The physician was not notified of two (2) consecutive elevated blood sugars as ordered, resulting in avoidable harm to this resident. The resident subsequently had a decline in her level of consciousness and was sent to the hospital for treatment. This was found for one (1) of seventeen (17) residents in the Stage 2 sample. Resident identifier: #83. Facility census: 61. Findings include: a) Resident #83 A review of the clinical record revealed Resident #83 was admitted to the facility on [DATE], following an acute hospitalization for diabetic ketoacidosis, a fall with left rib fractures, and a urinary tract infection. Her record indicated her blood sugar fluctuated daily from the 50's at 7:00 a.m. through the 300's later in the day. The physician's orders [REDACTED]. if 151-200 = 2u (units); 201-250 = 3u; 250-300 = 4u; 301-350 = 5u; 351-400 = 6u; 401-500 = 7u, subcutaneously two times a day related to Type 1 Diabetes mellitus with ketoacidosis without coma ., and . Fingerstick with Humalog Insulin. If <(less than) 60 or > (greater than) 400 or 2 consecutive readings >300 notify MD. The resident was described in the nurse's notes at 9:50 a.m. on 01/12/16, as, Alert, oriented to self & (and) time, pleasant. Skin warm & dry, color pink, resp (respirations) @ (at) ease with O2 (oxygen) in place @ 2L/min (2 liters per minute) via nasal cannula . Ate 100% of breakfast this morning along with 100% of house supplement. Took medications whole with H2O (water). No s/s (signs/symptoms) of diabetic ketoacidosis, denies abdominal pain, diarrhea, vomiting and dyspnea. At 11:05 a.m. on 01/12/16, an entry in the nurses' notes read, Notified (Dr's name) of blood sugar result 456 @ 11:00 today. Administered scheduled 6 units of Humalog . Awaiting any new orders. There was no evidence in the record of a recheck of the blood sugar after the coverage, or of a response from the physician. At 12:40 p.m. on the same day, the resident was interviewed by Social Worker (SW) #16 who stated in her notes, Pt (resident) is alert and seemed oriented during our conversation. She was tired and weak. The record revealed the resident's blood sugar at 4:00 p.m. on 01/12/16, was 355 and 5 units of coverage was given. This was the second consecutive blood sugar that was over 300, but the physician was not notified, nor was the blood sugar rechecked. At 7:50 p.m. on 01/12/16, the record stated, Resident in bed and very hard to arouse . Resident was not able to stay awake long enough to feed herself. I sat with the resident verbally arousing her between bites while totally attempting to feed her. Resident ate approximately 25% with constant cuing to open mouth. I went back in to check on resident at 7PM (7:00 p.m.) and was unable to arouse her at all. After a few minutes of attempting to stimulate her awake, resident responded. I was unable to get a blood pressure and asked the other nurse to attempt a blood pressure. VS (vital signs) T. (Temperature) 98.1 P. (Pulse) 108. R. (Respirations) 16. B/P (blood pressure) 60/40. O2 sats (saturation) 97% on O2. BS (blood sugar) 221. Order obtained from on call (physician) to send to (hospital) for evaluation at 7:20PM. At 11:40 p.m. on 01/12/16, an entry in the record stated, Return from hospital at this time via (ambulance). Alert and talkative. There was a delay in notifying the physician the resident's blood sugars were out of his ordered range for reporting and other symptoms in a resident newly admitted to the facility following an acute hospitalization for ketoacidosis. There was 3 hours and 20 minutes from the 4:00 p.m. blood sugar until 7:20 p.m. when the physician was reached and ordered the resident transferred to the hospital. This constituted actual harm to the resident. During an interview with Registered Nurse (RN) #74 at 12:45 p.m. on 02/15/16, she acknowledged after reviewing the record the nurse should have contacted the physician at 4:00 p.m. on 01/12/16, when the resident's blood sugar was over 300 for the 2nd time and definitely when she recognized the changes in the resident's demeanor at supper-time (approximately 5:30 p.m.). A further review of the nurses' notes for February 2016 found no evidence the physician had been notified of the following: -- 59 blood sugar at 7:00 a.m. on 02/03/16 with no indication of treatment or recheck; -- 56 blood sugar at 7:00 a.m. on 02/13/16 with the following entry: Resident alert/oriented - blood sugar this AM was 56 - Resident ate graham crackers with peanut butter and drank milk - re-check BS was 58 - Resident also drank OJ (orange juice) - recheck BS was 86.; -- consecutive blood sugars of 312 at 5:00 p.m. and 346 at 9:00 p.m. with appropriate coverage on 02/06/16. These were all outside of the physician ordered parameters for notification and the physician should have been called. In an interview with RN #11 (director of nurses) at 9:30 a.m. on 02/15/16, she said there was coverage in the absence of physicians by two (2) Nurse Practitioners (NP) and one of them was available at all times. She agreed there should have been contact with one of them sooner. During an interview with NP #84 on the morning of 02/15/16, she explained she or the other NP were available on an on-call basis at all times, but added when she was on call, it was for all the corporate facilities no matter where they were or where she was and acknowledged sometimes there was a delay in response. She said when this happened the facility should proceed with sendnig the resident to the hospital.

Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to provide timely care and services for a resident with a [DIAGNOSES REDACTED]. The physician was not notified, as directed by facility policy, when the resident's blood sugars were over 400 at varying times on three (3) consecutive days. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks. The the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of intervention by nursing, or notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED]. Employee #32, an RN, was interviewed on [DATE] at 3:30 p.m. She said she could not remember the situation, but it was likely the time from the receipt of the order until administration (12:30 p.m. to 3:30 p.m.) of the insulin was how long it took to obtain the medication from the pharmacy, as it was a new order. At 4:05 p.m. (16:05) on [DATE], an order was obtained to send the resident to the emergency room . At 8:26 p.m. (20:26) the resident expired at the acute care facility emergency room . This matter was discussed with the director of nursing (DON) at 2:30 p.m. on [DATE]. She said a blood sugar value that was over 400 was considered an "urgent" value for a finger stick that required immediate notification of the physician. She provided the facility's policy on finger sticks. The Policy Diabetic Care Protocol 15.14, effective [DATE] revised [DATE], in Section 9.1.1 included, "If parameters are not ordered, report following to physician URGENT: Notify immediately if blood glucose is greater than 400 or less than 70." .

Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to ensure the physician was notified as directed by facility policy when a resident's blood sugars were over 400. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks and the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED]. At 4:05 p.m. (16:05) on [DATE], an order was obtained to send the resident to the emergency room . At 8:26 p.m. (20:26) the resident expired at the acute care facility emergency room . This matter was discussed with the DON at 2:30 p.m. on [DATE]. She said a blood sugar value that was over 400 was considered an "urgent" value for a finger stick that required immediate notification of the physician. She provided the facility's policy on finger sticks. The Policy Diabetic Care Protocol 15.14, effective [DATE] revised [DATE], in Section 9.1.1 included "If parameters are not ordered, report following to physician URGENT: Notify immediately if blood glucose is greater than 400 or less than 70 ". .