Every finding on record at Sabine Retirement and Rehab Center

Based on interview and record review the facility failed to ensure all care and services were provided according to accepted professional standards of clinical practice for 1 (Resident #2) of 4 sampled residents. The facility failed to follow physician orders and obtain vital signs prior to medication administration for Resident #2. Findings:Review of an undated facility policy on 08/12/2026 at 8:51 a.m. titled, Medications-Administering revealed the following in part.Medications shall be administered in a safe and timely manner, and as prescribed. 8. The following information must be checked/verified for each resident prior to administering medications: B. Vital signs, if necessary. Review of Resident #2's medical record revealed an admission date of 07/17/2025 and included diagnoses in part.Hypertensive Heart Disease without Heart Failure and Paroxysmal Atrial Fibrillation.Review of Resident #2's 07/2026 Physician's orders revealed orders in part.-(Start Date: 07/18/2025) Metoprolol Succinate Extended Release oral tablet Extended Release 24 hour 50 milligrams; Give 1 tablet by mouth one time a day related to Hypertensive Heart Disease without Heart Failure; with supplementary documentation to include blood pressure and pulse. - (Start Date: 07/18/2025) Spironolactone oral tablet 50 milligram; Give 1 tablet by mouth one time a day related to Hypertensive Heart Disease without Heart Failure; with supplementary documentation to include edema, blood pressure and pulse. Review of Resident #2's 07/2026 and 08/2026 EMAR revealed the following in part.07/2026 EMAR: order for Metoprolol- on dates 3rd, 4th, 5th, 8th, 9th, 13th, 14th, 17th, 18th, 19th, 22nd, 28th, and 31st S3 LPN administered the medication and documented Not Applicable/NA for the supplementary documentation (blood pressure and pulse). 08/2026 EMAR: order for Metoprolol- on dates 1st, 2nd, 6th, 10th, and 11th S3 LPN administered the medication and documented Not Applicable/NA for the supplementary documentation (blood pressure and pulse).07/2026 EMAR: order for Spironolactone- on dates 3rd, 4th, 5th, 8th, 9th, 13th, 14th, 17th, 18th, 19th, 22nd, 28th, and 31st S3 LPN administered the medication and documented Not Applicable/NA for the supplementary documentation (blood pressure and pulse). 08/2026 EMAR: order for Spironolactone- on dates 1st, 2nd, 6th, 10th, and 11th S3 LPN administered the medication and documented Not Applicable/NA for the supplementary documentation (blood pressure and pulse). Review of Resident #2's Quarterly MDS with ARD of 07/31/2026 revealed the resident received diuretic therapies. Review of Resident #2's current care plan revealed the following part. (Initial Date: 07/17/2025) Problem: The resident is at risk for complications related to diagnosis of Hypertension and Atrial Fibrillation. Interventions: Metoprolol as ordered. Give anti-hypertensive medications as order. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. (Initial Date: 07/17/2025) Problem: The resident is at risk for dehydration related to diuretic usage daily. Interventions: Administer medications as ordered. Monitor vital signs as ordered/per protocol and record. Notify the Medical Doctor of significant abnormalities. Spironolactone as ordered. In an interview on 08/11/2026 at 1:03 p.m., S3 LPN, accompanied with this surveyor, reviewed Resident #2's active Physician's orders and 07/2026-08/2026 EMAR. S3 LPN confirmed Resident #2 had orders for Metoprolol and Spironolactone daily; with supplementary documentation that included to obtain a blood pressure and pulse prior to administration of medications. S3 LPN confirmed that she would document Not Applicable/NA and not actually obtain the blood pressure and pulse prior to medication administration. S3 LPN revealed supplementary documentation was optional for these particular Physician orders and that the supplementary documentation should be deleted all together, due to being optional. In an interview on 08/11/2026 at 1:29 p.m., S4 LPN revealed during medication pass, if supplementary documentation appears, it is required to obtain the information prior to medication administration. S4 LPN stated that for example. obtaining a blood pressure or pulse prior to administering antihypertensive or diuretic medications. S4 LPN revealed supplementary documentation was not optional and Not Applicable/NA should not be used; that the only time supplementary documentation would not be obtained would be if the resident refused the medication or was unavailable (hospitalized ). S4 LPN revealed in those particular cases the nurse should document refuse or H/hospitalized . In a shared interview on 08/11/2026 at 3:36 p.m., S1 Corp RN and S2 DON confirmed all the above findings for Resident #2's active Physician orders/supplementary documentation and 07/2026 and 08/2026 EMAR. S2 DON confirmed Resident #2 had active orders for Metoprolol and Spironolactone daily and supplementary documentations ordered; which required nurses to obtain a blood pressure and pulse prior to medication administration. S1 Corp RN and S2 DON confirmed that supplementary documentation was not optional; was a part of the physician's orders; expected to be performed; and documented in the medical record prior to medication administration. S2 DON revealed all nurses were aware of what the expectations were for documentation of supplementary documentation during medication administration. S1 Corp RN and S2 DON confirmed S3 LPN should not have documented Not Applicable/NA to the supplementary documentation and should have obtained the ordered vital signs prior to medication administration of Metoprolol and Spironolactone, but did not.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development of communicable diseases and infection. The facility failed to ensure Enhance Barrier Precautions (EBP) were implemented for 1 (R#1) of 4 sampled residents.Findings: Review of an undated facility policy on 08/12/2026 at 8:45 a.m. titled, Enhanced Barrier Precautions revealed the following in part .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms (MDRO). All are expected to comply with all designated precautions. Applicable conditions and devices: Wounds and/or indwelling medical devices (examples: urinary catheters). High contact resident care activities include: dressing, bathing, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care/urinary catheters.Review of an undated facility policy (Stop Signage) on 08/12/2026 at 8:45 a.m. titled, Enhanced Barrier Precautions revealed in part. Providers and staff must also: wear gloves and gown for the following high contact resident care activities.dressing bathing/showering, changing linens, providing hygiene, changing briefs, and device care (urinary catheters). Review of R#1's medical record revealed an admission date of 04/06/2026 and diagnoses of Quadriplegia, C1-C4 Incomplete, Other Retention of Urine, Other Neuromuscular Dysfunction of Bladder, Pressure Ulcer of Sacral Region, Stage 4, and Need for Assistance with Personal Care. Review of R#1's 08/2026 Physician's order revealed the following orders in part.- (Start Date: 04/07/2026) Clean suprapubic catheter with wound cleaner apply dry dressing to suprapubic catheter site every day shift; - (Start Date: 04/06/2026) Enhanced Barrier Precautions related to wound and suprapubic Foley; and- (Start Date: 04/08/2026) To stage 4 sacral pressure ulcer clean on Monday, Wednesday, and Friday with wound cleanser, apply collagen powder to the wound bed followed with calcium alginate over wound bed and cover with foam dressing until healed; off load pressure. Review of R#1's Quarterly MDS with ARD of 07/16/2026 revealed R#1 was dependent on staff for toileting hygiene, bathing/showering, and personal hygiene. R#1 had an indwelling urinary catheter; was always incontinent of bowels; had one stage 4 pressure ulcer; and required pressure injury care. Review of R#1's care plan revealed the following in part. (Date Initiated: 04/06/2026) The resident is at risk for skin impairments due to stage 4 pressure ulcer to sacral region. Interventions: Enhanced Barrier Precautions. Observation on 08/11/2026 at 9:08 a.m. revealed S6 CNA bring clean linens into R#1's room, including wash cloths and towels. Observed S5 CNA Supervisor also enter R#1's room at this time. Observation on 08/11/2026 at 9:10 a.m. revealed S6 CNA and S5 CNA Supervisor both come out of R#1's room; then reenter R#1's room; and close the door behind them. Observed EBP signage and a hanging door caddy on R#1's door with PPE stored. Observation did not reveal either staff member apply or gather PPE to provide care to the resident. Observation on 08/11/2026 at 9:29 a.m. revealed S6 CNA open R#1's door and with her gloved hands, placed dirty linens into a grey barrel outside of the resident's room. Observed S6 CNA without a gown and reentered R#1's room and closed the door. Observation on 08/11/2026 at 9:31 a.m. revealed S5 CNA Supervisor exit R#1's room without a gown; discard her gloves; apply sanitizer to hands; and begin to walk down the hallway. Observation on 08/11/2026 at 9:32 a.m. revealed S6 CNA without a gown; exit R#1's room; with gloved hands discard more dirty linen into the grey barrel; discard gloves; and sanitize her hands. Observation appeared S6 CNA had completed her tasks for R#1. In an interview on 08/11/2026 at 9:37 a.m., S6 CNA revealed she was assigned to R#1 and she and S5 CNA Supervisor had just provided a bed bath, clean linen change, incontinent care, turning/repositioning, and catheter care to R#1. S6 CNA revealed R#1 required total care with all the above procedures due to being paralyzed. At the time of interview, S6 CNA and surveyor observed R#1's EBP door signage and caddy. S6 CNA confirmed she nor S5 CNA Supervisor wore a gown during all the care provided to the resident, but should have. S6 CNA confirmed she and S5 CNA Supervisor had only worn gloves .that she forgot R#1 required EBP due to his wounds and urinary catheter.stating they should have worn both gown and gloves prior to providing direct care. In an interview on 08/11/2026 at 9:54 a.m., S5 CNA Supervisor revealed R#1 had a suprapubic catheter and wounds, which required staff to follow EBP procedures prior to providing direct care.such as bathing and incontinent care. S5 CNA Supervisor revealed she and S6 CNA were both aware of when to follow EBP procedures and just forgot, due to trying to complete tasks. S5 CNA Supervisor confirmed she and S6 CNA did not wear both gown and gloves while providing direct care to R#1, but should have. In a shared interview on 08/11/2026 at 3:32 p.m., S1 Corp RN and S2 DON revealed all staff were trained to identify residents who required EBP PPE by observing the posted signage on the resident's door and the PPE door caddy. S2 DON revealed EBP was required for residents with pressure ulcers, indwelling catheters, or other indwelling devices. S2 DON revealed R#1 required EBP procedures due to having a suprapubic urinary catheter and pressure ulcers.S2 DON expected all staff to wear gowns and gloves while providing direct care; such as bathing, incontinent care, or catheter care. S2 DON revealed S6 CNA and S5 CNA Supervisor were both aware of EBP procedures and should have worn gown and gloves prior to providing direct care to R#1.

Based on observation, record review, and interview the facility failed to protect a resident's right to privacy and confidentiality of personal and medical records by failing to ensure 1 (Resident #4) of 4 sampled resident's name, medical appointment and diagnosis were not visible in a public area within the facility. Findings:Review of a facility policy titled Resident Rights, with no review date read in part.8. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal medical records.b. The resident has a right to secure and confidential personal and medical records.Review of Resident #4's medical record revealed an admit date of 09/24/20215, with diagnoses that included in part.Malignant Neoplasm of Prostate, Vascular Dementia, and Other Sequelae Following Unspecified Cerebrovascular Disease.Review of a Radiation Oncology Consultation note date 06/01/2026 read in part.Chief Complaint: I am here to discuss radiation for my Prostate Cancer. Observation on 06/16/2026 at 10:20 a.m. of nurses' station located at the front entrance into the facility revealed a brown envelope with Resident #4's name, scheduled medical appointment time, name of the hospital with specification of the Cancer Center and telephone number. Observation and interview on 06/16/2026 at 10:25 a.m. with S1 DON at nurses' station located at the front entrance of the facility revealed the brown envelope with Resident #4's name, scheduled medical appointment time, name of the hospital with specification of the Cancer Center and telephone number. S1 DON stated Resident #4 went out to a doctor's appointment, and the envelope should have been sent with him. S1 DON at this time confirmed the envelope was left lying at the nurse's station in a visible area to the public and contained personal and medical information for Resident #4 and should not have been.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This deficient practice had the potential to affect all 106 residents who resided in the facility. The facility failed to:Ensure expired and unlabeled medications were not available for administration to residents in 1 (Med Room B) of 2 medication rooms; andEnsure expired medications and supplies were not available for administration to residents in 2 (Med Cart B and Med Cart E) of 5 medication carts. Findings:Review of a facility policy on 01/13/2026 at 10:40 a.m. titled, Pharmacy Services with a revision date of 01/05/2025 revealed the following in part .It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of an undated facility policy on 01/13/2026 at 10:10 a.m. titled, Medications-Storage revealed the following in part .The facility shall store all drugs and biological in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Review of an undated facility policy on 01/13/2026 at 10:10 a.m. titled, Medications-Administering revealed the following in part .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 1.Observation on 01/13/2026 at 8:15 a.m. of Med Room B with S7 ADON, revealed the following expired and/or undated items:One opened and undated bottle of 1% Lidocaine 100mg/10ml; andSix 3ml prefilled Normal Saline syringes with an expiration date of 05/02/2025.In an interview on 01/13/2026 at 8:45 a.m., S7 ADON confirmed the above findings and stated that all the nurses were responsible for disposing of expired medications and labelling multi-use medications once opened. S7 ADON confirmed all of the above medications should have been disposed of and not been available for resident use, but were not. 2.Observation on 01/13/2026 at 11:15 a.m. of Med Cart B with S8 LPN, revealed the following expired items:Four packages of five individual prefilled 3ml vials (20 total items) of Ipratropium/Albuterol Sulfate 3mg with an expiration date of 05/2025.In an interview on 01/13/2026 at 11:35 a.m., S8 LPN confirmed the above medications were expired and stated she administered these expired medications to a resident this morning. S8 LPN stated she was unware the medication was expired prior to administration. S8 LPN confirmed the above medications should have been disposed of, not available for resident use, and expired medications should not have been administered to a resident. Observation on 01/13/2026 at 12:00 p.m. of Med Cart E with S9 Treatment Nurse, revealed the following expired items:Eleven individual packets of Iodine with an expiration date of 10/2023;One bottle of Desenex 2% powder with an expiration date of 10/09/2025; Three Adaptive non-adherent dressings with an expiration of 07/31/2025; andGreater than 100 individually packaged 3g Lubricating Jelly with an expiration date of 03/03/2025. In an interview on 01/13/2026 at 12:18 p.m., S9 Treatment Nurse confirmed all of the above findings and stated no expired medications or supplies should have been available for resident use. S9 Treatment Nurse confirmed that all expired treatment supplies, medicated ointments, and powders should have been disposed of after the expiration date, but were not. In an interview on 01/13/2026 at 12:58 p.m., S2 DON revealed she expected all nurses to dispose of expired medications and treatment supplies from the medication/treatment carts and storage rooms. S2 DON stated that no expired medications or medical supplies should have been available for resident use in the medication/treatment carts or in the medication storage rooms.

Based on interview and record review the facility failed to ensure that each resident who were unable to carry out ADL's (Activities of Daily Living) received necessary services to maintain good grooming and personal hygiene. The facility failed to provide a shower/bath to dependent residents for 1 (Resident #3) of 27 sampled resident.Findings:Review of the facility's policy titled Activities of Daily Living (ADLs) with no review date, revealed in part.Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care.Policy Explanation and Compliance Guidelines:3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of Resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included in part.Hemiplegia and Hemiparesis following Infarction affecting Left Non-Dominant Side, Pain Unspecified, and Contracture of Left Hand.Review of Resident #3's Quarterly MDS with an ARD of 11/14/2025 revealed she had a BIMS score of 14 indicating intact cognition. The MDS revealed Resident #3 was dependent for transfers and shower/bath and required substantial/maximal assistance with personal hygiene. Resident #3's MDS coded with no behaviors/refusals of care.Review of Resident #3's care plan revealed in part. at risk for Self-Care Deficit related to Left Hemiplegia/Hemiparesis following a Cerebrovascular Accident, Contracture of Left Hand, with interventions that included to provide extensive assistance with bed baths.Observation and interview on 01/12/2026 at 10:14 a.m. revealed Resident #3 sitting in her room in a wheelchair. Resident #3 stated she had not received her shower as scheduled. Resident #3 stated staff had told her it was because she wiggled on the shower chair. Resident #3 revealed she received her baths in the evenings.Interview on 01/13/2026 at 9:15 a.m. with Resident #3 stated she did not receive a shower or bed bath the previous evening. Resident #3 stated her preference was a shower and she had told staff in the past that was her preference, but staff continued to bed bathe her.Interview on 01/13/2026 at 9:15 a.m. with S10 CNA revealed Resident #3 had complained in the past of not receiving a shower in the evenings.Interview on 01/13/2026 at 9:50 a.m. with S11 LPN/MDS revealed Resident #3 had no behaviors or refusal of care. S11 LPN/MDS revealed the care plan did not reflect when Resident #3 received a bath or what type of bath (bed bath or shower).Interview on 01/13/2026 at 10:35 a.m. with Resident #3's Responsible Party, revealed he had complained to staff numerous times about Resident #3 not receiving a shower and her hair being dirty. Resident #3's Responsible Party stated he had called the Corporate Administration to complain about a month ago and was told it would be looked into. Responsible Party stated Resident #3 had called him in the past to say she had not received her shower.Interview on 01/14/2026 at 8:05 a.m. with S2 DON stated it was not reported to her that staff was not showering Resident #3 due to positioning. S2 DON stated S3 CNA Supervisor had spoken with Resident #3 and said she wanted a shower but did not want the water in her face. Review of Resident #3's bath roster provided by S2 DON revealed 19 days of 31 days in 12/2025 with no documented evidence of a shower or bath.Interview on 01/14/2026 at 8:10 a.m. with S1 Administrator revealed Resident #3's Responsible Party had complained to Corporate Administration about Resident #3's hair being dirty and needed washing. S1 Administrator confirmed Corporate Administration had notified her of the complaint. S1 Administrator had no documented evidence of follow-up regarding the complaint.Interview on 01/14/2026 at 9:14 a.m. with S3 CNA Supervisor revealed she had received complaints from Resident #3 about not receiving her shower.

Based on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, for 1 (Resident #3) of 27 sampled residents.Findings: Review of the facility's policy titled Grievances/Complaints, with no review date, revealed in part.1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint to the facility.3. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations; and ensure that immediate action is taken if necessary to prevent further potential violations of any resident rights while the allegation is under investigation.5. The administrator will review the grievance.6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken.7. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident which includes date grievance was received, summary of the grievance, a statement of whether or not the grievance was confirmed, any corrective action to be taken by the facility and the date the decision was issued. The summaries will be maintained in the facility for a period of no less than 3 years from issuance of the decision.Review of Resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included in part.Hemiplegia and Hemiparesis following Infarction affecting Left Non-Dominant Side, Pain Unspecified, and Contracture of Left Hand.Review of Resident #3's Quarterly MDS with an ARD of 11/14/2025 revealed she had a BIMS score of 14 indicating intact cognition. The MDS revealed Resident #3 was dependent for transfers and shower/bath and required substantial/maximal assistance with personal hygiene. Resident #3's MDS coded with no behaviors/refusals of care.Review of Resident #3's care plan revealed in part. at risk for Self-Care Deficit related to Left Hemiplegia/Hemiparesis following a Cerebrovascular Accident, Contracture of Left Hand, withTelephone interview on 01/13/2026 at 10:35 a.m. with Resident #3's Responsible Party, revealed he had complained to staff numerous times about his wife not receiving a shower and about her hair being dirty. Responsible Party stated he had called the Corporate Administration to complain about a month ago and was told it would be looked into. Responsible Party stated Resident #3 had called him in the past to say she had not received her shower.Interview on 01/14/2026 at 8:10 a.m. with S1 Administrator revealed Resident #3's Responsible Party had complained to Corporate Administration about Resident #3's hair being dirty and needed washing. S1 Administrator confirmed Corporate had notified her of the complaint. S1 Administrator had no documented evidence of follow-up regarding the complaint.

Based on interview and record review the facility failed to ensure an allegation of resident to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the resident to resident physical abuse was discovered for Resident #55. Total sample size 27. Findings:Review of the facility's undated policy titled Abuse Prevention and Investigation read in part.Residents have the right to be free from verbal, sexual, physical, and mental abuse. Policy Interpretation and Implementation:1. The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Examples of physical abuse include: hitting, slapping, pinching, and kicking. 16. Reporting:a. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but no later than 2 hours after the allegation is made if the alleged violation involves abuse. Resident # 55 Review of Resident #55 's medical record revealed an initial admit date of 08/16/2022 with a re-entry date of 05/19/2025 with diagnoses that included in part: Transient Cerebral Ischemic Attack, Major Depressive Disorder, Unspecified Mood Disorder, Cerebral Infarction without Residual Deficits, Hypertension, and Presence of Other Specified Devices. Review of Resident #55's Minimum Data Set (MDS) with an ARD of 12/17/2025 revealed Resident #55 had a BIMS score of 14, indicating intact cognition. Resident #55 was independent with ADLs. Review of Resident #55's care plan, with a revision date of 12/17/2025, revealed in part.On 05/13/2025, Resident #55 received physical aggression from another resident. The residents were immediately separated and neurological checks initiated at that time. Resident #55 was sent to the emergency room for further evaluation. Resident # 110 Review of Resident #110 's medical record revealed an initial admit date of 07/30/2024 with a re-entry date of 09/15/2025 with diagnoses that included in part: Autistic Disorder, Anxiety Disorder, Extrapyramidal and Movement Disorder, Restlessness and Agitation, Moderate Intellectual Disabilities, Dementia, and Major Depressive Disorder. Review of Resident #110's Minimum Data Set (MDS) with an ARD of 06/27/2025 revealed Resident #110 had a BIMS score of 2, indicating severe cognitive impairment. Resident #110 was independent/ required minimal assistance with ADLs. Review of Resident 110's care plan read in part.Resident #110 was at risk for altered mood and behaviors related to diagnosis of Depression, Anxiety, Autism, and Dementia with Mood Disturbance. An intervention was initiated on 05/13/2025, which included: Administer Depakote as ordered. Review of an incident report dated 05/13/2025 at 4:30 p.m. read in part.Another resident struck Resident #55 on the head and back. Resident #55 reported a headache following the incident and was transferred to the emergency room for further evaluation. Resident #55 stated, He just started hitting me for no reason. The incident occurred in the dining room. Review of the facility's investigation dated 05/13/2025 read in part.at 4:30 p.m., staff reported Resident #110 became physically aggressive in the dining room toward Resident #55. Resident #110 became upset after another resident moved his walker and subsequently struck Resident #55 on the back of the head twice, making contact. On 01/13/2026 at 4:00 p.m., an interview with Resident #55 revealed that on the evening of 05/13/2025, she was seated in the dining room when Resident #110 approached her from behind and struck her on the head multiple times. Resident #55 stated she believed Resident #110 appeared angry. Resident #55 experienced a headache following the incident and was transported to the hospital for evaluation due to a previously placed cranial shunt. On 01/14/2026 at 8:36 a.m., an interview with S3CNA Supervisor confirmed that on 05/13/2025 she witnessed Resident #110 become upset in the dining room and strike Resident #55 on the head. On 01/14/2026 at 8:42 a.m., an interview with S6LPN revealed she witnessed Resident #110 strike Resident #55 on the head twice with a closed fist while in the dining room on 05/13/2025. S6LPN reported she escorted Resident #110 back to his room, where he stated he was upset with Resident #55.S6LPN confirmed that Resident #110 had a history of aggressive behaviors. On 1/14/2026 at 10:15 a.m., Interview with S1Admin revealed she was aware of the resident-to-resident abuse. S1Admin confirmed she did not report the incident to the State Agency because she did not believe the incident warranted reporting to the state.

F656Based on interview and record review the facility failed to develop/implement a Person-Centered Care plan for 1 (Resident #78) of 27 sampled residents to include a Percutaneous Endoscopic Gastrostomy (PEG tube) and appropriate nursing interventions.Findings: Review of Resident #78's medical record revealed an admit date of 10/07/2025 with diagnoses that included in part.Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Mild Protein-Calorie Malnutrition, Type II Diabetes Mellitus, Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit.Review of Resident #78's Significant Change MDS with and ARD of 11/21/2025 revealed a BIMS score of 4 which indicated severe cognitive impairment. The MDS revealed Resident #1 was dependent for all ADL's. The MDS revealed Resident #78 was coded for holding food in mouth/cheeks or residual food in mouth after meals.Observation on 01/12/2026 at 9:50 a.m. revealed Resident #78 lying in bed. Enteral feeding and water infusing via pump.Review of Resident #78's 01/2026 physician orders revealed in part.Enteral Feed Order every shift Diabetisource per PEG tube @ 80/HR/Pump with water auto flush 45ML/HR x 22 hours-Turn feeding off at 2PM and restart at 4PM. Start date 12/11/2025.Review of Resident #78's care plan revealed no documentation of Resident #1's PEG tube with appropriate nursing interventions.Interview on 01/13/2026 at 3:45 p.m. with S12 LPN/MDS confirmed Resident #78 did not have a PEG tube care plan with appropriate interventions and should have.

Based on interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring and administration of a prescribed medication (Amiodarone) to meet the needs of Resident #37. Total Sample size 27. Findings:Review of the facility's undated policy titled Medications-Administering read in part.Medications shall be administered in a safe and timely manner, and as prescribed. Review of Resident #37 's medical record revealed an admit date of 06/27/2025 with diagnoses that included in part: Chronic Atrial Fibrillation, Chronic Combined Systolic and Diastolic Heart Failure, Hyperlipidemia, Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hypertensive Heart Disease. Review of Resident #37's Minimum Data Set (MDS) with an ARD of 10/30/2025 revealed Resident #37 had a BIMS score of 13, indicating intact cognition. Resident #37 was independent/ required minimal assistance with activities of daily living. Review of Resident #37's Physician Orders for January 2026 revealed in part. Amiodarone HCl oral tablet 200mg- Administer 1 tablet by mouth two times a day related to Chronic Atrial Fibrillation with an ordered date of 07/31/2025. Review of Resident #37's Care Plan, with a revision date of 10/03/2025, revealed in part.Resident #37 was at risk for altered cardiovascular status related to Atrial Fibrillation, Congestive Heart Failure and Hypertension. Interventions to manage this risk included administration of Amiodarone as ordered. Review of Resident #37's Medication Administration Record (MAR) revealed the following documentation related to the administration of Amiodarone 200mg tablet:On 01/10/2026 at 10:00 a.m. and 01/11/2026 at 10:48 a.m., the MAR reflected code 9, indicating the medication was not administered with a directive to refer to the progress notes. Review of the corresponding progress note revealed the medication was unavailable and the facility was awaiting delivery from pharmacy. There was no documentation indicating the pharmacy or the prescribing provider was contacted regarding the missed doses. On 01/12/2026 at 10:15 a.m. Interview with Resident #37 revealed that the facility was unable to provide her prescribed cardiac medications for several days due to awaiting delivery from pharmacy. Resident #37 expressed concern regarding the missed medication. On 01/13/2026 at 9:11 a.m., an interview with S2DON revealed the facility's process when a medication is not administered due to unavailability requires the nurse to contact the pharmacy to determine whether the medication can be obtained. If the medication cannot be obtained, the nurse is responsible for documenting in the resident's progress notes the reason the medication was missed and notification of the prescribing provider. On 01/13/2026 at 12:55 p.m., a telephone interview with S4LPN confirmed she did not administer Resident #37's Amiodarone on the mornings of 01/10/2026 and 01/11/2026 due to medication being unavailable at the facility. S4LPN confirmed she did not contact the pharmacy or the prescribing provider regarding the medication unavailability or missed doses. On 01/14/2026 at 1:57 p.m., a telephone interview with S5LPN confirmed she did not administer Resident #37's Amiodarone on the evening of 01/10/2026 due to the medication being unavailable at the facility. S5LPN acknowledged an error in documentation indicating the medication had been administered when it had not. S5LPN confirmed she did not contact the pharmacy or the prescribing provider regarding the medication unavailability or missed doses. On 01/14/2026 at 2:33 p.m. An interview with S2DON confirmed review of Resident #37's MAR and acknowledged the nursing staff should have contacted both the pharmacy and prescribing provider, but had not.

Based on observation and interview the facility failed to ensure garbage was disposed properly. Findings: Review of the non-dated facility policy titled Trash read in part .All waste must be placed in sealed containers .All garbage and trash will be placed in a dumpster in a convenient area near the facility . Observation on 10/07/2024 at 8:54 a.m. accompanied by S2 Dietary Manager revealed 5 large trash bags on the ground next to the facility dumpsters. Interview on 10/07/2024 at the time of the observations with S2 Dietary Manager, confirmed that the trash bags should have been placed in the dumpsters and not left on the ground.

Based on record review and interview, the facility failed to ensure the Nurse Practitioner documented a clinical rationale for a denial of a dose reduction for 1 (#56) of 5 (#2, #23, #28, #56, #57) residents reviewed for unnecessary medications. The facility failed to ensure the Nurse Practitioner documented a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings: Review of Resident #56's clinical record revealed an admitted [DATE] with a Re-entry date of 05/25/2023 with diagnosis that included Alzheimer's Disease, Paranoid Schizophrenia, Generalized Anxiety Disorder, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Insomnia, Major Depressive Disorder, Extrapyramidal and Movement Disorder, Schizoaffective Disorder Bipolar Type Review of Resident #56's Quarterly MDS with an ARD of 12/11/2024 revealed a BIMS score of 99, severe cognitive impairment. Review of Resident #56's Physician's Orders for October 2024 revealed the following: Trazodone 75mg at Bedtime Seroquel 100mg every morning Seroquel 200mg at Bedtime Risperdal 3mg Twice a Day Buspar 5mg Three times a day Review of the Pharmaceutical Consultant Reports, dated 07/03/2024, revealed the following: Trazodone 75mg at Bedtime, Seroquel 100mg every morning, Seroquel 200mg at Bedtime, Risperdal 3mg Twice a Day, Buspar 5mg Three times a day. The pharmacy consultant requested a dose reduction of the five medications. The nurse practitioner denied a dose reduction but failed to provide a clinical rationale explaining why a dose reduction would be clinically contraindicated. An interview was conducted with S9 DON (Director of Nursing) on 10/09/2024 at 10:45 a.m. S9 DON reviewed Resident #56's Pharmaceutical Consultant Report, dated 07/03/2024, and confirmed a clinical rationale was not provided. S9 DON confirmed the Nurse Practitioner should have written in a clinical rationale as to why a dose reduction was contraindicated and did not.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure food items were stored in the refrigerator after opening. Findings: Review of the non-dated facility policy titled Storage: Refrigerator read in part . Keep all perishable foods below 41 degrees F (7 degrees C). Observation of the dry storage area in the kitchen on 10/07/2024 at 8:40 a.m. accompanied by S2 Dietary Manager revealed an open bottle of lemon juice with a hand written date of 09/15/2024, and a non-dated open bottle of teriyaki sauce. Review of the manufacture labels on the lemon juice and teriyaki sauce indicated to Refrigerate after opening. Interview on 10/07/2024 at the time of the observations with S2 Dietary Manager, confirmed that the lemon juice and teriyaki sauce should have been refrigerated after it was opened.

Based on interview and record review the facility failed to ensure each resident received adequate supervision to prevent incidents and accidents for 1 of 1 sampled resident (#230) reviewed for accidents. The deficient practice resulted in an actual harm situation for Resident # 230 that began on 10/31/2022 at 10:00 p.m., when Resident #230 was not provided 1:1 supervision on the 10:00 p.m. to 6:00 a.m. shift. Resident #230, who was on Fall Precautions, fell 4 times on the day shift on 10/31/2022, and was ordered 1:1 supervision on 10/31/2022 at 12:31 p.m. after the 3rd fall. The CNA who provided care to Resident #230 on the 10:00 p.m. to 6:00 a.m. shift on 10/31/2022, did not provide 1:1 supervision of Resident #230 as ordered, and Resident #230 was found at 11:45 p.m. on the floor in her room on her stomach. Resident #230 was transferred to the emergency room of a local hospital, and diagnosed with an Acute Compression Fracture of T12 and L2 vertebra, Contusions, and a Hematoma to her left eye. Findings: Review of the Facility's Policy titled Shift Report revealed the following in part . Policy: It is the policy of this facility to promote successful transfer of information between nursing staff at shift change in an effort to prevent adverse effects, medication errors and medical mishaps. Policy Explanation and Compliance Guidelines: 62. Nursing and CNA staff will report relevant information such as change in condition, incidents, etc. at the end of each shift to oncoming shift using a reporting form and/or verbally. Interview on 09/13/2023 at 2:19 p.m. with S2 DON revealed there was no 1:1 Supervision policy. Review of Resident #230's EHR revealed an admitted [DATE], and a discharge date of [DATE]. Resident #230 had the following diagnoses that included: Difficulty in Walking, not elsewhere classified; Alzheimer's disease; Unspecified Lack of Coordination; Unspecified Abnormalities of Gait and Mobility; Generalized Muscle Weakness; and Wasting & Atrophy, not elsewhere classified, unspecified site. Review of Resident #230's Quarterly MDS with an ARD of 09/30/2022 revealed a BIMS of 4 (indicating severe cognitive impairment). The MDS revealed Resident #230 was independent with bed mobility, transfers, walking in room, walking in corridor, locomotion on and off unit, dressing, eating, and toilet use. Resident #230 required supervision with personal hygiene and bathing. Resident #230's balance was not steady, but was able to stabilize without staff assistance. Resident #230 had no impairment to ROM to upper or lower extremities, and used a walker for mobility. Review of Resident #230's Care Plan with a start date of 11/01/2021, revealed in part .Resident #230 was at risk for falls r/t lack of coordination - actual fall x 5 on 10/31/2022. Review of Resident #230's Nursing Notes dated 10/31/2022 at 2:31 a.m., revealed Resident #230 tested positive for COVID 19 during facility outbreak testing, and was moved to a COVID isolation room. Review of an Incident Report dated 10/31/2022 for Resident #230 revealed the following in part . 10:26 a.m. - S7 LPN observed Resident #230 lean down and reach for a snack from the snack cart. Resident #230 then stumbled to floor sitting on butt. On assessment no injuries noted. Resident #230 recently tested positive for COVID with general weakness noted. 11:00 a.m. - CNA notified S7 LPN that Resident #230 continued with unsteadiness of gait. On observation, S7 LPN observed Resident #230 walking into doorway of room a. S7 LPN went to assist and observed Resident #230 stumble to floor sitting on right butt. On assessment, Resident #230 [NAME] without problems, and was assisted to w/c and into room. 12:40 p.m. - Staff observed Resident #230 ambulating from snack cart holding cup of water, with continued increased weakness. Resident #230 spilled water on floor, slipped and fell to floor, and began to stand without assistance. CNA assisted Resident #230 to w/c. 1:1 initiated. No injuries apparent. 1:16 p.m. - CNA reported Resident #230 stood up from w/c while sitting in room. CNA unable to reach Resident #230, and Resident #230 lost balance and slid to the floor, no injuries apparent. CNA assisted Resident #230 to bed after assessment complete. 1:1 continued. 11:45 p.m. - Called to room per S8 CNA. S6 LPN entered Resident #230's room, and observed her lying on her stomach on floor at foot of bed. Rolling walker in upright position at Resident #230's head. Resident #230 alert and verbal. Resident #230 c/o pain to left eyebrow and left side of neck. Resident #230 with marked increased confusion and weakness. Neuro checks WNL. Hematoma approximately 4 cm to left eyebrow. Hematoma approximately 7 cm along left jaw line. Bruising to left side of neck. Abrasion approximately 7 cm to right upper chest/clavicle. Resident #230 assessed. Neuro checks initiated. MD notified. Resident #230 out to ER via ambulance service at 12:15 a.m. on 11/01/2022. Review of Resident #230's undated Fall Time Line revealed the following: 1. Fall #1 - 10:25 a.m. - Happened during ambulation to isolation area, Resident #230 with weakness. Resident #230 was assisted up to and back to isolation room. Resident #230 noted ambulating up and down hallway with rolling walker. 2. Fall #2 - 11:00 a.m. - Resident #230 was ambulating back into room, stumbled and sat on floor. Resident #230 assessed, assisted up to w/c and propelled into isolation room and into bed. 3. Fall #3 - 12:40 p.m. - Resident #230 noted at Hall 1 snack cart, ambulating with cup of water, turned to walk back to her isolation room, she spilled water on the floor and then slipped in water. 1:1 initiated. 4. Fall #4 - Resident #230 1:1 in isolation room, Resident #230 attempted to stand up, 1:1 unable to reach her before she slid to the floor. Continue 1:1 CNA rounds at approximately 10:00 p.m. Resident #230 asleep in bed. 5. No 1:1 6. CNA rounds at 11:40 p.m., Resident #230 noted lying on her stomach at the foot of the bed. Review of Resident #230's 10/2022 Physician Orders included the following orders: 10/31/2022 - PT/OT/ST screen (per 10/31/2022 @ 10:26 a.m. Incident Report) Staff to assist Resident with getting snacks off of cart. 10/31/2022 - PT/OT/ST screen (per 10/31/2022 at 11:00 a.m. incident report). Frequent/Purposeful Staff Rounds. 10/31/2022 - 1:1 initiated (per 10/31/2022 at 12:40 p.m. incident report). PT/OT/ST screen. 10/31/2022 - Remind 1:1 to remain within arm's reach of resident. Review of Resident #230's Transfer/Referral Record dated 11/01/2022 at 12:08 a.m., revealed the resident was transferred to an ED from facility via ambulance. The reason for the transfer was documented as COVID positive, fall at 11:45 p.m. 10/31/2022, Hematoma left eyebrow, left jaw line, abrasion right clavicle/upper chest, marked increased confusion. Review of Resident #230's Hospital CT of Chest dated 11/01/2022, revealed the following in part .Impression: T-12 and L2 upper vertebral bodies with mild acute compression fracture deformities. Partially imaged left lower neck with findings concerning for hematoma, or other mass in the left sternocleidomastoid muscle. Telephone interview with S7 LPN was unsuccessful. Interview with HR on 09/13/2023 at 9:50 a.m. revealed S7 LPN no longer worked at the facility. Telephone interview with S6 LPN was attempted several times on 09/13/2023 by surveyor without success. Interview on 09/13/2023 at 10:32 a.m. with S8 CNA revealed she worked the 10:00 p.m. - 2:00 a.m. shift on October 31, 2022, and found Resident #230 on the floor in her room. S8 CNA stated she was assigned Hall W (hall Resident #230 resided on), and Hall X because 1 CNA worked 2 halls on the night shift. S8 CNA stated she started her shift on Hall X, and then went to Hall W after completion of Hall X. S8 CNA stated she received report from staff prior to starting work, but had not been told that Resident #230 had fallen 4 times earlier in the day, and was not told about Resident #230 being 1:1 supervision. S8 CNA stated she entered Resident #230's room when making rounds, and found Resident #230 on the floor on her stomach. Interview on 09/13/2023 at 11:28 a.m. with S2 DON revealed Resident #230 was ordered 1:1 supervision after falling several times on 10/31/2022. S2 DON confirmed Resident #230 was not on 1:1 supervision at the time of her fall on 10/31/2022 at 11:45 p.m. and should have been.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #231) of 1 (Resident #231) residents sampled for pain. The facility failed to ensure Resident #231 who displayed verbal and/or nonverbal indicators of pain received the ordered interventions to alleviate severe pain. Findings: Review of the facility policy titled, Pain Management revealed in part Optimum and effective pain management is only successful through a systematic and total team effort. Continual monitoring, assessment and evaluation, resident education and utilization of scheduled medications and modalities is crucial to the success of each resident's pain management plan. Review of Resident #231's clinical record revealed an admitted [DATE]. Review of the clinical record also revealed Resident #231 had diagnoses that included Dorsalgia, Osteoarthritis, Polyneuropathy, Spinal Stenosis, and Pain. Review of Resident #231's CPOC with a target date of 10/13/2023 revealed in part . Resident #231 has the potential for alteration in comfort related to Diabetic Neuropathy, Generalized Osteoarthritis, Cervical Stenosis, Dorsalgia, Thoracic Spine Pain, Mild Osteopenia, Degenerative Joint Disease, and Enthesophyte formation. Approaches included to administer pain medications as needed, monitor for effectiveness and to administer Percocet as ordered. Interview on 09/11/2023 at 12:44 p.m. with Resident #231 revealed he was not feeling well. Resident #231 stated his back was hurting and grimaced while motioning to his lower back. Resident #231 stated he normally took medication for his back pain every morning but had not taken any this morning because the nurse told him he was out of medicine. Resident #231 stated the nurse had given him Tylenol that morning but the Tylenol did not do much for his pain. Review of Resident #231's September 2023 Physician Orders revealed in part Percocet 5-325mg tablet give one by mouth every 8 hours PRN moderate/severe pain. Order date noted as 02/15/2023. Tylenol 500mg by mouth every 6 hours PRN mild pain. Order date noted as 01/11/2023. Review of Resident #231's September MAR revealed on 09/11/2023 at 11:32 a.m. Resident #231 had received Tylenol 500mg for complaints of pain rated at a 9 out of 10 on the pain scale. Interview on 09/11/2023 at 12:21 p.m. with S3 LPN revealed Resident #231 complained of back pain daily. S3 LPN stated Resident #231 last received Percocet for pain on 09/10/2023 at 11:00 a.m. S3 LPN stated Resident #231 was currently out of prescription pain medications. S3 LPN stated Resident #231's Percocet medication card was empty so she had reordered the medication this morning. S3 LPN stated medication was supposed to be reordered when there are 5 pills remaining. S3 LPN stated Resident #231's Percocet was ordered to be given every 8 hours as needed. S3 LPN confirmed Resident #231 asked for Percocet for his back pain this morning and did not receive it because the medication was not available. S3 LPN stated she had to give Resident #231 Tylenol instead. Review of a nurses' note dated 09/11/2023 at 12:34 p.m. revealed Resident #231 approached S3 LPN with complaints of pain and discomfort in his mid-back. PRN Tylenol had been administered at 11:32 a.m. with little to no relief. S3 LPN notified PCP that a hard script was needed to be sent to the pharmacy for refill. Interview on 09/12/2023 at 9:00 a.m. with S2 DON revealed prescription pain medications required hard scripts from providers and contact should be made with providers within 3 days of the last dose being administered to ensure pain medications do not run out. Review of Resident #231's narcotic log accompanied by S2 DON revealed Resident #231 received Percocet daily. Review of the log revealed Resident #231's count was 3 Percocet tablets remaining on 09/07/2023. Interview on 09/12/2023 at 9:30 a.m. with S2 DON revealed Resident #231's Percocet should have been reordered on 09/07/2023 to ensure Resident #231's pain was effectively managed by having medications available and was not done.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the residents' status during the observation period for 1 (Resident #9) of 1 sampled resident for hospice. Findings: Review of Resident #9's clinical record revealed Resident #9 was admitted to the facility on [DATE]. Resident #9 had diagnoses that included Hypertensive Heart Disease with Heart Failure, Adult Failure to Thrive, Mild Protein Calorie Malnutrition, Muscle Wasting and Atrophy, and Difficulty Walking. Review of Resident #9's Physician Orders revealed in part . 06/01/2023 Admit to hospice. Review of Resident #9's Significant Change MDS Assessment with an ARD 06/09/2023 indicated Resident #9 was receiving dialysis while a resident. Review of the Assessment did not reveal Resident #9 was receiving hospice services. Review of Resident #9's May 2023 and June 2023 Physician orders revealed no orders for dialysis. Interview on 09/11/2023 at 2:55 p.m. with Resident #9 revealed she was not on dialysis. Interview on 09/12/2023 at 8:40 a.m. S3 LPN revealed she was assigned to Resident #9 and had been working on the hall for 2 months. S3 LPN stated she was not aware of Resident #9 being on dialysis. Interview on 09/12/2023 at 8:52 a.m. with S2 DON revealed Resident #9 was not receiving dialysis services. Interview on 09/12/2023 at 9:40 a.m. with S4 LPN/MDS Coordinator revealed Resident #9 should have been assessed for being on hospice and was not. S4 LPN/MDS Coordinator revealed Resident #9 was coded for dialysis by mistake. S4 LPN/MDS Coordinator confirmed Resident #9's 06/09/2023 Significant Change assessment was not accurate and should have been.

Based on interview and record review the facility failed to ensure each resident's assessment will be coordinated by and certified as complete by a registered nurse for 1 (#64) of 1 resident sampled for MDS record over 120 days old. The facility failed to ensure Resident #64's MDS Correction Request was signed by a registered nurse. Findings: Review of an MDS assessment transmission report revealed Resident #64's 05/05/2023 Significant Change Assessment had been attested on [DATE]. Review of the Resident #64's MDS Correction Request form dated 08/17/2023 revealed a modification had been requested due to an item coding error. Review also revealed the signature box designated as RN Assessment Coordinator Attestation of Completion, had been electronically signed by S4 LPN/MDS Coordinator. Interview on 09/12/2023 at 4:00 p.m. with S2 DON and S4 LPN/MDS Coordinator confirmed the correction request/attestation of completion for Resident #64's Significant Change Assessment with target date 05/05/2023 had not been signed by a registered nurse and should have been.

Based on observation, record review and interview the facility failed to provide pharmaceutical services to ensure procedures that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident. The facility failed to provide medications and/or biologicals to meet the needs of residents for 1 (Resident #231) of 1 residents sampled. Findings: Review of the facility's policy titled, Orders-Medication revealed in part . Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than (3) days prior to the last dosage being administered to ensure that refills are readily available. Interview on 09/11/2023 at 12:44 p.m. with Resident #231 revealed he was not feeling well. Resident #231 stated his back was hurting and grimaced while motioning to his lower back. Resident #231 stated he normally took medication for his back pain every morning but had not taken any this morning because the nurse told him he was out of medicine. Interview on 09/11/2023 at 12:21 p.m. with S3 LPN revealed Resident #231 complained of back pain daily. S3 LPN stated Resident #231 last received pain medications on 09/10/2023 at 11:00 a.m. S3 LPN stated Resident #231 was currently out of prescription pain medications. S3 LPN stated Resident #231's Percocet medication card was empty so she had reordered the medication this morning. S3 LPN stated medication was supposed to be reordered when there are 5 pills remaining. S3 LPN stated Resident #231's Percocet was ordered to be given every 8 hours as needed. S3 LPN confirmed Resident #231 asked for Percocet for his back pain this morning and did not receive it because the medication was not available. Interview on 09/12/2023 at 9:00 a.m. with S2 DON revealed prescription pain medications required hard scripts from providers and contact should be made with providers within 3 days of last dose being administered to ensure medications do not run out. Review of Resident #231's narcotic log accompanied by S2 DON revealed Resident #231 received Percocet daily. Review revealed Resident #231's count was 3 Percocet tablets remaining on 09/07/2023. Review of a facility fax cover sheet revealed a request for a prescription for Percocet 5/325mg had been sent to Resident #231's provider on 09/08/2023 Interview on 09/12/2023 at 9:20 a.m. with S2 DON revealed she had no confirmation the fax had been received by the provider on 09/08/2023. S2 DON stated there was no documentation the request sent on 09/08/2023 had been followed up. Interview on 09/12/2023 at 9:30 a.m. with S2 DON revealed Resident #231's Percocet should have been reordered on 09/07/2023 to ensure availability and was not done.

Based on interview and record review the facility failed to ensure residents' rights to be free from sexual abuse for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. The facility failed to protect Resident #3 from non-consensual, inappropriate sexual contact by Resident #1. This deficient practice resulted in an Actual Harm for Resident #3 that occurred on 02/15/2023, when Resident #3, a cognitively impaired resident, was sitting at the dining room table and Resident #1 was observed with his hand in Resident #3's blouse with her breast exposed. Resident #1 did not remove his hand until staff repeatedly told him to stop. Resident #1, (who had no prior history of inappropriate sexual behavior), was immediately removed from the area and immediately placed on 1:1 supervision, then on in-sight supervision. On 02/15/2023, an appointment was scheduled for Resident #3 to receive counseling as an intervention due to the sexual abuse on 02/15/2023. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility policy titled Abuse/Neglect Policy Statement revealed in part . it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #3 Review of Resident #3's clinical record revealed an admitted [DATE] with diagnoses that included in part .Cerebral Vascular Accident, Anxiety Disorder, Depressive Disorder and Multiple Sclerosis. Review of Resident #3's Quarterly MDS Assessment with an ARD of 03/01/2023 revealed a BIMS score of 9 (moderately cognitive impairment). Resident #3 required extensive assistance of 2 persons with toileting, bed mobility, transfers, and required to be fed by staff. Review of Resident #3's Comprehensive Plan of Care with a goal date of 05/31/2023 read as follows in part .Resident #3 was diagnosed with Anxiety Disorder on 04/27/2020. On 02/25/2023, Resident #3's plan of care was updated to include a problem of at risk for altered mood after Resident #3 was inappropriately touched by another resident. Approaches included: observe for mental status change and report to the Physician; Social Service to evaluate and visit resident quarterly; approach the resident warmly and positively. On 02/15/2023 an appointment for counseling was scheduled and staff are to monitor resident for changes in mood and allow resident to express self, an assure resident that she is safe. Review of a facility incident report documented by S2 DON revealed that on 02/15/2023 at 7:12 a.m., Resident #1 was observed by staff inappropriately touching Resident #3 without her consent. Both residents were in the dining room during meal service. As soon as the action was observed Resident #1 and Resident #3 were separated. Resident #1 was taken to his room and was placed on 1:1 supervision. Resident #3 was allowed to finish her meal in the dining room. The Medical Director, Family/RP and Police were contacted and a report was taken. Observation on 03/20/2023 at 10:29 a.m. revealed Resident #3 sitting up in her wheelchair in the dining room with her back turned to all residents at a table to be fed. Interview with Resident #3 on 03/20/2023 at that time revealed Resident #3's speech was slow with delayed thought process, a flat affect was noted to her facial expression. When asked how she was feeling, Resident #3 responded with jumbled wording. When asked yes or no questions Resident #3 responded with a yes or no nod of the head. Resident #3 responded with a yes nod when asked if she had been sexually inappropriately touched by Resident #1. When asked again if she had been sexually touched inappropriately by Resident #1, Resident #3 responded by shaking her head no. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE], and diagnoses that included in part .Major Depressive Disorder, DM 2, and PVD. Resident #1's medical record revealed there was no history or warning signs of inappropriate sexual behavior. Review of Resident #1's Quarterly MDS with an ARD of 02/03/2023, revealed in part . BIMS Score of 9 (moderate cognitive impairment), and Functional Status that included in part . Transfers - limited one person physical assistance; Locomotion on and off the unit - independent with no physical assistance required; ROM impairment on one side for upper and lower extremities, and wheelchair use for mobility. Interview with Resident #1 on 03/20/2023 at 10:35 a.m. revealed he did remember the incident where he inappropriately touched Resident #3, but stated I'm cured, because they sent me out of here to a psych facility and they cured me. Resident #1 stated he should have never gone to that dining table where she was at. In a telephone interview with S7 LPN on 03/22/2023 at 10:34 a.m., she revealed she was the nurse responsible for lunch and dinner monitoring of the residents. S7 LPN revealed while in the dining room on 02/15/2023, S8 CNA alerted her that Resident #1 was being inappropriate with Resident #3. S7 LPN stated that she and S8 CNA immediately walked toward Resident #1, telling him to stop, but Resident #1 did not stop until they reached him and separated him from Resident #3. S7 LPN stated she stayed with Resident #3 while staff escorted Resident #1 to his room. S7 LPN revealed Resident #1 was not crying, but she could tell by her facial expressions she was upset. S7 LPN stated the staff tried to comfort Resident #3 and make sure she knew she was safe. In a telephone interview with S8 CNA on 03/22/2023 at 12:45 p.m., S8 CNA revealed she worked on 02/15/2023 when Resident #1 inappropriately touched Resident #3. S8 CNA revealed she was passing out trays in the dining room when she turned around from picking up a tray at the window and saw Resident #1 with his hand under Resident #3's blouse. S8 CNA stated she alerted S7 LPN as she (S8 CNA) was walking towards Resident #1 and Resident #3. S8 CNA stated Resident #1 would not respond to their verbal commands to stop, and she and S7 LPN had to back Resident #1 away (in his wheelchair) from Resident #3. S8 CNA stated they immediately separated them and S7 LPN told another CNA to take Resident #1 to his room. S8 CNA stated she and S7 LPN checked on Resident #3 to make sure she was okay. S8 CNA stated Resident #3 never showed any expression other that she closed her eyes when it occurred. S8 CNA stated Resident #1 was immediately placed 1:1. Interview with S2 DON on 03/20/203 at 10:45 a.m. revealed Resident #1 after returning from the behavioral hospital on 03/07/2023, was placed on in line of sight supervision when in public. S2 DON revealed there had been no further issues with Resident #1 being inappropriate with another resident since his return. S2 DON revealed that they were in the process of decreasing Resident #1's supervision since he had not had any further issues after his behavioral hospital stay. S2 DON revealed that when Resident #1 was not in his room, it was the entire staff's responsibility to ensure Resident #1 was not inappropriate with any other resident. S2 DON stated Resident #1's floor nurse and CNA were responsible for documenting Resident #1's supervision. Interview with S4 CNA on 03/20/2023 at 11:10 a.m. revealed she documented in Resident #1's medical record multiple times a day her observations that Resident #1 was within line of sight. S4 CNA revealed she observed Resident #1 on 02/24/2023 attempting to go into another female resident's room, while the female resident was on the toilet. S4 CNA revealed she blocked his attempt and immediately told him to get down the hall. S4 CNA revealed she then reported it to the nurse. Interview with S5 LPN on 03/20/2023 at 11:20 a.m. revealed Resident #1 was her resident, and she was responsible for making sure he was in line of sight at all times, encourage him to stay in his room, and remind the CNAs to keep an eye on him. S5 LPN revealed she was responsible for documenting in Resident #1's medical record that he was observed being in line of sight when out of his room. Interview with S6 Restorative CNA on 03/20/2023 at 11:50 a.m. revealed she had received an in-service on abuse after the incident with Resident #1 and Resident #3 on 02/15/2023). S6 Restorative CNA revealed she was aware she was to monitor to ensure that Resident #1 did not go around other female residents. Interview with the Psych NP on 03/20/2023 at 11:57 a.m. revealed he was scheduled to see Resident #1 on 02/16/2023 about the incident that occurred on 02/15/2023. The Psych NP stated he evaluated Resident #1 and did not make any recommendations other than what the facility staff were already doing by having him 1:1 supervision. The Psych NP stated he was scheduled to see Resident #1 the following week after the incident when he came as scheduled. The Psych NP revealed Resident #1 was out of the facility at an appointment last week when he came to see him. Review of the Discharge Transition orders from the behavioral facility dated 03/07/2023 revealed medication changes had been made, and Resident #1 was in stable condition. There were no supervision orders noted on the Discharge orders. Review of the verbal written discharge orders dated 03/07/2023 by S3 ADON revealed a verbal order had been written for Resident #1 to remain in line of sight when in public after Resident #1's return to the facility from the behavioral hospital. Interview with S3 ADON on 03/20/2023 at 1:40 p.m. revealed some of the orders she transcribed were written on the hospital discharge sheet, but she had contacted the behavioral hospital and spoke with a staff person, who was not the Physician, and resumed all previous orders as directed by the staff person. S3 ADON revealed she should have not written the order to continue line of sight supervision when in public, because she had not received the order from the Physician. Interview with the Behavioral Hospital's Psychiatrist on 03/21/2023 at 11:13 a.m. revealed he was the Psychiatrist who treated Resident #1 during his hospital stay on 02/15/2023 - 03/07/2023. The Psychiatrist stated he had made some medication changes for Resident #1. The Psychiatrist stated upon Resident #1's discharge, Resident #1 was in stable condition and able to return to his home. The Psychiatrist was asked if he discharged Resident #1 back to the nursing home on 1:1 supervision or in line of sight supervision, and he stated absolutely not. If Resident #1 had required that much supervision he would have kept him at the hospital until he was more stable. The Psychiatrist stated Resident #1 did not require 1:1 supervision, or in line of sight supervision when he (Resident #1) was discharged back to the nursing facility. The facility implemented the following actions to correct the deficient practice: Resident #1 was immediately put on 1:1, in-services were done and staff were educated on abuse. Multiple attempts to admit Resident #1 to a behavioral hospital were unsuccessful due to the resident having a wound. A list of facilities were included. In-services initiated immediately after the incident on 02/15/2023 and continued until all staff were educated. Education was continued with the Attorney General's office on abuse presenting an in-service on 03/07/2023 on abuse. The facility will continue to educate/in-service all staff on abuse and neglect. The next in-service on abuse/neglect will be held in April. 2023. Training and retraining of all staff included: Objective: to ensure the safety of all resident are free from abuse. Initial training session was done 02/15/2023 at 12:00 noon and lasted approximately 30 minutes. Other staff were in-serviced individually, per department head nurse/administration/DON as needed. Abuse policy and procedure were reviewed, no changes were made at the time of the review. Resident #1 was sent to a behavioral hospital on 02/24/2023 and returned on 03/07/2023, with new order for Risperidone 0.5mg p.o. QHS. No other orders for were made for 1:1 or in line of sight from behavioral hospital at discharge. No inappropriate behavior has been noted from Resident #1 since his return from the behavioral hospital. QAA Evaluation of abuse, neglect, exploitation or misappropriation reports: For all reports of abuse, neglect, exploitation or misappropriation, the QAA committee will complete the following: Was a thorough investigation conducted? Yes. All interviewable residents were interviewed to see if they had seen or had any appropriate behaviors done to them. Body assessments were performed on resident that were not cognitively aware, for signs and symptoms of abuse. Were other resident's protected? How? Yes. Resident #1 was placed 1:1 immediately after the incident on 02/15/2023 and monitoring was continued as ordered. All residents were immediately protect after this incident. Was an analysis conducted as to why the situation occurred? Explain: Yes, this was an isolated incident for Resident #1, who had no known history or warning signs of inappropriate behavior. Risk factor that contributed to the abuse: No known history of inappropriate sexual behavior had been exhibited by Resident #1 since his admission on 08/26/2022. Isolated incident - addressed immediately Overall Goal: no inappropriate sexual behavior/abuse Identified Factor/Issue: Male resident inappropriately touched a female resident's breast Project Team Members: All Staff Plan: types of monitoring done - in-serviced staff on abuse policy, routine monitoring inappropriate behavior. Resident #1 was placed 1:1, then line of sight, daily smart chart review (supervision) of monitoring per DON/ADON, daily hall rounds per department head nurse, monitoring of daily rounds/round sheets per ADM/AIT. Plan for Monitoring/Completion Date: Monitor for any inappropriate behaviors and ensure that staff were following the plan of care on daily rounds. If any concerns, implement new interventions. Monitoring was initiated immediately after the incident on (02/15/2023) and continued until D/C order was received from the MD. No issues were found in the monitoring process. Will continue to re-educate staff on abuse. Line of sight was discontinued on 03/20/2023 related to clarification received from MD that the line of sight should not have continued upon re-admit to the NH on 03/07/2023. Today (03/21/2023), we began Q shift monitoring by LPN and Q2H monitoring per CNA and any sign or symptoms of inappropriate behavior, the DON/ADON will daily check smart chart review (supervision) for monitoring. QA team will meet in 2 weeks to review/change current plan. The Behavioral Hospital representative stated if line of sight or 1:1 was recommended, it would have been listed on the transition record. There were none of these recommendations made upon discharge. The line of sight order from 03/07/2023 was transcribed in error, clarification with the physician supports this was not ordered or needed after behavioral hospital stay. Expected Behaviors: No more sexually inappropriate behaviors have been displayed from Resident #1. QA committee will meet in April of 2023 to review/evaluate the plan of action related to this incident. Facility correction date 03/07/2023.

Based on observation, interview and record review, the Facility failed to ensure drugs and biologicals were stored appropriately based on current acceptable professional principles. Findings: Observation on [DATE] at 8:15 a.m. of Med Cart B accompanied by S9 LPN revealed one undated open stock bottle of adult low dose aspirin 81mg tablets Lot#911V03 with an expiration date of ,d+[DATE]. Interview at the time of observation with S9 LPN revealed she did not know when the stock bottle of baby aspirin was opened. Observation on [DATE] at 9:00 a.m. of the locked refrigerator in Med room B accompanied by S7 LPN revealed two boxes of [NAME] Acetaminophen 650mg suppositories (48 suppositories in each box) Lot # 8LT0315 with an expiration date of ,d+[DATE]. Interview at the time of observation with S7 LPN verified two boxes of acetaminophen suppositories were expired and should have been discarded. Observation on [DATE] at 9:10 a.m. of Med Cart C accompanied by S7 LPN revealed one undated open stock bottle of Acetaminophen 500mg tablets Lot#201V07 with an expiration date of ,d+[DATE] and one undated open stock bottle of [MEDICATION(S)] 1mg tablets Lot#HC 8 with an expiration date of ,d+[DATE]. Interview at the time of observation with S7 LPN revealed she was unaware when the stock bottles were opened. Observation on [DATE] at 9:15 a.m. of the locked refrigerator in Med Room A accompanied by S7 LPN revealed one opened vial of [MEDICATION(S)] 5 units/0.1 ml multi-dose vial Lot #C5994AA expiration date [DATE] with no date when the vial was opened. Interview at the time of observation with S7 LPN verified the vial was open and undated and stated she did not know when the seal was broken. Observation on [DATE] at 9:25 a.m. of Med Cart A accompanied by S8 LPN revealed the following open undated stock bottles available for use: Multivitamin tablets Lot #501V06 expiration date ,d+[DATE]. Aspirin adult low dose 81mg tablets Lot #981V01 exp. date ,d+[DATE]. Naproxen Sodium 220mg caplets Lot #951T01 exp. date ,d+[DATE]. [MEDICATION(S)] 400mg tablets Lot #634T16 exp. date ,d+[DATE]. Ibuprofen 200mg tablets Lot #941V03 exp. date ,d+[DATE]. [MEDICATION(S)] Sodium 100mg soft gels Lot #401V07 exp. date ,d+[DATE]. [MEDICATION(S)] Sodium 100mg tablets Lot #421V08 exp. date ,d+[DATE]. Major Acetaminophen PM 500mg/25mg caplets Lot # 3 exp. date ,d+[DATE]. Interview at the time of observation with S8 LPN verified the above stock bottles were not dated as to when opened and confirmed that the stock bottles should have been. Interview on [DATE] at 9:40 a.m. with S6 ADON in Med Room B confirmed two boxes acetaminophen suppositories 650mg Lot # 8LT0315 were expired (expiration date of ,d+[DATE]). S6 ADON confirmed the suppositories should have been discarded and not available for resident use. Observation and interview on [DATE] at 9:50 a.m. with S6 ADON accompanied with S7 LPN confirmed the opened undated stock bottles of acetaminophen 500mg tablets and [MEDICATION(S)] 1mg tablets on Med Cart B should have been labeled with the date when opened. Observation and interview on [DATE] at 9:55 a.m. with S6 ADON accompanied with S8 LPN confirmed the opened undated stock bottles listed above on Med Cart A and confirmed they should have been labeled with the date when opened. Observation and interview on [DATE] at 10:00 a.m. with S6 ADON in Med Room A accompanied with S8 LPN confirmed the open undated [MEDICATION(S)] multidose vial and confirmed it should have been labeled with the date that the seal was broken on the vial.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions and 2) ensure food preparation equipment was clean. This deficient practice had the potential to affect the 72 Residents that received meals prepared in the kitchen. Findings: Review of the Facility's Policy titled Ice Pass, Water Pitchers & Ice Machines read in part: Ice Machines must be emptied and cleaned according to the manufacture's instruction at least monthly. Observation of the kitchen on 09/12/2022 at 9:51 a.m. revealed: 1. A 32 quart pot stored under storage counter was stored with dried yellow substance on the inside of the pot. 2. 32 clean 9 ounces serving bowls were stored on 3 tier stainless steel table, were stacked on top of each other, and were noted to be wet with water dripping. 3. Serving utensils (food scoops, food strainers, spatulas, and fork) were stored in a drawer lined with wrinkled aluminum foil which was noted to be greasy with yellow and brown gel like substances on the foil, and dark flaky substance in the bottom of the drawer. 4. Four 9 inch serving pans stored on top of a 3 tier rolling stainless steel cart were noted to have dried white, brown and/or yellow food particles stuck on the side, bottom, and/or around the rim of the outside of the pans. 5. Rubber gaskets of the ice machine were noted to have dark black substance in between the grooves. 6. Refrigerator rubber gaskets on the juices and milk refrigerator were noted to have dark black substance in between the grooves. Interview with S4 Dietary Manager on 09/10/2022 at 10:45 a.m. confirmed all of the above findings at the time during the observations. S4 Dietary Manager stated that each dietary worker who was assigned to washing the dishes was responsible for ensuring that all of the cooking and eating utensils are stored washed/dried and stored properly. S4 Dietary Manager further confirmed that she had no cleaning policy which addressed cleaning and storage of cooking and eating utensils.

Based on interview and record review the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being (#106) for 1 of 3 (#75, #112) Stage 2 residents reviewed for hospitalization in a Stage 2 Sample of 33. The facility failed to: 1. identify that a newly admitted resident with a [DIAGNOSES REDACTED]. 2. consult with the physician for a newly admitted resident with a [DIAGNOSES REDACTED]. 3. develop an individualized care plan for the problem of DM at the time of admission to identify the resident's risk for complications related to Diabetes Mellitus. Resident #106 was admitted to the facility on [DATE] after being discharged from the acute care hospital due to [MEDICAL CONDITION]. During the resident's hospital stay, he had a [DIAGNOSES REDACTED]. On 4/18/11 the facility received faxed hospital documents which reflected the resident's course of treatment during his hospital stay. The hospital records reflected the resident's blood sugar level ranged from 58-265 mg/dl (normal reference 80-115 mg/dl), and Insulin was administered in accordance with sliding scale orders. The resident's admission orders [REDACTED]. There was no evidence in the record to reflect the resident 's physician was consulted to obtain orders for assessment of capillary blood sugar levels. Interview with S15LPN (nurse that conducted the resident's admission assessment), S11LPN (care plan nurse who reviewed the admission orders [REDACTED]. LPNS15, LPNS11 and RNS19 confirmed they did not consult the physician for order clarification to assess the resident's blood sugar levels on admission. On 5/5/11 the resident exhibited lethargy throughout his treatment during Physical Therapy. On 5/5/11 during OT, the resident was noted to be very sleepy and began to demonstrate decreased processing skill during therapy while propelling his wheelchair. On 5/6/11 during OT, the resident was disoriented and very confused. The resident cognitive status prior to 5/4/11 was alert and oriented x4. According to the therapist, the resident's functional ability had declined from 5/4/11 - 5/5/11 and he required maximum assistance from 2 people to transfer, and S17LPN was notified of the resident's change on 5/5/11. S17LPN revealed that she did not notice a change in the resident when she assessed him on 5/5/11 and therefore did not consult with the physician. On 5/6/11 the resident was more confused and disoriented, his CBSFS was obtained and was found to have the result of "Hi " (normal reference 80-115 mg/dl) . The physician then ordered a blood glucose level and the result was >625 mg/dl (normal reference 80-115 mg/dl). The resident was transferred to the hospital and admitted with DM out of Control, [MEDICAL CONDITIONS], Dehydration and UTI. Findings: Review of the Hospital to Nursing Facility Transfer Form reflected the resident was in the hospital from 4/12/11 to 4/18/11 with the [DIAGNOSES REDACTED]. Review of the hospital's physician consult report dated 4/12/11 reflected the resident was admitted to the hospital with [REDACTED]. The physician's plan included the instructions to hold [MEDICATION NAME] and [MEDICATION NAME] and start Regular Insulin to sliding scale. Review of the Medication Reconciliation Discharge Form reflected Regular Insulin was ordered to sliding scale on 4/13/11 and the MAR indicated [REDACTED]= 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units; >450 call MD. Review of the Medication Reconciliation Discharge Form reflected [MEDICATION NAME] 100 mg was ordered on [DATE]. Review of the hospital's Nursing/Physician Vital Sign form dated 4/15/11 through 4/18/11 reflected the resident's glucose findings were: (4/15/11) 220, 136, 234; (4/16/11) 174, 265, 136, 198; (4/17/11) 142, 58, 135, 239; (4/18/11) 134. Review of the hospital's Medication Reconciliation Discharge Form dated 4/18/11 reflected an order to discontinue Sliding Scale Regular Insulin and [MEDICATION NAME], and continue [MEDICATION NAME] 100 mg daily. Further review of the above hospital records reflected they were faxed to the facility on [DATE]. Review of the physician admission orders [REDACTED]. The orders included an order for [REDACTED]. Review of the telephone orders reflected an order to add the [DIAGNOSES REDACTED]. Interview on 8/3/11 at 3:00 p.m. with S15LPN reflected she did the admission assessment on 4/18/11 and reviewed the admission orders [REDACTED]. Interview reflected there was no order for accuchecks on the admission orders [REDACTED]'s physician for order clarification to assess the resident's blood sugar levels. Interview on 8/3/11 at 2:45 p.m. with S11LPN, MDS Care Plan Nurse reflected she had reviewed the resident's admission orders [REDACTED]. Further interview reflected she did not review the hospital record that was faxed to the facility on [DATE] and did not consult the resident's physician for order clarification to assess the resident's blood sugar levels. Interview on 8/3/11 at 3:05 p.m. with S6DON confirmed the facility received the hospital papers by fax on 4/18/11 and there was no order for an accucheck on admission. Further interview reflected she relied on the admission nurses, MDS nurses and the treatment nurse to complete the initial resident assessments and to review hospital records. Further interview reflected she did not consult the resident's physician for order clarification to assess the resident's blood sugar levels. Interview on 8/4/11 at 9:50 a.m. with S19RN, Treatment Nurse reflected she did a body audit and skin assessment on the new admits. Interview reflected she did the resident's initial body audit on 4/18/11 and noted a Diabetic ulcer to the 4th toe of his right foot that was healed on 4/24/11 and reopened on 5/2/11. Further interview confirmed she did not review the resident's hospital papers on admission. Telephone interview on 8/3/11 at 4:25 p.m. with the resident's physician reflected the resident had a history of [REDACTED]. Interview with the physician reflected the resident had a fracture in April, was admitted for care to a hospital that was out of town and required admission to the nursing home after hospital discharge. Interview with the physician reflected he had not been made aware the resident was taken off [MEDICATION NAME] at the hospital, and not getting accuchecks done at the nursing home. Further interview reflected the physician made rounds on 4/20/11 however he was not made aware that the resident was taken off [MEDICATION NAME] and not getting accuchecks done. Interview at the above time reflected the physician did not have a copy of the hospital papers dated 4/12/11 - 4/18/11 in the resident's office record. Interview on 8/4/11 at 8:30 a.m. with S12LPN, MDS reflected she reviewed the hospital discharge orders but did not review all of the hospital documentation faxed to the facility on [DATE] and did not consult the resident's physician for order clarification to assess the resident's blood sugar levels. Interview with S12LPN MDS confirmed the physician should have been consulted to clarify the orders for admission. Review of the nurses' notes dated 4/20/11 reflected the resident was alert and oriented X4. Review of PT documentation dated 5/5/11 reflected the resident was lethargic throughout treatment. OT documentation dated 5/5/11 reflected the resident was noted to be very sleepy and began to demonstrate decreased processing skills during w/c propulsion. Interview on 8/4/11 at 3:12 p.m. with S18OT reflected she noted the resident's functional ability had declined from 5/4/11 to 5/5/11 and stated the resident had required a 1 person assist on 5/4/11 for sit to stand activity but on 5/5/11 the resident required the maximum assistance of 2 people for transfer from bed to w/c with verbal cues. Interview reflected the OT notified the resident's nurse. Review of the nurse' notes documented by S17LPN dated 5/5/11 at 2:00 p.m. reflected the therapist reported the resident was sleepy during therapy, will monitor sleeping pattern, NAD noted, resident without complaints. Review of OT documentation dated 5/6/11 reflected the resident was noted to be very disoriented to place and time and very confused as he wanted to know who set the trees on fire in his room. Documentation reflected the nurse was notified and the nurse assessed. Interview on 8/3/11 at 3:10 p.m. with S17LPN confirmed she provided care for the resident on the day shift on 5/4/11, 5/5/11 and 5/6/11. Interview reflected the therapist did report the resident was more sleepy on 5/5/11, that she performed an assessment and did not notice any changes, therefore did not notify the physician. Further interview reflected a change in the resident's condition was noted on 5/6/11, and stated the physician was notified. Further interview reflected the resident was confused and disoriented and was found to have a CBSFS of " Hi " (normal reference 80-115 mg/dl). Review of the Lab Report dated 5/6/11 reflected a Chemistry level was drawn at (13:45) 1:45 p.m. with results Glucose >625 mg/dL (80-115); Na 127 L (136-145); K 5.6 H (3.5-5.1); BUN 68 (7.0-20.0); creat 2.30 (0.6-1.1). Review of the May, 2011 MAR indicated [REDACTED] Review of the hospital Discharge Summary dated 5/11/11 reflected the resident was admitted to the hospital on [DATE] and remained in the hospital until 5/11/11 with [DIAGNOSES REDACTED]. Physician Discharge Summary instructions included Accucheck twice daily with sliding scale Regular Insulin, [MEDICATION NAME] ER 10 mg bid, and [MEDICATION NAME] 100 mg q day. Review of the medical record failed to reflect documentation of an interim plan of care for the problem of Diabetes Mellitus for admission on 4/18/11. Review of the Comprehensive Care Plan reflected the problem: Resident has dx of Diabetes Mellitus (problem onset of 4/27/11); goal: Diabetes will be controlled thru 7/28/11, 10/7/11; approaches: give medications as ordered, glucose monitoring as ordered, monitor for s/s of hypo/[MEDICAL CONDITION], labs as ordered, notify MD of lab results, diet as ordered, weekly body audit per tx nurse; 5/6/11 accucheck as ordered, 5/18/11 Insulin as ordered. Review of the facility policy "Assessment and Care Planning Process" reflected #19 Care plan goals (objectives) are the desired outcomes for a specific problem or strength and are resident oriented, measurable, and defined within a time frame. Interview on 8/4/11 at 1:15 p.m. with S6DON confirmed the resident was not initially care planned for the problem of Diabetes Mellitus. Interview reflected the facility thought the physician had reviewed the hospital records when he visited the facility on 4/20/11 and confirmed nursing staff did not consult the physician on admission related to Diabetes Mellitus for order clarification to assess the resident's blood sugar levels.

Based on record review and interview the facility failed to ensure the resident's physician was consulted at the time of admission to clarify the medication orders (anti-diabetic medications) and the performance of blood glucose monitoring, and when changes were noted by the therapist (#106) for 1 of 3 (#75, #112) Stage 2 residents reviewed for hospitalization in a Stage 2 Sample of 33. The facility failed to: 1. consult with the physician for a newly admitted resident with a [DIAGNOSES REDACTED]. Resident #106 was admitted to the facility on [DATE] after being discharged from the acute care hospital due to [MEDICAL CONDITION]. During the resident's hospital stay, he had a [DIAGNOSES REDACTED]. On 4/18/11 the facility received faxed hospital documents which reflected the resident's course of treatment during his hospital stay. The hospital records reflected the resident's blood sugar level ranged from 58-265 mg/dl (normal reference 70-115 mg/dl), and Insulin was administered in accordance with sliding scale orders. The resident's admission orders [REDACTED]. There was no evidence in the record to reflect the resident's physician was consulted to obtain orders for assessment of capillary blood sugar levels. Interview with S15LPN (nurse that conducted the resident's admission assessment), S11LPN (care plan nurse who reviewed the admission orders [REDACTED]. LPNS15, LPNS11 and RNS19 confirmed they did not consult the physician for order clarification to assess the resident's blood sugar levels on admission. On 5/5/11 the resident exhibited lethargy throughout his treatment during Physical Therapy. On 5/5/11 during OT, the resident was noted to be very sleepy and began to demonstrate decreased processing skill during therapy while propelling his wheelchair. On 5/6/11 during OT, the resident was disoriented and very confused. The resident cognitive status prior to 5/4/11 was alert and oriented x4. According to the therapist, the resident's functional ability had declined from 5/4/11 -5/5/11 and he required maximum assistance from 2 people to transfer, and S17LPN was notified of the resident ' s change on 5/5/11. S17LPN revealed that she did not notice a change in the resident when she assessed him on 5/5/11 and therefore did not consult with the physician. On 5/6/11 the resident was more confused and disoriented, his CBSFS was obtained and was found to have the result of " Hi " (normal reference 80-115 mg/dl) . The physician then ordered a blood glucose level and the result was >625 mg/dl (normal reference 80-115 mg/dl). The resident was transferred to the hospital and admitted with DM out of Control, [MEDICAL CONDITIONS], Dehydration and UTI. Findings: Review of the Hospital to Nursing Facility Transfer Form reflected the resident was in the hospital from 4/12/11 to 4/18/11 with the [DIAGNOSES REDACTED]. Review of the hospital's physician consult report dated 4/12/11 reflected the resident was admitted to the hospital with [REDACTED]. The physician's plan included the instructions to hold [MEDICATION NAME] and [MEDICATION NAME] and start Regular Insulin to sliding scale. Review of the Medication Reconciliation Discharge Form reflected Regular Insulin was ordered to sliding scale on 4/13/11 and the MAR indicated [REDACTED]= 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units; >450 call MD. Review of the Medication Reconciliation Discharge Form reflected [MEDICATION NAME] 100 mg was ordered on [DATE]. Review of the hospital's Nursing/Physician Vital Sign form dated 4/15/11 through 4/18/11 reflected the resident's glucose findings were: (4/15/11) 220, 136, 234; (4/16/11) 174, 265, 136, 198; (4/17/11) 142, 58, 135, 239; (4/18/11) 134. Review of the hospital's Medication Reconciliation Discharge Form dated 4/18/11 reflected discontinue Sliding Scale Regular Insulin and [MEDICATION NAME], and continue [MEDICATION NAME] 100 mg daily. Further review of the above hospital records reflected they were faxed to the facility on [DATE]. Review of the physician admission orders [REDACTED]. The orders included an order for [REDACTED]. Review of the telephone orders reflected an order to add the [DIAGNOSES REDACTED]. Interview on 8/3/11 at 3:00 p.m. with S15LPN reflected she did the admission assessment on 4/18/11 and reviewed the admission orders [REDACTED]. Interview reflected there was no order for accuchecks on the admission orders [REDACTED]'s physician for order clarification to assess the resident's blood sugar levels. Interview on 8/3/11 at 2:45 p.m. with S11LPN, MDS Care Plan Nurse reflected she had reviewed the resident's admission orders [REDACTED]. Further interview reflected she did not review the hospital record that was faxed to the facility on [DATE] and did not consult the resident's physician for order clarification to assess the resident's blood sugar levels. Interview on 8/3/11 at 3:05 p.m. with S6DON confirmed the facility received the hospital papers by fax on 4/18/11 and there was no order for an accucheck on admission. Further interview reflected she relied on the admission nurses, MDS nurses and the treatment nurse to complete the initial resident assessments and to review hospital records. Further interview reflected she did not consult the resident's physician for order clarification to assess the resident's blood sugar levels. Interview on 8/4/11 at 9:50 a.m. with S19RN, Treatment Nurse reflected she did a body audit and skin assessment on the new admits. Interview reflected she did the resident's initial body audit on 4/18/11 and noted a Diabetic ulcer to the 4th toe of his right foot. Further interview confirmed she did not review the resident's hospital papers on admission. Telephone interview on 8/3/11 at 4:25 p.m. with the resident's physician reflected the resident had a history of [REDACTED]. Interview with the physician reflected the resident had a fracture in April, was admitted for care to a hospital that was out of town and required admission to the nursing home after hospital discharge. Interview with the physician reflected he had not been made aware the resident was taken off [MEDICATION NAME] at the hospital, and not getting accuchecks done at the nursing home. Further interview reflected the physician made rounds on 4/20/11 however he was not made aware that the resident was taken off [MEDICATION NAME] and not getting accuchecks done. Interview at the above time reflected the physician did not have a copy of the hospital papers dated 4/12/11 - 4/18/11 in the resident's office record. Interview on 8/4/11 at 8:30 a.m. with S12LPN, MDS reflected she reviewed the hospital discharge orders but did not review all of the hospital documentation faxed to the facility on [DATE] and did not consult the resident's physician for order clarification to assess the resident's blood sugar levels. Interview with S12LPN MDS confirmed the physician should have been consulted to clarify the orders for admission. Review of the nurses' note dated 4/20/11 reflected the resident was alert and oriented X4. Review of PT documentation dated 5/5/11 reflected the resident was lethargic throughout treatment. OT documentation dated 5/5/11 reflected the resident was noted to be very sleepy and began to demonstrate decreased processing skills during w/c propulsion. Interview on 8/4/11 at 3:12 p.m. with S18OT reflected she noted the resident's functional ability had declined from 5/4/11 to 5/5/11 and stated the resident had required a 1 person assist on 5/4/11 for sit to stand activity but on 5/5/11 the resident required the maximum assistance of 2 people for transfer from bed to w/c with verbal cues. Interview reflected the OT notified the resident's nurse. Review of the nurse' notes documented by S17LPN dated 5/5/11 at 2:00 p.m. reflected the therapist reported the resident was sleepy during therapy, will monitor sleeping pattern, NAD noted, resident without complaints. Review of OT documentation dated 5/6/11 reflected the resident was noted to be very disoriented to place and time and very confused as he wanted to know who set the trees on fire in his room. Documentation reflected the nurse was notified and the nurse assessed. Interview on 8/3/11 at 3:10 p.m. with S17LPN confirmed she provided care for the resident on the day shift on 5/4/11, 5/5/11 and 5/6/11. Interview reflected the therapist did report the resident was more sleepy on 5/5/11, that she performed an assessment and did not notice any changes, therefore did not notify the physician. Further interview reflected a change in the resident's condition was noted on 5/6/11, and stated the physician was notified. Further interview reflected the resident was confused and disoriented and was found to have a CBSFS of " Hi ". Review of the Lab Report dated 5/6/11 reflected a Chemistry level was drawn at (13:45) 1:45 p.m. with results Glucose >625 mg/dL (80-115); Na 127 L (136-145); K 5.6 H (3.5-5.1); BUN 68 (7.0-20.0); creat 2.30 (0.6-1.1). Review of the May, 2011 MAR indicated [REDACTED] Review of the hospital Discharge Summary dated 5/11/11 reflected the resident was admitted to the hospital on [DATE] and remained in the hospital until 5/11/11 with [DIAGNOSES REDACTED]. Physician Discharge Summary instructions included Accucheck twice daily with sliding scale Regular Insulin, [MEDICATION NAME] ER 10 mg bid, and [MEDICATION NAME] 100 mg q day. Interview on 8/4/11 at 1:15 p.m. with S6DON reflected the facility thought the physician had reviewed the hospital records when he visited the facility on 4/20/11 and confirmed nursing staff did not consult the physician on admission related to Diabetes Mellitus for order clarification to assess the resident's blood sugar levels.