Every finding on record at Silver Tree Nursing and Rehabilitation Center

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 2 residents (Resident #1 and #2) reviewed for care plans.1. The facility failed to ensure Resident #1's comprehensive care plan reflected that resident had sustained left side rib fractures.2. The facility failed to ensure Resident #2's comprehensive care plan reflected that resident requires 2 staff to be present during resident care.These failures could place residents at risk for not having their needs met.The findings were:1. Record review of Resident #1's face sheet dated 08/05/2026, reflected an [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: dementia (loss of memory, language, and problem-solving abilities) and pneumonia (infection in the lungs).Record review of Resident #1's hospital record dated 06/29/2026 revealed a one-view diagnostic chest x-ray diagnosis of left-sided rib fractures.Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 03 out of 15, which indicated severe cognitive impairment. Record review of Resident #1's care plan, dated 06/10/2026, was not updated to reflect the diagnosis of left side rib fractures or possible interventions. During an interview on 08/04/2026 at 12:09 pm, with Resident #1's RP, he stated Resident #1 had a fall at the facility on 06/29/2026 and was transferred to the hospital where they discovered she had left side rib fractures. The RP stated Resident #1 returned to the facility on [DATE] and was currently being kept comfortable and receiving hospice services and he had no concerns with her care at this time. 2. Record review of Resident #2's face sheet, dated 08/05/2026, reflected a [AGE] year-old female admitted on [DATE]. Her diagnosis included: memory deficit following other cerebrovascular disease (conditions that affect blood flow to the brain).Record review of Resident #2's quarterly MDS assessment, dated 06/28/2026 revealed a BIMS score of 08 out of 15, which indicated moderate cognitive impairment.Record review of Provider Investigation Report dated 06/30/2026, indicated Resident #2's care plan was updated to reflect two caregivers are to be present during resident care.Record review of Resident #2's care plan on 08/05/2026 did not reflect the need for 2 staff members to be present during resident care.During an interview with RN B on 08/06/2026 at 10:10am, RN stated Resident #2 was required to have two staff members present during care, but she does not know if the care plan reflects that information.During an interview on 08/06/2026 at 12:45pm, LVN A revealed he was an MDS nurse and was responsible for comprehensive care plans which were updated after quarterly assessments are completed. LVN A stated that Resident #1 did not have a care plan for rib fractures and Resident #2 did not have a care plan indicating the need for two staff to be present during care, but those care plans should be in place and he would add them. He did not know why they had not been implemented. During an interview on 08/06/2026 at 1:07pm, the DON stated care plans reflect the needs of the residents so the nursing staff would know how to provide care for the residents. Acute care plans were initiated by nurse management team and Resident #1's rib fractures and Resident #2's need for two staff members to be present during care should have been care planned by the nurse management team and/or MDS nurses during the morning meetings.Record review of the facility's policy Comprehensive Care Planning, no date, reflected Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident and to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 6 residents (Resident #8 and Resident #20), 1 of 4 medication carts (the 500 hall medication aide cart), and 1 of 2 medication rooms (the long term care unit medication room) reviewed for pharmacy services.1. The facility failed to ensure Resident #8's long-acting insulin was accurately prepared before administration.2. The facility failed to ensure Resident #20's controlled medication log for the opioid medication Hydrocodone-Acetaminophen 7.5-325 mg accurately reflected the number of doses administered.3. The facility failed to ensure the controlled substance reconciliation log for the 500 hall medication aide cart was signed for accuracy of medication quantities at the time of shift change.4. The facility failed to ensure the long-term care unit medication room contained no unexpired supplies.These failures could place residents at risk of not receiving their prescribed medications, of not benefiting from the full therapeutic effect of their medications or treatments, of experiencing untreated pain, and a decreased quality of life.The findings included: 1. Record review of Resident #8's admission sheet dated [DATE] with an original admission date of [DATE], documented a [AGE] year-old male resident with diagnoses including heart failure, high blood pressure, high cholesterol, and type 2 diabetes mellitus. Record review of Resident #8's MDS dated [DATE] documented a BIMS score of 6 indicating severe cognitive impairment and recorded the use of insulin injections in Section N - Medications N0350 Insulin A. Insulin Injections. Record review of Resident #8's order summary included an order for Insulin Glargine Pen-injector 100 UNIT/ML with directions to inject 15 unit subcutaneously one time a day for diabetes. Record review of Resident #8's care plan with an initiation date of [DATE] documented The resident has Diabetes Mellitus ., with interventions including Diabetes medications as ordered by doctor. During an observation of medication pass with LVN D on [DATE] at 7:20 AM, LVN D administered 15 units of Resident #8's Insulin Glargine pen, a long acting insulin used to manage type 1 and type 2 diabetes mellitus. LVN D did not prime the insulin pen prior to administering the medication to Resident #8. During an interview with LVN D on [DATE] at 7:53 AM, LVN D stated it was important to prime insulin pens before use to ensure the pen was working properly. LVN D stated if insulin pens were not primed before administration to residents, the dose might not be as effective or the correct amount, and the resident's blood sugar could be high. During an interview with the DON on [DATE] at 7:59 AM, the DON stated she expects her employees to give therapeutic care to the residents and she would discuss the proper usage of medication pens with the staff. 2. Record review of Resident #20's admission sheet dated [DATE] documented a [AGE] year-old female resident with diagnoses including asthma, depression, high cholesterol, high blood pressure, and sciatica (pain that travels along the path of the sciatic nerve which extends from the lower back through the buttocks down each leg). Record review of Resident #20's MDS dated [DATE] documented a BIMS score of 7 indicating severe cognitive impairment and recorded an active diagnosis of sciatica in Section I - Active Diagnoses I8000 H. Sciatica. Record review of Resident #20's order summary included an order for the opioid medication Hydrocodone-Acetaminophen 7.5-325 mg with orders to give 1 tablet by mouth three times a day for pain. Record review of Resident #20's care plan with an initiation date of [DATE] documented the resident was Allergic to aspirin, codeine, erythromycin/retinoic acid, gabapentin, sulfamethoxazole, Celebrex, Darvocet ., with interventions including Do not administer and/or come in contact with allergen. During an observation of the 700/800 hall nurse cart with LVN D on [DATE] at 9:34 AM, the controlled medication log for Resident #20's opioid medication Hydrocodone-Acetaminophen 7.5-325 mg with directions to give 1 tablet three times a day for pain, did not match the quantity of tablets remaining in the resident's blister pack. The medication log showed 6 tablets should be available; however, the blister pack contained 5 tablets. During an interview with LVN D on [DATE] at 9:37 AM, LVN D stated it was important to log out the tablet immediately after administering the medication. LVN D stated there could be the possibility of double dosing, and a resident could get too much sedation if they were overmedicated or if a pill was missing, the resident may experience pain if their pain medication was unavailable. 3. During an observation of the 500 hall medication aide cart with MA F on [DATE] at 9:48 AM, the controlled medication reconciliation log used to audit the quantities of controlled substances stored in the cart during shift changes had been signed in advance of the next shift change on [DATE]. During an interview with MA F on [DATE] at 9:50 AM, MA F stated the log should not be signed in advance of shift change, because you could leave and a card could get taken away. MA F stated something could go missing and a resident might not get their medication and could experience pain. 4. During an observation of the long-term care unit medication room with LVN D on [DATE] at 10:17 AM, an expired IV tubing with an expiration date of [DATE] was discovered on the shelves containing medication equipment and supplies. During an interview with LVN D on [DATE] at 10:18 AM, LVN D stated there should not be any expired items in the storage room. LVN D stated they do not want to use expired items because they might not work properly, and a resident might not get enough of their medication or could have a reaction. During an interview with the DON on [DATE] at 2:30 PM, the DON stated the facility policy explains the correct way to document the administration of controlled substances on the medication log sheets. The DON stated the do not want any medication errors, or to overdose a resident it they did not think they gave a medication which had already been given. The DON stated if a resident received too much of their medication, the resident could experience a harmful overdose. Regarding controlled substance reconciliation logs, the DON stated the staff should not be signing the logs in advance of shift change should be signed when the cart is handed off to the next employee. The DON stated it was important for the reconciliation logs to be accurate should they need to log a medication error, to prevent drug diversion, and to have a proper accounting of where the keys to the cart are located. Regarding expired supplies, the DON stated her expectation was that there should not be expired supplies in the medication rooms. The DON stated expired items might not be working adequately and could be ineffective, and the resident might not get the therapeutic benefit of their medication. During an interview with the Administrator on [DATE] at 2:56 PM the Administrator stated controlled medication reconciliation logs should not be signed in advance because the log could be inaccurate by the end of the shift. Regarding expired supplies, the Administrator stated expired supplies should not be the medication rooms, and they would not want to use any expired items for resident safety, because they might not be suitable for use. Record review of the Medication Pass Guidelines check off for LVN D dated [DATE] recorded an answer of met by g. Medication dose preparation. Record review of the facility policy titled Insulin Pen Use with a revision date of [DATE] noted Step 3. Perform a Safety test Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: -ensuring that pen and needle work properly, -removing air bubbles A. Select a dose of 2 units by turning the dosage selector. B. Hold the pen with the needle pointing upwards. C. Tap the insulin reservoir so that any air bubbles rise up towards the needle. D. Press the injection button all the way in. Check if insulin comes out of the needle tip. Record review of the facility policy titled Controlled Medications - Administration, dated 2025, noted Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations ., and When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: -Date and time of administration, -Amount administered, -Signature of the nurse administering the dose, completed after the medication is actually administered ., and At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 6 residents (Resident #51), 3 of 4 medication carts (the 700/800 hall nurse cart, the 800 hall medication aide cart, and the 500/600 hall nurse cart) and 1 of 2 medication rooms (the rehabilitation unit medication room) reviewed for medication storage and labeling. The facility failed to ensure the labels of all prescription medications located inside the 700/800 hall nurse cart and the 800 hall medication aide cart, matched the orders in the electronic medical record for Resident #51. The facility failed to ensure all medications located inside the 500/600 hall nurse cart were stored in labeled containers. The facility failed to ensure the refrigerator in the rehabilitation unit medication room contained a locked, affixed container to store controlled medications. These failures could place residents who receive medications at risk of not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others.The findings included: During an observation of medication pass with LVN D on 6/11/2026 at 7:20 AM, LVN D prepared to administer an opioid medication from the 700/800 hall nurse cart to Resident #51 from a blister pack with a prescription label which read Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed. Upon verification in the EMR, the order was written as Hydrocodone-Acetaminophen 10-300 mg, give 1 tablet by mouth every 6 hours as needed. During an interview with LVN D on 6/11/2026 at 7:21 AM, LVN D stated the order in the EMR did not match the directions on the prescription label of the blister pack. LVN D stated she needed to clarify the order with the prescriber and would check the 800 hall medication aide cart to see if it contained a blister pack with a different order for Resident #51. During an observation of medication pass with LVN E on 6/11/2026 at 7:33 AM, LVN E prepared to administer an opioid medication from the 800 hall medication aide cart to Resident #51 from a blister pack with a prescription label which read Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed. Upon verification in the EMR, the order was written as Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth twice daily. During an interview with LVN E on 6/11/2026 at 7:35 AM, LVN E stated the blister pack with a label for PRN dosing should not have been located in the 800 hall medication aide cart. LVN E stated the 800 hall medication aide cart should have had a blister pack with routine dosing for Resident #51's opioid medication. LVN E stated if the label on the blister pack did not match the order in the EMR, double dosing of medication could occur which could cause increased drowsiness and decreased vital signs. During an interview with the DON on 6/11/2026 7:59 AM, the DON stated it was important for the prescription labels on the blister pack to match the orders in the EMR. The DON stated a resident could receive non-therapeutic care for pain if too little medication was given or an overdose if too much medication was given. The DON stated she expected her staff to follow doctors orders, input orders correctly, and to clarify orders with the prescriber when needed. During an observation of the 500/600 hall nurse cart with RN B on 6/12/26 at 9:16 AM, a loose pill was discovered lying in the third drawer of the medication cart. During an interview with RN B on 6/12/2026 at 9:20 AM, RN B stated loose pills should not be in the medication carts, because if they are unlabeled, anyone could take it, and they would not know what it was. RN B stated if a resident consumed an unlabeled pill, it could be dangerous and cause the resident to get sick or have a heart attack. During an observation of the rehabilitation unit medication room with RN G on 6/12/26 at 10:11 AM, the lock box for controlled medication storage was not affixed to the refrigerator. During an interview with RN G on 6/12/2026 at 10:13 AM, RN G stated no one should be able to pick the lock box up and take it out of the refrigerator. RN G stated the box should be affixed to the refrigerator so it could not be removed. RN G stated if the lock box was not affixed to the refrigerator, a drug diversion could occur. During an interview with the DON on 6/12/26 at 2:30 PM, the DON stated there should not be loose pills in the medication carts, and it was an infection control issue and unacceptable. The DON stated if there were loose pills in the carts, medications might not be tracked or appropriately wasted. The DON stated a resident might not have received the therapeutic benefit of their medication if it was dropped in the cart and not administered. Regarding the lock boxes, the DON stated all lock boxes for controlled medication storage should be affixed to the refrigerator in the medication rooms. The DON stated if the lock boxes were not affixed, drug diversion could occur and residents might not receive therapeutic care if their medications are unavailable. During an interview with the Administrator on 6/12/26 at 2:56 PM, the Administrator stated his expectation for lock boxes was that they be affixed to the refrigerator and that narcotics needed to be locked up securely for the safety of residents and staff. The Administrator stated his expectation for medication carts was that they contained no loose pills, and that loose pills could indicate a nurse dropped a medication. The Administrator stated if a medication had been dropped in a cart unnoticed, a resident might not get the benefit of their drug, or a resident could experience a negative effect if they received a medication for which they were not prescribed. Record review of Resident #51's admission sheet dated 3/18/2026 with an original admission date of 4/19/2023 documented a [AGE] year-old male resident with diagnoses including depression, anxiety, seizures, and diabetic neuropathy (a common complication of diabetes characterized by nerve damage that can lead to pain, numbness and various dysfunctions in the body). Record review of Resident #51's MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition and recorded the use of opioid medications in Section N - Medications N0415 High-Risk Drug Classes: Use and Indication. Record review of Resident #51's order summary included an order for Hydrocodone-Acetaminophen 10-300 mg with an order date of 5/06/2026 with directions to give 1 tablet by mouth every 6 hours as needed for pain, Hydrocodone-Acetaminophen 10-325 mg with an order date of 6/11/2026 with directions to give 1 tablet by mouth every 6 hours as needed for moderate pain, and Hydrocodone-Acetaminophen 10-325 mg with an order date of 3/20/2026 with directions to give 1 tablet by mouth two times a day for moderate pain. Record review of Resident #51's care plan with an initiation date of 4/23/2026 documented The resident is on Pain medication Therapy ., with interventions including Administer medication as ordered. Record review of the facility policy titled Medication Labels, dated 2025, noted Medications are labeled in accordance with facility requirements, state, and federal laws ., 1. Each prescription medication label includes: Specific direction for use, including route of administration ., Nursing can request a 'refer to order change' sticker to affix to label until updated supply/label is provided. Record review of the facility policy titled Medication Storage in the Facility, dated 2025, noted Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The pharmacy dispenses medications in containers that meet legal requirements including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Record review of the facility policy titled Controlled Medications - Administration, dated 2025, noted Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations ., Medications listed in Schedules II are stored under double lock in a locked cabinet or safe designed for that purpose, separate from all other medications.

Based on interview and record review, the facility failed to maintain medical records for each resident that were complete and accurately documented for 2 (Residents #8 and #11) of 32 residents reviewed for complete and accurately documented clinical records, in that: 1. Resident #8's clinical record included an order to notify the Medical Doctor or Nurse Practitioner if the resident's blood sugar level was measured above 250 and an additional order to notify the Medical Doctor or Nurse Practitioner if the resident's blood sugar level was measured above 400. 2. Resident #11's diagnoses of insomnia and anxiety were not included in the resident's list of diagnoses and were therefore not listed on the resident's facesheet. These deficient practices could result in substandard level of care. The findings included: 1. Record review of Resident #8's facesheet, dated 06/12/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, type 2 diabetes mellitus, and heart failure. Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #8's care plan, revised 01/23/2020, revealed, The resident has Diabetes Mellitus. Record review of Resident #8's order summary, dated 06/12/2026, revealed an order dated 02/10/2025, [Check blood sugar] two times a day Notify MD/NP if BS [less than] 90 or [greater than] 250. Further review revealed an order dated 12/19/2025, Insulin [brand] Injection Solution (Insulin [brand]) Inject as per sliding scale: if 200 - 250 = 2u; 251 - 300 = 4u; 301 - 350 = 6u; 351 - 400 = 8u; 401+ = 10 units if greater than 400 give 10 units and call md, subcutaneously four times a day for DM. 2. Record review of Resident #11's facesheet revealed the resident was admitted to the facility on [DATE] with diagnoses including: vascular dementia, cerebral infarction, and paranoid personality disorder. Record review of Resident #11's significant change MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderate cognitive impairment. Record review of Resident #11's care plan, revised 05/07/2026, revealed, The resident uses anti-anxiety medications [due to] anxiety disorder. Record review of Resident #11's psychological services progress note, dated 01/05/2026, revealed, Diagnoses: primary insomnia, anxiety disorder. Further review of Resident #11's facesheet revealed the diagnoses of insomnia and anxiety were not listed. During an interview with the DON on 06/12/2026 at 12:25 p.m., the DON confirmed Resident #8's orders to notify the medical doctor or nurse practitioner of potentially high blood sugar levels were conflicting and stated she would contact Resident #8's physician for clarification. The DON on 06/12/2026 at 12:25 p.m., the DON stated Resident #11's diagnoses of insomnia and anxiety should have been included in the resident's list of diagnoses and therefore listed on the resident's facesheet. The DON confirmed that diagnoses from outside providers such as psychological services should be included in the resident's facility clinical record so that the resident's physician and facility care team could coordinate appropriately. The DON also confirmed that the resident's facesheet was utilized as a means of communicating the resident's status to hospitals and other providers outside of the facility and should accurately reflect the resident's status. The DON further stated the facility's annual survey commenced on her second day of employment with the facility and that she would ensure a system of communication and coordination between the facility and outside providers was in place. The facility policy regarding clinical records was requested on 06/12/2026 and was not received by the time of survey exit.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 4 of 24 residents (Residents #54, #57, #81 and #91) reviewed for resident assessments. 1. The facility failed to ensure Resident #54's injection type was accurately reflected on her admission MDS assessment dated [DATE]. 2. The facility failed to document Resident #57's use of antidepressant and scheduled pain medication on the quarterly MDS assessment. 3. The facility failed to ensure Resident #81s active diagnosis of respiratory failure was reflected on his quarterly MDS assessment dated [DATE]. 4. The facility failed to document Resident #91's use of opioids and scheduled pain medication on the quarterly MDS assessment. These deficient practices could place residents at risk of inadequate care. The findings include: 1.Record review of Resident #54's electronic face sheet dated 06/10/2026 reflected an [AGE] year-old female admitted on [DATE]. Her diagnosis included: type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #54's admission MDS assessment dated [DATE] reflected that she could understand others and be understood. She scored 3 of 15 on her BIMS which signified her cognitive status was severely impaired. She required maximum assistance with her ADLs. She was noted to have an active diagnosis of diabetes mellitus. She was noted to have 2 injections in the previous 7 days of the assessment and 2 insulin injections. She was noted to be taking a hypoglycemic (a drug used to help reduce the amount of sugar present in the blood). Record review of Resident #54's comprehensive care plan dated 04/15/2026 reflected Focus, resident has diabetes mellitus, Interventions/Tasks, diabetes medication as ordered by the doctor. Record review of Resident #54's Active Orders as of: 06/10/2026 reflected Liraglutide (a synthetic glucagon-like peptide-1 receptor agonist) Subcutaneous Solution Pen-Injector 18MG/3ML, inject 1.8 milligrams subcutaneously one time a day related to type 2 diabetes mellitus. She was not prescribed insulin. Record review of Resident #54's MAR dated 04/01/2026 to 04/30/2026 reflected that she had 2 subcutaneous injections of Liraglutide and not insulin. During an interview on 06/09/2026 at 12:00 pm, Resident #54 stated she received injections for her diabetes. During an interview on 06/12/2026 at 1:41 pm, the MDS Nurse stated even though the Liraglutide acted as a diabetic medication, it was not insulin and Resident #54's admission MDS should not have noted insulin injections. She stated MDS accuracy was important because it reflected the resident and care required which could be miscommunicated or missed. 2. Record review of Resident #57's admission sheet dated 01/22/2026, documented an [AGE] year-old female resident with diagnoses including pain in unspecified joint, hypertension (high blood pressure), diabetes mellitus, seizures, hyperlipidemia (high cholesterol), and cognitive communication deficit. Record review of Resident #57's MDS dated [DATE] documented a BIMS score of 3 indicating severe cognitive impairment and recorded the use of anticoagulant, antiplatelet, hypoglycemic, and anticonvulsant medication. The assessment did not include the use of antidepressants in Section N – Medications N0415. High-Risk Drug Classes: Use and Indication. Further review of the MDS revealed the assessment did not record the use of scheduled pain medication in Section J – Health Conditions J0100. Pain Management At any time is the last 5 days, has the resident: A. Received scheduled pain medication regimen? Record review of Resident #57's order summary included active orders for the antidepressant medication Trazodone, the analgesic medication Tylenol, and the anti-inflammatory medication Voltaren. Trazodone was ordered as Trazodone 150 mg, Give 1 tablet by mouth one time a day related to INSOMNIA. Tylenol was ordered as Tylenol 325 mg, Give 2 tablets by mouth two times a day related to PAIN IN UNSPECIFIED JOINT. Voltaren was ordered as Voltaren External gel 1%, Apply to LEFT KNEE topically two times a day for PAIN. Record review of Resident #57's April 2026 and May 2026 MARs documented the resident had been receiving Tylenol and Voltaren as prescribed during the five day lookback period from 4/27/2026 through 5/01/2026. Further review of the April and May MARs, documented the resident had been receiving Trazodone as prescribed during the seven day lookback period from 4/25/2026 through 5/01/2026. Record Review of Resident #57's care plan with an initiation date of 01/27/2026 documented The resident requires antidepressant medication ., Give antidepressant medications as ordered by physician. Further review of the resident's care plan documented The resident has a potential for uncontrolled pain ., Evaluate the effectiveness of pain interventions. 3. Record review of Resident #81's electronic face sheet dated 06/11/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnosis included: acute and chronic respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function). Record review of Resident #81's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 10 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required minimal to moderate assistance with ADLs. Respiratory failure was not noted to be an active diagnosis. Record review of Resident #81's comprehensive care plan dated 07/18/2025 reflected Focus, resident has oxygen therapy and nebulizer related to ineffective gas exchange, respiratory illness, Interventions/Tasks, give medication as ordered. Record review of Resident #81's Active Orders as of: 05/01/2026 reflected acetazolamide oral tablet 250mg, give one tablet by mouth one time a day for respiratory failure, start date 10/30/2024. Observation on 06/09/2026 at 11:30 am of Resident #81 revealed he was sitting in his room in a wheelchair. An oxygen concentrator was near his bed with oxygen tubing unbagged secured around the top. During an interview on 06/09/2026 at 11:32 am, Resident #81 stated he used oxygen at night to help him to breathe because of his respiratory failure. During an interview on 06/12/2026 at 1:41 pm, the MDS Nurse stated Resident #81 did have an active diagnosis of respiratory failure and received medications. She stated she did not know how it was missed on the quarterly MDS assessment. She stated MDS accuracy was important because it reflected the resident and care required which could be miscommunicated or missed. During an interview on 06/12/2026 at 2:30 pm, the DON who was new at the facility stated the MDS painted a picture of the resident and their care and drove the care plan. The DON stated an inaccurate MDS could lead to a lack of care. During an interview on 06/12/2026 at 2:40 pm, the ADM stated MDS accuracy was important for reimbursement, and care planning. The ADM stated that an inaccurate MDS could result in missed care. 4. Record review or Resident #91's admission sheet dated 8/05/2022 with an original admission date of 02/26/2020 documented a [AGE] year-old male resident with diagnoses including cerebral infarction (stroke), diabetes mellitus, chronic pain, and right hand contracture (a condition causing the shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments). Record review of Resident #91's MDS assessment dated [DATE] documented a BIMS score of 7 indicating severe cognitive impairment and recorded the use of antidepressant, anticoagulant, diuretic, and anticonvulsant medication. The assessment did not include the use of opioids in Section N – Medications N0415. High-Risk Drug Classes: Use and Indication. Further review of the MDS revealed the assessment did not record the use of scheduled pain medication in Section J – Health Conditions J0100. Pain Management At any time is the last 5 days, has the resident: A. Received scheduled pain medication regimen? Record review of Resident #91's order summary included an active order for the opioid medication Tramadol. Tramadol was ordered as Tramadol 50 mg, Give 1 tablet by mouth two times a day related to OTHER CHRONIC PAIN. Record review of Resident #91's May 2026 MAR documented the resident was receiving Tramadol as prescribed during the five day lookback period from 5/10/2026 through 5/14/2026. Record review of Resident #91's care plan with an initiation date of 9/22/2021, documented The resident has a potential for uncontrolled pain ., with interventions including Evaluate the effectiveness of pain interventions. During an interview with the MDS Nurse on 6/12/26 at 1:41 PM, the MDS Nurse stated she was responsible for ensuring the accuracy of the information included on the MDS. The MDS Nurse stated the assessment should be accurate because it was the regulation and a picture of resident care. The MDS Nurse stated if the MDS was inaccurate, resident care could not be delivered correctly and something could be missed. Record review of the facility's policy and procedure titled Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy dated August/2025 reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in thecomprehensive assessment for 3 Residents (Resident #7, Resident #44, Resident #54, and Resident #81) of 32 residents reviewed forcare plans. 1.The facility failed to reflect Resident #7's hospice services in her comprehensive care plan. 2.The facility failed to reflect Resident #44 used a sensor pad in his comprehensive care plan. 3.The facility failed to reflect Resident #81 would take off his oxygen canula and put it on. These deficient practices place residents at risk of missed or miscommunicated care.The findings include: 1.Record review of Resident #7's electronic face sheet dated 06/10/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: cerebral infarction (the death of neural (brain) tissue because of ischemia (lack of oxygen), and malignant neoplasm of colon (abnormal cancer cells that begin in the large intestine and can spread). Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected that she could understand others and be understood. She scored 6 of 15 on her BIMS which signified her cognitive status was severely impaired. She required moderate assistance with ADLs. She was noted to have hospice care. Record review of Resident #7's comprehensive care plan dated 02/17/2026 failed to reflect that she received hospice care. Record review of Resident #7's Active Orders as of: 06/10/2026 reflected Admit to Hospice, DX CVA, start dated 02/04/2026. Observation on 06/09/2026 at 11:00 am revealed Resident #7 lying in bed attended by a hospice aide who applied lotion to her legs. During an interview on 06/09/2026 at 11:03 am, Resident #7 stated hospice came and gave her baths and showers. 2. Record review of Resident #44's electronic face sheet dated 06/10/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: Parkinsonism (clinical syndrome that presents with various neurodegenerativediseases which manifest motor symptoms such as rigidity, tremors, and unstable posture, leading to gait impairment),muscle spasms (sudden, involuntary contraction of one or more muscles) and seizures (sudden burst of electrical activityin the brain which can cause changes in behaviors and movement and levels of consciousness). Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected he was able to be understood andable to understand others. He scored 12 of 15 on his BIMS which signified his cognitive status was moderately impaired.He required substantial assistance to total dependence for most of his ADLs. He used a manual wheelchair and required.maximal assistance for locomotion and mobility. Record review of Resident #44's comprehensive care plan dated 05/01/2026 reflected Focus, resident has an ADL selfcare.performance deficit r/t Parkinsons, muscle weakness, Interventions/Tasks, encourage the resident to use call bell forassistance. Resident #44's need for a sensor pad instead of a call bell was not reflected. Observation on 06/09/2026 at 10:45 am of Resident #44 revealed he was sitting in a tall wheelchair in his room.approximately 3 feet away from his bed. His sensor pad was lying on his bed. During an interview on 06/09/2026 at 10:47 am, Resident #44 stated he would use his sensor pad to call someone if heneeded help. 3. Record review of Resident #81's electronic face sheet dated 06/11/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnosis included: acute and chronic respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function). Record review of Resident #81's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 10 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required minimal to moderate assistance with ADLs. Respiratory failure was not noted to be an active diagnosis. Record review of Resident #81's comprehensive care plan dated 07/18/2025 reflected Focus, resident has oxygen therapy and nebulizer related to ineffective gas exchange, respiratory illness, Interventions/Tasks, give medication as ordered. Resident #81's behavior of taking off and putting on his oxygen was not reflected. Record review of Resident #81's Active Orders as of: 05/01/2026 reflected acetazolamide oral tablet 250mg, give one tablet by mouth one time a day for respiratory failure, start date 10/30/2024. Observation on 06/09/2026 at 11:30 am of Resident #81 revealed he was sitting in his room in a wheelchair. An oxygen concentrator was near his bed with oxygen tubing unbagged secured around the top. During an interview on 06/09/2026 at 11:32 am, Resident #81 stated he used oxygen at night to help him to breath because of his respiratory failure. He stated he put his oxygen on and took it off himself. He stated he would turn the concentrator on and off. He stated he was on oxygen between 2 and 4 L/min. During an interview on 06/12/2026 at 12:51, RN C stated Resident #81 could take off his own nasal canula and put it on. She stated she did not know if it was in his care plan. During an interview on 06/12/2026 at 1:41 pm, the MDS Nurse stated Resident #7's hospice services, Resident #44's sensor pad and Resident #81's behaviors of putting on and taking off his oxygen canula needed to be reflected in their care plans, and she did not know why they were not. She stated the wrong type of care or missed care could result with an inaccurate care plan. She stated behaviors needed to be communicated to other direct care staff so they would be aware. During an interview on 06/12/2026 at 2:30 pm, the DON who was new at the facility stated the comprehensive care plan should show what care the residents required and what they could or could not do to include behaviors and preferences. She stated she was accountable for many parts of the care plan process. During an interview on 06/12/2026 at 2:40 pm, the ADM stated care plans needed to show the residents' needs, preferences and goals. Record review of the facility's policy and procedure titled Comprehensive Care Planning (undated) reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 32 residents (Resident #7 and Resident #81) reviewed for infection control in that: 1. The facility failed to ensure RN B maintained proper hand hygiene when administering medication through Resident #7's PEG tube (a small, flexible tube placed through the abdominal wall directly into the stomach allowing for the provision of nutrition, fluids, and medications without swallowing). 2. The facility failed to ensure Resident #81's oxygen tubing was bagged when not in use. These facility failures could place residents at risk of cross contamination and the spread of infections. The findings included: 1. Record review of Resident #7's admission sheet dated 02/03/2026 with an original date of 4/29/2025 documented a [AGE] year-old female resident with diagnoses including cerebral infarction (stroke), malignant neoplasm of colon (colon cancer), diabetes mellitus, hyperlipidemia (high cholesterol), hypertension (high blood pressure), and kidney disease. Record review of Resident #7's MDS dated [DATE] documented a BIMS score of 6 indicated severe cognitive impairment and recorded the use of a feeding tube in Section K – Swallowing/Nutritional Status K0520. Nutritional Approaches. Record review of Resident #7's order summary documented an active order for the pain medication Acetaminophen with an order date of 9/04/2025 and an active order for EBP with an order date of 5/06/2025. Acetaminophen was ordered as Acetaminophen 325 mg, Give 2 tablets via PEG-Tube every 6 hours as needed for pain/fever. EPB was ordered as Enhanced Barrier Precautions, every shift. Record review of Resident #7's care plan with an initiation date of 02/17/2026 noted The resident requires tube feeding .Meds and water flushes only ., and The resident has a potential for uncontrolled pain Arthritis / shoulder pain ., with interventions including Administer analgesia (specify medication) as per orders. Further review of the care plan noted the resident is on enhanced barrier precautions ., with a goal of There will not be any transmission of infection from or to the resident. During an observation of medication administration with RN E on 6/10/2026 at 12:37 PM, RN E did not sanitize her hands between glove changes during administration of Resident #7's pain medication through the resident's PEG tube. During an interview with RN E on 6/10/2026 at 12:39 PM, RN E stated she was supposed to sanitize her hands between glove changes when giving medications through a PEG tube. RN E stated it was important to sanitize between glove changes because Resident #7 is on EBP, and when they administer medications, they touch surfaces and could spread germs when they do not sanitize properly. During an interview with the DON on 6/10/2026 at 12:56 PM, the DON stated it was important for staff to sanitize between glove changes to prevent cross contamination when administering medications through a PEG tube. The DON stated she expected her staff to use EBP to protect themselves and residents to prevent cross contamination Record review of RN E's Hand Hygiene Checkoff dated 5/15/2026 documented RN E had received training on hand hygiene including hand washing with soap and water, and hand washing with hand sanitizer. Record review of the facility policy titled Fundamentals of Infection Control Precautions, undated, noted Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: Before and after handling peripheral vascular catheters and other invasive devices; After removing gloves. 2. Record review of Resident #81's electronic face sheet dated 06/11/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnosis included: acute and chronic respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function). Record review of Resident #81's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 10 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required minimal to moderate assistance with ADLs. Respiratory failure was not noted to be an active diagnosis. Record review of Resident #81's Active Orders as of: 05/01/2026 reflected acetazolamide oral tablet 250mg, give one tablet by mouth one time a day for respiratory failure, start date 10/30/2024. Record review of Resident #81's comprehensive care plan dated 07/18/2025 reflected Focus, resident has oxygen therapy and nebulizer related to ineffective gas exchange, respiratory illness, Interventions/Tasks, give medication as ordered. Observation on 06/09/2026 at 11:30 am of Resident #81 revealed he was sitting in his room in a wheelchair. An oxygen concentrator was near his bed with oxygen tubing unbagged secured around the top. During an interview on 06/09/2026 at 11:32 am, Resident #81 stated he used oxygen at night to help him to breathe because of his respiratory failure. He stated his tubing was not bagged, and staff had not provided him with a bag to put it in when not in use. During an interview on 06/12/2026 at 12:51 pm, RN C stated Resident #81 could take off his own nasal canula and put it on. She stated the importance of bagging the oxygen tubing when not in use to prevent dust or dirt particles from entering and cause an infection. During an interview on 06/12/2026 at 2:30 pm, the DON who was new at the facility stated the oxygen tubing needed to be bagged when not in use or there could be cross contamination. During an interview on 06/12/2026 at 2:40 pm, the ADM stated cross contamination, and infection could occur when oxygen tubing is left unprotected when not in use. Record review of the facility's policy and procedure titled Respiratory Policies and Procedures dated June 1, 2006, reflected replace entire set-up every seven days. Date and store in treatment bag when not in use. Record review of the facility's policy and procedure titled Fundamentals of Infection Control Precautions (undated) reflected A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions, Hand Hygiene, after removing gloves or aprons.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation for residents.needs for 1of 8 residents (Resident #44) reviewed for quality of care. The facility failed to ensure Resident #44's call sensor pad was within reach. The deficient practice could place residents at risk of not receiving care or attention needed. Findings include: Record review of Resident #44's electronic face sheet dated 06/10/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: Parkinsonism (clinical syndrome that presents with various neurodegenerativediseases which manifest motor symptoms such as rigidity, tremors, and unstable posture, leading to gait impairment),muscle spasms (sudden, involuntary contraction of one or more muscles) and seizures (sudden burst of electrical activityin the brain which can cause changes in behaviors and movement and levels of consciousness). Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected he was able to be understood andable to understand others. He scored 12 of 15 on his BIMS which signified his cognitive status was moderately impaired.He required substantial assistance to total dependence for most of his ADLs. He used a manual wheelchair and required.maximal assistance for locomotion and mobility. Record review of Resident #44's comprehensive care plan dated 05/01/2026 reflected Focus, resident has an ADL selfcare.performance deficit r/t Parkinsons, muscle weakness, Interventions/Tasks, encourage the resident to use call bell forassistance. Observation on 06/09/2026 at 10:45 am of Resident #44 revealed he was sitting in a tall wheelchair in his room.approximately 3 feet away from his bed. His sensor pad was lying on his bed. During an interview on 06/09/2026 at 10:47 am, Resident #44 stated he would use his sensor pad to call someone if heneeded help. He stated he could not reach or get to the sensor pad and would have to yell if he needed help. During an interview on 06/12/2026 at 1:03 pm, CNA A, who was assigned to care for Resident #44 on 06/09/2026, shestated she could not remember who helped Resident #44 out of bed, but that he would not be able to reach his sensor pad.if it was on his bed and he was in his chair a few feet away. She stated if he had an emergency, he would not be able toget help. During an interview on 06/12/2026 at 1:16 pm, RN B, who was assigned to care for Resident #44 on 06/09/2026 stated.She did not notice Resident #44's sensor pad placement that morning. She stated it was important for residents to have.their call lights or devices within reach in case they needed help quickly. During an interview on 06/12/2026 at 2:30 pm, the DON who was new at the facility stated residents needed to have call.lights or devices within reach when they were in their rooms in case an emergency arose. During an interview on 06/12/2026 at 2:40 pm, the ADM stated staff needed to check for call light or device placement sothat residents had a way to get help. Record review of the facility's policy and procedure titled Resident Rights (undated) reflected the right to reside andreceive services in the facility with reasonable accommodation of resident needs and preferences except when to do so.would endanger the health or safety of the resident or other residents.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan for 2 (Residents #1 and #8) of 32 residents reviewed for comprehensive care plans, in that: 1. Resident #1's diagnoses of frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis were not included in the resident's care plan. 2. Resident #8's physician order for biannual blood tests to check drug levels and screen for potential side effects of valproic acid was not included in the resident's care plan. These deficient practices could result in substandard level of care. The findings included: 1. Record review of Resident #1's facesheet, dated 06/12/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #1's care plan, revised 03/05/2026, revealed the resident's diagnoses of frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis were not included in the resident's care plan. 2. Record review of Resident #8's facesheet, dated 06/12/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, type 2 diabetes mellitus, and heart failure. Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #8's order summary, dated 06/12/2026, revealed and order dated 01/23/2025 [valproic acid]LEVEL Q 6 MONTHS (OCT, APRIL). Record review of Resident #8's care plan, revised 05/14/2026, revealed the physician order for biannual blood tests to check drug levels and screen for potential side effects of valproic acid was not included in the resident's care plan. During an interview with the DON on 06/12/2026 at 12:25 p.m., the DON stated Resident #1's diagnoses of frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis were being address by the facility and should have been included in the resident's care plan. The DON also stated that Resident #8's physician order for biannual blood tests to check drug levels and screen for potential side effects of valproic acid should have been included in the resident's care plan. During an interview with the MDS Coordinator on 06/12/2026 at 2:00 p.m., the MDS Coordinator stated Resident #1's diagnoses of frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis should have been included in the resident's care plan, that Resident #8's physician order for biannual blood tests to check drug levels and screen for potential side effects of valproic acid should have been included in the resident's care plan, and that the omission was an oversight. Record review of the facility policy, Comprehensive Care Planning, undated, revealed, the resident's care plan will be reviewed.and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #2), reviewed for resident assessment. Resident #2's PASRR level 1 screening form did not indicate mental illness. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. The findings were:The findings were: Record review of Resident #2's face sheet dated 6/11/26 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2's diagnoses included encephalopathy unspecified (diffuse disease of the brain that alters brain function or structure), and other schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves and can include a combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE] revealed A1500 was marked no for Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectualdisability or a related condition? and A1510 for serious mental illness was left blank. The resident had unclear speech, rarely or never understood others and was rarely or never understood by others and had a BIMS score of 00 indicating the resident was severely cognitively impaired. The resident used a manual wheelchair, and section I6000 was marked yes for schizophrenia diagnosis. Record review of Resident #2's undated care plan revealed a focus initiated on 5/13/26 for impaired cognitive function and impaired thought processes, and the resident required anti-psychotic medications with interventions that included monitoring and notifying the resident's physician. Record review of Resident #2's hospital discharge paperwork revealed the resident had been admitted from a different long term care facility, had a history of schizophrenia, was unable to answer questions appropriately, and was calling out for her sister who had previously passed away. Resident #2's on-going treatment list included Schizophrenia. Record review of Resident #2's PASSR level 1 screening dated 5/12/26 was marked no for serious mental illness. Record review of Resident #2's EHR (Electronic Health Record) revealed no corrected PASSR level 1 screening was completed. In an interview on 6/11/26 at 10:17 a.m., the MDS Nurse 2 stated he was unable to know who specifically reviewed Resident #2's PASRR screening for accuracy. MDS Nurse 2 stated it was a negative level 1 prescreening dated 5/12/26 and that a diagnosis of schizophrenia would not require a level 2 evaluation unless the resident had been recently hospitalized for mental illness. The MDS Nurse 2 stated he was unsure who reviewed Resident #2's PASRR level 1 screening. In an interview on 6/12/26 at 1:30 p.m. with the DON and MDS Nurse, the MDS Nurse stated she was responsible for reviewing and ensuring the PASRR level 1 for Resident #2 was completed correctly. The MDS Nurse stated she should have filled out form 1012 to trigger the PASRR level 2 evaluation. The MDS Nurse stated not completing this form 1012 could potentially prevent resident's from receiving specialized services, but in Resident #2's case, there were no potential consequences for this resident due to the resident's payor source, and she would be marked a no by the PASRR level 2 evaluation. Review of the facility policy on PASSR level 1 screening revised 3/6/2019 indicated . 3. The Facility will review the PASRR level 1 Screening form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers, and DOB is correct. The Date of the PL1 is correct (i.e., correct day, month, and year) and review each item on the PL1 to ensure accuracy and prevent a regulatory problem.

Based on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System including. A subset of items upon a resident's transfer, reentry, discharge, and death, for 1 (Resident #83) of 4 residents reviewed for completed MDS data, in that: The facility did not complete, encode, or transmit an MDS assessment upon the discharge of Resident #83. This deficient practice could result in inaccurate MDS data regarding residents reflected in the CMS system. The findings included: Record review of Resident #83's facesheet, dated 06/12/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: other nondisplaced fracture of upper end of right humerus, hyperlipidemia, and nondisplaced fracture of shaft of right clavicle. Record review of Resident #83's facility closed clinical record revealed an entry MDS was completed on 01/12/2026. Further review of Resident #83's facility closed clinical record revealed a signed AMA form, dated 01/12/2026, which indicated the resident discharged from the facility on the same day as admission. Further review of Resident #83's facility closed clinical record revealed a discharge MDS was not completed, encoded, or transmitted. During an interview with the DON on 06/12/2026 at 12:25 p.m., the DON stated a discharge MDS should have been completed, encoded, and transmitted for Resident #83 upon the resident's discharge from the facility. During an interview with the MDS Coordinator on 06/12/2026 at 2:00 p.m., the MDS Coordinator stated a discharge MDS should have been completed, encoded, and transmitted for Resident #83 upon the resident's discharge from the facility and stated the omission was an oversight. Record review of the facility policy, Minimum Data Set (MDS) Policy for MDS Assessment Data Accuracy, dated 08/2025, revealed, Federal regulations.require that: 1. The assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #2 physician progress notes were obtained by the medical provider and uploaded into the medical record. This failure could affect residents whose records were maintained by the facility and could place them at risk for an incomplete clinical picture and errors in care and treatment. The findings included: Record review of Resident #2's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: acute kidney failure, essential hypertension (high blood pressure), and rheumatoid arthritis (chronic immune disease which attacks the joints causing pain and stiffness). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 13 which indicated she was cognitively intact with total functional dependance on staff for movement. Record review of Resident #2's electronic medical record on 1/28/2026 revealed there were no physician notes in the medical record. During an interview on 1/28/2026 at 12:48 p.m. the DON stated confirmation that no physician progress notes had been uploaded into Resident #2's medical record. During an interview on 1/28/2026 at 1:11 p.m., the DON was able to provide physician notes for 3/21/2025, 10/15/2025 and 11/17/2025. She stated none of these physician notes were in the electronic medical record. She stated they had not been uploaded because the facility was behind with uploads and doing it as fast as they could. She stated the medical records person was responsible for uploading. During an interview on 1/28/2026 at 1:20 p.m. the Medical Records staff stated he was not on a facility email group with the facility doctors. He stated he had noticed the physicians were behind with providing physician notes and the Administrator was aware. He stated if there was any document that was specifically needed, he could call the physician office, request the document and get it fairly quickly. Medical Records stated he had been doing the job since June of 2025. He stated he was told his expectation was to upload and scan documents. When asked about a time frame he stated he could not upload a document unless someone requested a specific document because he was not in the email group, and he does not upload unless there was a specific request for a specific document, he used the example of this surveyor requesting physician notes for Resident #2 as an example of a request. He stated the physician notes were not coming to him to upload unless he requested them specifically and he was not requesting them unless there was a specific need. During an interview on 1/28/2026 at 2:08 p.m., the DON stated the physician offices were behind in sending their notes to the facility. She stated it was the Administrators responsibility to contact the physician's office on a regular basis to get these records. The DON stated she was not sure what the facility policy indicated for uploading of physician notes into the medical record. She stated it was her expectation that medical records staff upload as quickly as possible once they were received. The DON stated the Medical Records staff would be responsible for contacting a physician office when a document was noted as needed. She stated she didn't know if Medical Records had any sort of schedule for regular contact. She stated she would assume he was auditing records and contacting whom he needed for missing documentation. The DON stated she was not providing medical record oversight. She stated it was a corporate person providing oversight and she was unsure who was doing it. During an interview on 1/28/2026 at 3:07 p.m., the Administrator stated she was aware some of the physicians' offices were behind in sending documentation. She stated it was not her hyperfocus. She stated she did not have a system for requesting physician notes or records. She stated they just request what was needed at the time. The Administrator stated the physician visits were compliant it was a failure between the physician office and the facility office to get them uploaded. The Administrator stated she did not know the facility policy off the top of her head. She stated it was important to have physician visits in the medical record for accuracy of documentation. Record review of a policy titled Physician's Progress Notes (PPN) dated 2023 revealed: 2. It is our responsibility to notify the physician when a physician's progress note is due. Routine clinical chart audits will alert you which physician needs to be notified.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1's comprehensive care plan was accurate and included the correct diagnoses of hypothyroidism (instead of hyperthyroidism) with appropriate interventions. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:Record review of Resident #1's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke), gastro-esophageal reflux disease without esophagitis (GERD)(reflux of acid from stomach into esophagus resulting in heartburn), and hypothyroidism (2/08/2025). Record review of Resident #1's care plan dated 3/13/2025 revealed a diagnosis of hyperthyroidism (the opposite of hypothyroidism) with interventions which included interventions for adjustment of lighting to prevent eye irritation, safety for altered mental status and altered muscle coordination and encourage periods of rest to reduce energy needs. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 which indicated a moderate cognitive impairment with reliance of moderate assistance for ADL's. The MDS did not list either hypo or hyperthyroidism as a diagnosis. Record review of Resident #1's provider note dated 1/23/2026 revealed a current diagnosis which included unspecified hypothyroidism. During an interview on 1/28/2026 at 1:38 p.m., the MDS Coordinator stated he was the nurse responsible for MDS assessments and care plans. He stated any licensed charge nurse; any member of the management team could alter and/or change a resident care plan. He stated care plans were discussed in morning meetings and reviewed with quarterly assessments. He stated Resident #1's Care Plan indicated hyperthyroidism instead of her actual disease process of hypothyroidism. he stated the interventions listed were not all appropriate for hypothyroidism. He stated the care plan for hyperthyroidism was created by LVN A who no longer worked for the facility. He stated it was not something that was caught during the reviews. He stated the last review was 1/14/2026. During an interview on 1/28/2026 at 2:08 p.m., the DON stated on admission important items for the care plan are added by various members of the team which included: the wound care nurse, ADON and DON. She stated the active diagnoses are entered by the MDS nurse after the MDS assessment. She stated she reviews the assessments for accuracy. She stated for Resident #1 she did not review the MDS assessment. She stated accurate care plans were important for the accuracy of care for the resident. Record review of the facility policy titled Comprehensive Care Planning (undated) revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Comprehensive care plan will describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status of 1 of 4 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's quarterly MDS assessment dated [DATE] accurately coded to reflect Resident #1's diagnoses of GERD (gastric reflex) and hypothyroidism.The facility failed to ensure Resident #1's quarterly MDS assessment dated [DATE] and Resident #2's assessment were accurate and reviewed and signed by a Registered Nurse before submission. This failure could place residents at risk for not receiving needed care and services to maintain the highest level of well-being. The findings included: Record review of Resident #1's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke), gastro-esophageal reflux disease without esophagitis (GERD)(reflux of acid from stomach into esophagus resulting in heartburn), and hypothyroidism (2/08/2025). Record review of Resident #1's care plan dated 3/13/2025 revealed a diagnosis of hyperthyroidism (the opposite of hypothyroidism) (in error). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 which indicated a moderate cognitive impairment. The MDS did not list either hypo or hyperthyroidism or GERD as a diagnosis. The assessment is signed by the MDS Coordinator who is a LVN on 12/02/2025 under section Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion. The assessment was not signed by an RN.Record review of Resident #1's care plan dated 3/13/2025 revealed a diagnosis of hyperthyroidism (the opposite of hypothyroidism).Record review of Resident #1's provider note dated 1/23/2026 revealed a current diagnosis which included unspecified hypothyroidism. Record review of Resident #2's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: acute kidney failure, essential hypertension (high blood pressure), and rheumatoid arthritis (chronic immune disease which attacks the joints causing pain and stiffness).Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 13 which indicated she was cognitively intact with total functional dependance on staff form movement. The assessment was signed by the MDS Coordinator who was a Licensed Vocational Nurse on 11/06/2025 under section z0500 marked signature of RN Assessment Coordinator Verifying Assessment Completion. An RN did not sign the assessment.During an interview on 1/28/2026 at 1:38 p.m., the MDS Coordinator stated he was responsible for MDS assessments and care plans. He stated after reviewing her medical record in November when the assessment was completed and currently, Resident #1 was being treated for both GERD by protonix and hypothyroidism with levothyroxine. He stated they were active diagnoses that were not included on the MDS assessment. He stated active diagnoses were normally auto populated into the MDS assessment. He stated he did not see a button to push to add GERD or hypothyroidism like some of the other diagnoses. He stated she should have written in both diagnoses under the category of other since they were both being treated and both should have been on the assessment. The MDS Coordinator stated it was just an oversight and something he would have to be more careful about. the MDS Coordinator confirmed he was a LVN. He stated he was aware the MDS assessments required review and a signature from a RN. He stated he did not know why Resident #1 and Resident #2's MDS assessments were not reviewed or signed by a RN and had his signature. He stated he normally would give the DON a list every week of what needed to be signed. He stated he would take his laptop to the DON's office to review the assessments. The MDS Coordinator stated sometimes he would mark the assessments as completed by signing them to check for errors but may have failed to unmark it as incomplete because he was in a rush. He stated he believed it was an oversight and something he would have to be more careful about.During an interview on 1/28/2026 at 2:08 p.m., the DON stated she was unable to speak to the missing GERD and hypothyroidism diagnosis from Resident #1's quarterly MDS assessment. She stated the assessment was asking for active diagnoses and there was no category for those diagnoses. She stated the MDS Coordinator could have documented the diagnoses under the category other. The DON stated it was important to include all diagnoses for accuracy. The DON stated she reviews and signs MDS assessments for accuracy. She stated she did not know why Resident #1 and Resident #2's MDS assessments had not been signed by an RN. She stated she was not sure what happened. She stated the MDS Coordinator was in her office several times a week. The DON stated an RN had to sign and validate and check for accuracy the MDS assessments. She stated an LVN could not sign them. She stated she could not speak to the missing diagnoses of GERD and Hypothyroidism from Resident #1's assessment. The DON stated it was important for an RN to review the assessments for accuracy.Record review of the facility policy titled Minimum Data Set (MDS) Policy for MDS assessment Date Accuracy dated 8/2025 revealed: The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status. Record review of the facility policy titled Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy dated 8/2025 revealed: Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status 2. a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals.

Based on observation, interview and record review the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 was transferred with the appropriate number of qualified staff required when using a mechanical lift. This failure could place the residents at risk of injury by not following the resident's care plan and clinical standards of practice. Findings included: Record review of Resident #1's electronic health record reflected a [AGE] year-old female, with an admission date of 04/08/202. Resident #1 had diagnoses which included: Generalized anxiety disorder (excessive persistent worry about everyday things), Muscle wasting and atrophy (thinning or loss of muscle tissue), Rheumatoid arthritis (autoimmune disease causing swelling, pain and stiffness of joints), Lack of Coordination, Sequelae Cerebral Infarction (physical, cognitive, & emotional impairments such as one-sided weakness or paralysis, speech problems, memory problems), Hypomagnesemia (low magnesium in the blood causing weakness, seizures, muscle cramps), Vascular Dementia with mood disturbance (decline in cognition due to reduced blood flow to the brain and can include depression, irritability or sudden anger), Schizoaffective Disorder (condition combining schizophrenia such as hallucinations and disorganized thinking, and mood disorder like bipolar or depression), End stage renal disease (kidney failure and can no longer perform their function). Resident #1 had a BIMS of 09, which indicated moderate cognitive impairment. Record review of Resident #1's electronic health record reflected the most recent Care Plan, dated 09/11/25, date initiated 02/02/2021, revealed, transferring: requires staff x2 for assistance use [mechanical lift]. Record review of Resident #1's electronic health record reflected the MDS dated [DATE], Section GG, Chair/bed-to-chair transfer requires 01-Dependent- Helper does all the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review Resident #1's electronic health record reflected the MDS dated [DATE], Section GG, Chair/bed-to-chair transfer requires 01-Dependent- Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. In an observation on 11/29/25 at 3:12 p.m., CNA A wheeled a mechanical lift out of Resident #1's room and placed it against the wall and walked back into Resident #1's room. CNA A rolled Resident #1 to her side towards CNA A's body and removed the sling from under Resident #1. No other staff member was in the room. Resident #1 did not have any injuries noted. In an interview on 11/29/25 at 3:12 p.m., CNA A stated she transferred Resident #1 from her wheelchair to the bed with the mechanical lift on her own because Resident #1 wanted to lay down. CNA A stated it was her first day at the facility and she was orientating. She stated she had not been trained on mechanical lift transfers by the facility. CNA A stated she had been a CNA for 20 years and she knew there were supposed to be two people to use a mechanical lift to transfer a resident. CNA A stated everyone was busy and the staff she was supposed to be orientating with, CNA B, was down the hall changing other patients because the previous shift did not change their patients. She stated she took it upon herself to transfer Resident #1 with the mechanical lift, and she did not ask anyone for help with the transfer. CNA A stated Resident #1 was not injured. When asked how the residents could be affected, CNA A stated when a facility was short staffed, staff did one-person mechanical lift transfers and nothing bad happened to the residents. In an interview on 11/29/25 at 4:57 p.m., Resident #1 stated staff used a mechanical lift to transfer her. She stated CNA A transferred her by herself with the mechanical lift, but she did not get hurt. Resident #1 stated she did not remember how many people the staff used normally but she has never been hurt during a transfer. In an interview on 11/29/25 at 5:28 p.m., LVN C stated she was CNA A's direct supervisor, and she was in the dining room talking to a resident when CNA A transferred Resident #1. She stated she was not aware CNA A needed assistance with Resident #1, and she had not been asked to help. LVN C stated staff knew where she was and knew the expectation was to use two people to transfer a resident with a mechanical lift. LVN C stated she did not know where CNA B was at the time of the incident. In an interview on 11/29/25 at 6:00 pm, LVN D stated she did not know CNA A was transferring Resident #1 with a mechanical lift by herself and she had not asked her for any assistance. LVN D stated she did not know where CNA B was at the time of the incident. In an interview on 11/29/25 at 6:07 p.m., CNA B stated she was trained on mechanical lift transfers by the facility. She stated she was orientating CNA A since 6:00 a.m. that morning. CNA B stated she was in the bathroom at the time of the incident, and she told CNA A she was going to the bathroom and then they would put Resident #1 down together. CNA B stated her, and CNA A had done mechanical lift transfers together during the shift and CNA A knew she was supposed to wait and use two people to transfer with a mechanical lift. CNA B stated she was not sure why CNA A transferred Resident #1 without a second person other than they were busy because one staff came in late and a second staff did not take good care of the residents, so she assisted those residents as well as her assigned residents. In an interview on 11/29/25 at 7:00 p.m., HR stated CNA A had not yet been trained on mechanical lift transfers by the facility. HR stated today was CNA A's first day working on the floor and staff had 14 days before all training had to be completed. She stated CNA A was orientating today, and her and CNA B knew they were to work together. In an interview on 11/29/25 at 7:56 p.m., Resident #4 stated he was a mechanical lift transfer, and they always used two, sometimes three, people to operate and transfer him with the mechanical lift. He stated he felt safe and had not been hurt during a mechanical transfer. In an interview on 11/30/25 at 11:13 a.m., Resident #6 stated staff use a mechanical lift to get her up and put her back down in bed. She stated the staff used two or three people for mechanical transfer her and she had not been hurt. In an interview on 11/30/25 at 1:29 p.m., CNA E stated she had been trained on mechanical lift transfers upon hire by the facility. She stated to always use at least two people but to also follow the care plan and to use as many people as needed to make the residents comfortable. In an interview on 11/30/25 at 8:42 p.m., the mechanical lift manufacturer's recommendations were requested from the ADM. This was not provided by exit from the facility. In an interview on 12/01/25 at 1:30 p.m., the DON stated all staff knew to use two people and follow the care plan on mechanical lift transfers. Staff were trained upon hire and were in-serviced regularly. The DON stated CNA A was removed from the floor and suspended and not sure if she was going to be able to return as she had 20 years' experience. The DON stated there was no resident harm and this type of incident was not tolerated because it could cause injury to the resident if the mechanical lift tipped or something went wrong. The DON stated CNA A should have asked a nurse for help or waited on the other aide for help. In an interview on 12/01/25 at 2:05 p.m., the ADM stated staff were trained on mechanical lift transfers when hired and that was why they were orientated. The ADM stated she did not feel there was any reason to ever transfer a resident with a mechanical lift with one person, and it was not what was allowed at the facility. She stated CNA A should have waited for CNA B or went and asked a nurse for assistance before completing the transfer. The ADM did not state why this is important. Record review of Nursing Direct Care message from the ADM, dated 11/29/25 at 3:19 p.m., reflected Whenever you are transferring a resident, always follow their individualized plan of care. For example, if the care plan requires a two-person assist, ensure that two staff members are present. If a mechanical lift is indicated, use the mechanical lift with two staff members as directed. Adhering to these guidelines ensures the safety of both the residents and the staff. Do not attempt to transfer a resident alone if the care plan specifies the use of a mechanical lift. Mechanical lift must always be used with two trained staff members.Record review of the facility's, undated, Comprehensive Care Planning policy, reflected The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. 'Professional standards of Quality' means that care and services are provided according to accepted standards of clinical practice. Record review of the facility's, undated, Hydraulic Lift policy reflected the number of staff to provide assistance with the transfer should be determined by the manufacturer's recommendations. Record review of OSHA Nursing Home Guidelines reflected in Figure 1 Transfer to and from bed to chair, chair to toilet, chair to chair, or car to chair: If patient is uncooperative or if patient does not have upper extremity strength to use full body sling lift and 2 caregivers. Record review of the FDA Patient Lifts Safety Guide recommended most lifts require two or more caregivers to safely operate lifts and handle a patient.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide appropriate supervision for Resident #1 resulting in Resident #1 leaving the facility without the facility's knowledge on 08/28/2025 between 1:20 and 1:40 AM and being found face down on the ground in the facility parking lot. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/28/25 and ended on 08/29/25. The facility had corrected the noncompliance before the investigation began.This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included:Record review of Resident #1's admission Record, dated 10/08/25, reflected Resident #1 was an [AGE] year-old female admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities) and repeated falls. Record review of Resident #1's quarterly MDS assessment, dated 06/06/2025, reflected Resident #1 had a BIMS of 7 out of 15 indicating moderately impaired cognition. RR of Resident #1's quarterly Elopement Risk Assessment, dated 08/25/2025, reflected resident had statement and/or threats to leave facility, frequent request to go home, confused expressions related to tasks to complete, and verbalizes anger and frustration re: placement. Resident #1 scored 13, identifying her as an elopement risk. RR of Resident #1's care plan, undated, reflected Resident #1 was At risk for elopement and Actual elopement or elopement attempt Resident was confused and wandered outside the facility unattended, initiated on 08/28/2025. There were no interventions prior to this date. Record Review of the Provider Investigation Report for this incident, dated 08/28/25 and authored by the ADM, reflected the investigation summary On 08/28/2025 at 1:40am, the resident was found to be laying on the ground, outside the dining room door. The staff heard the door alarm and immediately started searching. Once the resident was located the staff, immediately assisted her and notified EMS due to her nose bleeding and having skin tears on her forehead and cheek. [Resident #1] was transferred to the local ED and returned a few hours later with no injuries noted. When [Resident #1] returned, she was placed on one on one monitoring and skin assessment was completed. Upon investigation, it was noted that the CNAs last saw her at 1:20am in the hallway with coffee in her hand while they were completing a round. Elopement protocol was immediately initiated and completed. On 8/29/2025, the resident was transferred to another facility with a secure unit. Observation on 10/08/2025 at 3:07 PM revealed the distance from the dining room exit door to the alleged spot where Resident #1 fell was 0.01 miles. Interview on 10/08/2025 at 2:40 PM, LVN A revealed she heard the alarm for the exit door in the dining room alarming. She revealed she went to the dining room door that was sounding and saw something that looked like possible bicycle wheels outside and went to get assistance. She further revealed when she came back with help, they saw a wheelchair and it appeared a resident had fallen. Interview on 10/09/2025 at 9:45 AM, Med Aide B revealed she was doing her rounds around 1:20 AM and had to escort Resident #1 back to her room. She revealed at 1:40 AM, she was told Resident #1 was on the ground, outside of the facility. She revealed she could not really hear the alarm. She further revealed Resident #1 was not exit-seeking prior to this event. Interview on 10/09/2025 at 10 AM, LVN AA revealed Resident #1 would wander and would be confused/looking for her family member at night but would stay around the nurse's station. She revealed she had never seen Resident #1 exit seek. Interview on 10/09/25 at 03:56 PM, the ADM and the DON revealed Resident #1 scored high on her elopement risk assessment because she was agitated from her family member's recent visit. They revealed if the admission elopement risk was high, they would wait a couple of days until the resident got acclimated so they could understand resident's true behaviors. They let staff know if there was a resident who was at high risk for elopement via care plans and word of mouth.Interview on 10/10/25 at 02:11 PM, Resident #1's doctor revealed this facility took precautions to prevent elopements like letting people in at the entrance, and there were not any residents he was concerned would exit seek. He revealed it was important to stop people from eloping to prevent injuries. He revealed he did not think Resident #1 was an elopement risk because she did not try to exit the facility. The facility's policy, undated, reflected 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team.3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes.4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. The Administrator was notified on 10/10/25 at 11:27 AM, that a past non-compliance Immediate Jeopardy situation had been identified due to the above failure. The facility implemented the following interventions. Record Review of Monitoring Chart, dated 08/28/25 and 08/29/25, reflected Resident #1 was put on 1:1 monitoring every 15 minutes until her discharge to a facility with a secure unit on 08/29/2025. The facility completed an audit on all residents to determine other elopement risks on 08/28/2025. RR of Elopement Prevention QA checklist, dated 08/28/2025, reflected Alarm sounded but was not loud enough and added another alarm and lighting. Routine door lock/alarm monitoring was started on 08/28/2025. RR of in-service training report, dated 08/28/25, reflected that all staff were in-serviced 08/28/2025 on the elopement procedure and policy, additional alarm for the dining room door, and abuse/neglect. Interviews with staff on all shifts confirmed knowledge. RR of Elopement Drill or Actual Elopement Guide revealed elopement drills were conducted for staff on all shifts on 08/28/2025 for 2P-10P shift, 08/29/2025 for 10P-6A shift, 09/02/2025 for 6A-2P shift, 09/04/2025 for 6A-2P, 09/11/2025 for 2P-10P shift, 09/16/2025 for 10P-6A shift. Interviews with staff on all shifts confirmed these were done. Observation on 10/08/2025 at 03:07 PM revealed the exit door to the alleged spot that the Resident was found was 0.01 miles (52 ft, when taking the ramp) Observation on 10/08/2025 at 03:08 PM the alarm in the dining room was set off and nursing staff from 100/200 and 300/400 nurse's station went straight to this door. (approximately 10 staff members). Interview on 10/09/2025 at 10 AM, LVN AA (worked overnight) revealed she had been trained on elopement prevention and learned to monitor residents especially confused and exit seeking. She revealed the facility put a new, louder alarm for the emergency exit that Resident #1 exited. She revealed the ADM has performed an elopement drill on her shift. Interview on 10/09/2025 at 10:42 AM, LVN Z (worked PRN for all shifts) revealed she was trained on elopement prevention to include keeping eyes on all residents and monitoring their behaviors. She revealed if the alarm sounded, she would go outside immediately and check rooms on the way to the door. She revealed they did head counts after elopements. She revealed she had been through an elopement drill. Interview on 10/09/25 at 02:50 PM, RN C (worked 6AM-2PM) revealed she was trained on elopement response and knew how each door alarm sounded. She revealed they responded to exit alarm, investigated the situation, and performed a head count of all residents. She revealed the maintenance director tested every door frequently. She revealed when the alarm goes off, they responded right away.Interview on 10/09/25 at 03:47 PM, ADON AC (worked PRN for all shifts) revealed she was trained on the elopement policy. She revealed residents at risk for elopement would have interventions in their care plans, like having someone sitting with residents, finding placement in a secured unit if needed. She revealed she was trained on elopement response to include following the door alarm sound and doing head counts after elopements. Interview on 10/09/25 at 06:15 PM, CNA D, NA E, LVN A revealed they were trained on elopement prevention/response and knowing how each exit door sounded in order to respond more quickly. They revealed there were no current residents that are exit seeking. They revealed if there were residents that started to wander around the facility, they'd tell all staff and monitor these residents.Interview on 10/09/2025 at 06:35 PM, ADON F (PRN, worked all shifts) revealed she was trained on elopement prevention and response. She revealed if there were exit doors that alarmed, she would respond immediately.Interview on 10/10/25 at 05:48 AM, RN G (PRN, worked all shifts) revealed he was trained on elopement procedures and to respond to door alarms right away. He revealed there were no current residents that were at risk for elopement or needed extra monitoring.Interview on 10/10/25 at 05:52 A, LVN H (worked overnight) and CNA I (worked overnight) revealed they were trained on elopements, how door alarms sound, and to respond to the door alarms immediately. They revealed they would report to the ADM right away and do head counts. They revealed nurses would assess resident. They further revealed there was no current resident who was at risk for elopement. Interview on 10/10/25 at 09:40 AM, SW (8A-5P) and PT J (worked day, night, and weekends) revealed they had been doing elopement drills. They revealed the code for elopements got called, everyone dispersed to look everywhere, and when residents were found they did head counts. They further revealed they always kept eyes on exit doors to ensure residents would not exit. They revealed to prevent elopements; they monitored residents if they were elopement/wandering risks. Interview on 10/10/25 at 09:45 AM, CNA K (worked 6AM-2PM) revealed she was trained on elopement response and prevention. She revealed if there was a resident that started wandering and elopement, they would alert all staff and monitor resident. She revealed if there were door alarms going off, they go straight to the door and split up tasks per the elopement response policy. She revealed they did head counts. She revealed they contacted ADM/DON/ADONs for elopements. Interview on 10/10/25 at 09:52 AM, CNA L (worked 6AM-2PM) and CNA M (worked 6AM-2PM) revealed there was a code orange for elopements. They revealed they were trained on responding to door alarms, searching for residents, and doing head counts of residents on all wings. They revealed they would report elopements to the ADM immediately. Interview on 10/10/25 at 09:55AM, NA N (worked 6AM-2PM), COTA O (worked days), and COTA P (worked days) revealed they have been having frequent elopement drills recently and knew what other door alarms sounded. They revealed if the alarm went off, they went to check to see if a resident went out and did head counts of all residents. They revealed they notified the ADM and charge nurse about elopements. Interview on 10/10/25 at 10:03 AM, OT Q (worked 8AM-4PM), PTA S (worked 8AM-4PM), HSK R (worked 6:30AM-2PM), Med Aide T (worked 6AM-2PM), and Rehab Director-COTA (worked 8AM-5PM) revealed they were trained on what to do for elopements, which were classified as a code orange. They revealed if there was an alarm, everyone goes to the alarm, they split up tasks, and given assignments to look for head counts/do rounds/go outside. They revealed they had multiple meetings during the day to discuss residents that needed to be monitored to prevent elopement. They revealed they would contact the ADM immediately. Interview on 10/10/25 at 10:09AM, RN U (worked 6AM-2PM) and CNA V (worked 6AM-2PM) revealed a code orange was for elopements. They revealed when a door alarm sounded, they followed the sound. They revealed they have done drills to include searching for a resident outside and doing head counts for all residents. They revealed they would notify the ADM immediately.Interview on 10/10/25 at 10:17 AM, Dietary Staff W, Dietary Staff X, [NAME] Y, HSK AB and HSK Supervisor revealed when there was an alarm they checked the door immediately. They revealed if a resident was outside then they reported it to the nurse right away. They knew to monitor residents if they exhibited behaviors of wandering or exit seeking, but there were no current residents that had these behaviors. They further revealed they would report elopements to the ADM immediately. The noncompliance was identified as PNC. The Immediate Jeopardy began on 08/28/25 and ended on 08/29/25. The facility had corrected the noncompliance before the investigation began.

Based on interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 6 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's wound treatment was accurately documented from 10/01/25 to 10/06/25. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included:Record review of Resident #2's admission record, dated 10/10/25, revealed resident was an [AGE] year-old male resident admitted [DATE] with diagnoses to include protein-calorie malnutrition. Record review of Resident #2's admission MDS assessment, dated 09/11/25, revealed Resident #2's had a BIMS score of 06 out of 15, indicating severe cognitive impairment. Record review of Resident #2's care plan reflected a focus The resident has a potential for pressure ulcer development., initiated 09/10/25, with interventions . [Resident #2] with hx of wound care refusal, initiated 10/07/25. Record review of Resident #2's October 2025 Wound Administration Record reflected WOUND CARE: unstageable PI to right buttock. one time a day for WOUND HEALING for Lib A (liberal in the AM shift meaning wound treatment could be done any time during the morning shift) did not have anything documented for 10/01/25 to 10/06/25. Interview on 10/09/2025 at 11:59 AM, LVN AD revealed in the last 2 weeks, Resident #2 had a history of refusing wound care and had to get Resident #2's family member to help Resident #2 agree to wound treatment. Interview on 10/09/25 at 02:50 PM, RN C revealed she did wound treatment for Resident #2 from 09/30/25 to 10/03/25 and 10/06/25. She revealed Resident #2 had a history of refusing wound care. She revealed she tried 2 or 3 times for wound treatment, but he continued to refuse wound treatment. She revealed they had to educate family member and Resident #2 every day about importance of wound treatment. Interview on 10/10/25 at 04:37 PM, the ADM and DON revealed Resident #2 refusing wound treatment should be documented in his administration record. They revealed this was important, so his records were accurate.Record review of the facility's policy Wound Treatment Management, dated 2021, reflected 7. Treatments will be documented on the Treatment Administration Record.Record review of facility's policy Documentation, undated, reflected 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #2 and #3) reviewed for care plans: The facility failed to ensure Residents #2's Care Plan reflected he refused wound treatment prior to 10/01/25. The facility failed to ensure Residents #3's Care Plan reflected her behaviors of making allegations/accusations about resident care.The findings included: Record review of Resident #2's admission record, dated 10/10/25, revealed resident was an [AGE] year-old male resident admitted [DATE] with diagnoses to include protein-calorie malnutrition. Record review of Resident #2's admission MDS assessment, dated 09/11/25, revealed Resident #2's had a BIMS score of 06 out of 15, indicating severe cognitive impairment. Record review of Resident #2's care plan, undated, reflected a focus The resident has a potential for pressure ulcer development., initiated 09/10/25, with interventions . [Resident #2] with hx of wound care refusal, initiated 10/07/25. Record review of Resident #2's October 2025 Wound Administration Record reflected WOUND CARE: unstageable PI to right buttock. one time a day for WOUND HEALING for Lib A (liberal in the AM shift, meaning wound treatment could be done any time in the morning) did not have anything documented for 10/01/25 to 10/06/25. Record review of Resident #3's admission record, dated 10/10/25, revealed resident was a [AGE] year-old female resident admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #3's annual MDS assessment, dated 09/06/25, revealed Resident #3's had a BIMS score of 08 out of 15, indicating moderate cognitive impairment. Record review of Resident #3's care plan, undated, reflected no mention of resident having behaviors of making false accusations/allegations. Interview on 10/09/2025 at 10 AM, LVN AA revealed Resident #3 had behaviors and can be really dramatic at times. She revealed Resident #3 got mad easily and would get mad at certain CNAs (not let certain staff care for her). She revealed they accommodated for Resident #3's preferences like ensured staff she liked helped her.Interview on 10/09/2025 at 11:59 AM, LVN AD revealed in the last 2 weeks, Resident #2 had a history of refusing wound care and had to get Resident #2's family member to help Resident #2 agree to wound treatment. LVN AD revealed Resident #3 had a history of making accusations against staff Interview on 10/09/25 at 02:50 PM, RN C revealed she did wound treatment for Resident #2 from 09/30/25 to 10/03/25 and 10/06/25. She revealed Resident #2 had a history of refusing wound care. She revealed she tried 2 or 3 times for wound treatment, but he continued to refuse wound treatment. She revealed they had to educate Resident #2 and Resident #2's family member every day about importance of wound treatment. Interview on 10/10/25 at 01:03 PM, SW revealed Resident #3 had a history of making unsubstantiated allegations against staff. (specific examples not given) Interview on 10/10/25 at 01:27 PM, Resident #3's RP revealed Resident #3 could be manipulative when she got mad and did not get her way. She revealed Resident #3 had a history of making up stories about her care in order to make it seem like Resident #3 had to come home instead of staying at the facility. Interview on 10/10/25 at 04:37 PM, the ADM and DON revealed they should have documented Resident #2 refused wound treatments in his care plan because care plans were person centered and reflected what care resident received. They further revealed for Resident #3 they did not document in her care plan that she made accusations and allegations of her care. (The ADM revealed these accusations and allegations were not reportable events.) They revealed Resident #3 had a history of making allegations about staff, and they had been working on helping this resident with these behaviors through psychiatric and psychological services. Interview on 10/13/25 at 03:54 PM, [Mental Health Organization] counselor revealed Resident #3 did not like being in the facility because she wanted to go home. She revealed Resident #3 had a history of making up accusations about care. She revealed if Resident #3 got into a bad mood, anything bothered her. She revealed the facility and she had been working on these behaviors with her. Record review of the facility's policy, titled Comprehensive Care Planning, undated, reflected The comprehensive care plan will describe the following- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and the right to refuse treatment

Based on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed quality of care. On 4/20/2025, early morning, LVN A failed to provide quality care for Resident #1, by not following facility protocol for an unwitnessed fall with injuries to begin neurological assessments, reporting to the physician and the residents representative, when Resident #1 was discovered on the floor by her bedside and hospitalized for chronic heart failure with fluid overload in addition to fractures to right ribs 3rd, 7th and 9th ribs, 3 hours later. On 4/20/2025, CNAs Y and Z discovered Resident #1 on the floor and repositioned her back into bed without having the nurse assess prior to the repositioning. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. Facility had implemented interventions on 04/25/2025 prior to surveyor entrance on 04/25/2025. This failure could place residents at risk for harm . The findings include: A record review of Resident #1's admission record, dated 4/25/2025, revealed an admitted [DATE] with diagnoses which included end stage renal disease (kidney failure) and hypertension (high blood pressure). A record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term care after a hospitalization related to a fall. Further review revealed Resident #1 was assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #1 was assessed with minimal difficulty hearing, with clear speech, could usually make herself understood and could usually understand others. Resident #1 was assessed with adequate vision and did not glasses. Resident was assessed without a mood disturbance, hallucinations, and or a change in mental status. Resident #1 was assessed with the Important preference of having family or a close friend involved in discussions about your care. Resident #1 was assessed as being independent with Activities of Daily Life, used a manual wheelchair, and had weakness in both arms. Resident #1 was assessed with occasional urinary incontinence and frequent bowel incontinence. Resident #1 was assessed as medically complex. A record review of Resident #1's care plan dated 3/25/2024 revealed, The resident has bowel incontinence . Check resident every two hours and assist with toileting as needed A record review of Resident #1's hospital record dated 3/19/2025 revealed, Resident #1 was diagnosed with pancreatic cancer which has spread to other parts of her body and had a fall on 3/10/2025 at her home and was hospitalized . The hospital documented Resident #1's family reported general weakness and Resident #1 has lost the ability to self-transfer from her bed to her wheelchair. A record review of Resident #1's nursing progress notes, on 4/19/2025 prior to 4/20/2025, revealed Resident #1 had increased episodes of altered mental status to which the physician and family were notified, Nursing Progress Note . 4/19/2025 07:00:00 (7:00 AM) . Nursing . Registered Nurse (B) . Note Text:; Pt had increased confusion, asked multiple times ' Are you going to kill me?' stating after that 'I cannot hear' .Nursing Progress Note . 4/19/2025 18:38:00 (6:38 PM) . Registered Nurse B . Dr . (physician's name) was notified of the pt's increase confusion. A record review of Resident #1's nurse progress note dated 4/20/2025 at 4:22 AM revealed LVN A documented, . Location of event: Resident Room Level of pain from 0-10 . pain:0 . Injury: Yes . Describe any injuries: Abrasion to bilat knees, 0 bleeding noted. CNAs reported that during rounds they found resident kneeling on her knees next to bedside on fall mat. CNA also reported resident was assisted back into bed by CNAs. This nurse entered resident's room and observed resident in bed. Resident noted to have abrasions to bilateral knees: without bleeding. Areas cleansed with wound cleanser and (name brand small bandage) applied to each knee. Initial Treatment/New Orders: Areas cleansed with wound cleanser and (name brand small bandage) applied knee. Resident Statement: When asked why resident was kneeling on floor resident stated, I don't know. Name of MD/NP notified: (NP) N.P. Date/time of notification: 04/21/2025 2:02 AM. Name of RP notified: (Resident #1's Representative) Date/time of notification: 04/20/2025 4:22 AM. Interventions: Bed in low position, fall mat in place. Call light in reach. A record review of Resident #1's nurse progress note dated 4/20/2025 at 7:23 AM revealed RN B documented Resident #1 was assessed with a change in status and sent to the hospital by EMS 911, (Resident #1) was transferred to a Hospital on 04/20/2025 7:30 AM related to Pt sic(patient) had decreased LOC sic(level of conscience), disoriented, moving in bed constantly erratically. Pt had bruises on left knee, left wrist and palm. A record review of Resident #1's hospital admission records dated 4/20/2025 revealed she was admitted after a fall at the nursing home and was diagnosed with liver cancer, confusion, and rib fractures, history of present illness chief complaint: patient is a [AGE] year-old female with past medical history significant for end stage renal disease on hemodialysis Mondays, Wednesdays, and Fridays, hypertension, recently diagnosed metastatic gastrointestinal cancer (cancer of the digestive system which has spread to other parts of the body). Presents to our emergency department from nursing home after she had fallen. Per (Resident representative) patient had fallen from bed height at nursing home and became altered. Apparently her usual state until her fall today sic(4/20/2025). The patient had significant change in her mental status. In the emergency department she was found to have bilateral pleural effusion sic(fluid in the lungs), moderate pericardial effusion sic(fluid around the heart), right rib fracture 3-7, 9 and CT sic(computed tomography scan) findings of metastasis sic(spread of cancer) to liver. patient currently altered and unable to cooperate with exam. She has a 3cm by 3-centimeter contusion sic(bruise) over the medial aspect of the knee. During an observation and interview on 4/26/2025 at 10:32 AM revealed Resident #1 presented at the hospital asleep in her bed. Resident #1's representative was at the bedside and stated she was not given a report about Resident #1's fall at 4:00 AM on 4/20/2025 until she arrived at the nursing home to visit Resident #1 around 7:00 AM. Resident #1's representative stated she arrived and discovered Resident #1 was confused and had injuries to her knees, Resident #1's representative stated, I reported the injuries to the CNA and the nurse. Resident #1's representative stated after Resident #1's Representative alerted RN B then RN B assessed Resident #1 and called 911 , EMS arrived and took Resident #1 to the hospital where she was discovered with broken ribs and bruises. Resident #1's representative stated she was upset and concerned she was not alerted to the fall and confusion and felt Resident #1 was delayed in receiving care and stated, I don't know if the doctor was called. During an interview on 4/26/2025 at 12:30 PM, RN B stated Resident #1 begun to be confused and hallucinating on 4/19/2025 and reported the change to the physician and the physician had not given any new orders. RN B stated at 10:00 PM, she ended her shift and gave a report to LVN A. RN B stated she returned to work the following morning, 4/20/2025 at 7:20 AM, and received a report from LVN A that Resident #1 had fallen around 4 AM. RN B stated she assessed Resident #1 with Resident #1's representative at the bedside and discovered Resident #1 was confused with bruises and bandages to her knees and called EMS 911 . During an interview on 4/26/25 at 4:15 PM, LVN A stated she was alerted by CNAs Resident #1 was discovered on the floor by her bedside and the CNAs picked her up and placed her back in bed . LVN A stated she assessed Resident #1 in her bed, discovered her knees were red and abraded without bleeding, performed first aid, and applied a small self-adhesive bandages to her knees. LVN A stated Resident #1 could not say how she came to be on her knees next to the bed and no one witnessed the way she became to be on her knees. LVN A stated she had not considered Resident #1's incident a fall and Resident #1 had not complained of pain and was calm and sleepy at 4:00 AM. LVN A stated she documented she reported the incident to Resident #1's physician and her representative but had not reported the incident to the physician nor Resident #1's representative. LVN A stated she documented she reported to the NP and the representative because she had intended to call the NP during business hours. LVN A stated, I called Resident #1's representative and no one answered so I left a message . During an interview on 4/26/2025 at 5:40 PM the Medical Director stated his expectation for unwitnessed falls with injuries was for nursing staff to call and report the finding to a physician and or their Nurse Practitioner within a reasonable time for example an hour after the assessment. The MD stated the risk to residents could have been delayed care. During a joint interview on 4/26/2025 at 5:50 PM, the Administrator and the DON stated they had not recognized LVN A had not followed facility protocols, such as reporting the incident to the physician and to Resident #1's Representative, for Resident #1's unwitnessed fall on 4/20/2025 until early 4/25/2025 and began an investigation and self-reported the incident to the state survey agency. The Administrator and the DON stated they suspended LVN A pending the investigation, assessed all the residents for injuries, developed and implemented in-services for all staff which included fall protocols and reporting to the physician and residents' families. The DON and the Administrator stated their expectations for LVN A was for her to have followed the risk management fall protocol which included a report to the physician and a report to the family. Interviews from 4/26/2025 to 4/27/2025 with 44 of the 69 nursing staff which included all shifts revealed all interviewed were able to confirm they received the in-service which covered unwitnessed falls, assessing residents post falls, documenting the assessments, notifying the physician, and family. A record review of the facility's Risk Management Reporting; Completion Of policy, dated 4/25/2025, revealed The facility will complete an Event report in Risk Management for variances that occur within the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures . All break in planes are considered a fall. All Events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident. Documentation of the notification and subsequent interventions and comments must be recorded in the resident's clinical record and/or on the Event Note. Any physician order should be followed. All unwitnessed falls or head injuries require neuros per facility policy. A record review of the facility's Notifying the Physician of Change in Status policy, dated 3/11/2013, revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 5. The resident's family member or legal guardian should be notified of significant change in resident's status . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions PNC verification The facility identified the deficient practice, took actions to identify residents at risk for the deficiency, and developed and implemented, saftey survey assesments (Quality of Life Rounds) for 88 of 88 residents, in-services for fall protocols and the ANE prevention protocols to the entire staff which included nursing staff. Record review of the facility's nursing roster revealed 113 employees which included 69 nurses and CNAs. A record review of the facility ' s department of social services Quality Life Rounds dated 4/25/2025 revealed 88 of the facility ' s census of 88 residents were assessed for safety with no one evidenced for injuries. Record review of the facility's in-services titled fall protocol and ANE prevention, dated 4/25/2025, revealed 113 staff received the in-service, and the training which included, Falls: all falls require risk management assessments to include reporting to the physician, resident family representative, and immediate supervisor, and SBAR (Situation, Background, Assessment and Recommendation). All unwitnessed falls require neuro checks During an interview on 4/26/2025 at 9:00 PM LVN C stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN C stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:04 PM RN B stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. RN B stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:10 PM LVN D stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN D stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:14 PM LVN E stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN E stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:18 PM RN F stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. RN F stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:20 PM LVN G stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. LVN G stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:22 PM LVN H stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN H stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:24 PM LVN I stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN I stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:29 PM CNA J stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA J stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM CNA K stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA K stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:01 PM CNA L stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA L stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:03 PM CNA M stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA M stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 1:48 PM CNA N stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA N stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 2:38 PM CNA O stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA O stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM RN P stated she worked the 6:00 AM to 10:00 PM shifts on the weekends and on 4/25/2025 she received in-services which included ANE prevention and Fall Protocols, such as assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 2:38 PM CNA Q stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA Q stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:11 PM CNA R stated she worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA R stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:14 PM RN S stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. RN S stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there was a an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention, and or a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for notification to the physician. LVN A failed to report to the physician and Resident #1's representative a change of condition when Resident #1 was discovered injured and confused on the floor by her bedside on 04/20/2025 and was hospitalized and diagnosed with acute congested heart failure fluid overload, in addition to right rib fractures to the 3rd, 7th and 9th ribs, 3 hours later. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. Facility had implemented intervention on 04/25/2025 prior to surveyor entrance on 04/25/2025. This failure could place residents at risk for harm. The findings include: A record review of Resident #1's admission record, dated 4/25/2025, revealed an admitted [DATE]. Resident #1 had diagnoses which included end stage renal disease (kidney failure) and hypertension (high blood pressure). A record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old female who was admitted to the facility for long term care after a hospitalization related to a fall. Resident #1 was assessed with a BIMS score of 13 out of a possible 15, which indicated intact cognition. Resident #1 was assessed with minimal difficulty hearing, with clear speech, could usually make herself understood and could usually understand others. Resident #1 was assessed with adequate vision and did not wear glasses. The resident was assessed without a mood disturbance, hallucinations, and or a change in mental status. Resident #1 was assessed with the Important preference of having family or a close friend involved in discussions about your care. Resident #1 was assessed as being independent with Activities of Daily Life, used a manual wheelchair, and had weakness in both arms. Resident #1 was assessed with occasional urinary incontinence and frequent bowel incontinence. Resident #1 was assessed as medically complex. A record review of Resident #1's care plan, dated 3/25/2024, revealed, The resident has bowel incontinence . Check resident every two hours and assist with toileting as needed A record review of Resident #1's hospital record, dated 3/19/2025 , revealed Resident #1 was diagnosed with pancreatic cancer which has spread to other parts of her body and had a fall on 3/10/2025 at her home and was hospitalized . The hospital documented Resident #1's family reported general weakness and Resident #1 had lost the ability to self-transfer from her bed to her wheelchair. A record review of Resident #1's nursing progress notes, on 4/19/2025 prior to 4/20/2025, revealed Resident #1 had increased episodes of altered mental status to which the physician and family were notified, Nursing Progress Note . 4/19/2025 07:00:00 (7:00 AM) . Nursing . Registered Nurse (B) . Note Text: Pt had increased confusion, asked multiple times ' Are you going to kill me?' stating after that 'I cannot hear' .Nursing Progress Note . 4/19/2025 18:38:00 (6:38 PM) . Registered Nurse B . Dr . (physician's name) was notified of the pt's increase confusion. A record review of Resident #1's nurse progress note, dated 4/20/2025 at 4:22 AM, revealed LVN A documented, . Location of event: Resident Room Level of pain from 0-10 . pain:0 . Injury: Yes . Describe any injuries: Abrasion to bilat knees, 0 bleeding noted. CNAs reported that during rounds they found resident kneeling on her knees next to bedside on fall mat. CNA also reported resident was assisted back into bed by CNAs. This nurse entered resident's room and observed resident in bed. Resident noted to have abrasions to bilateral knees: without bleeding. Areas cleansed with wound cleanser and (name brand small bandage) applied to each knee. Initial Treatment/New Orders: Areas cleansed with wound cleanser and (name brand small bandage) applied knee. Resident Statement: When asked why resident was kneeling on floor resident stated, 'I don't know.' Name of MD/NP notified: (NP) N.P. Date/time of notification: 04/21/2025 at 2:02 AM. Name of RP notified: (Resident #1's Representative) Date/time of notification: 04/20/2025 4:22 AM. Interventions: bed in low position, fall mat in place. Call light in reach . A record review of Resident #1's nurse progress note, dated 4/20/2025 at 7:23 AM, revealed RN B documented Resident #1 was assessed with a change in status and sent to the hospital by EMS 911, (Resident #1) was transferred to a Hospital on 04/20/2025 at 7:30 AM related to Pt sic(patient) had decreased LOC sic(level of conscience), disoriented, moving in bed constantly erratically. Pt had bruises on left knee, left wrist and palm. A record review of Resident #1's hospital admission records, dated 4/20/2025, revealed she was admitted after a fall at the nursing home and was diagnosed with liver cancer, confusion, and rib fractures, history of present illness chief complaint: patient is a [AGE] year-old female with past medical history significant for end stage renal disease on hemodialysis Mondays, Wednesdays, and Fridays, hypertension, recently diagnosed metastatic gastrointestinal cancer (cancer of the digestive system which has spread to other parts of the body). Presents to our emergency department from nursing home after she had fallen. Per (Resident representative) patient had fallen from bed height at nursing home and became altered. Apparently her usual state until her fall today sic(4/20/2025). The patient had significant change in her mental status. In the emergency department she was found to have bilateral pleural effusion [sic ](fluid in the lungs), moderate pericardial effusion sic (fluid around the heart), right rib fracture 3-7, 9 and CT sic(computed tomography scan) findings of metastasis sic(spread of cancer) to liver. patient currently altered and unable to cooperate with exam. She has a 3cm by 3-centimeter contusion sic(bruise) over the medial aspect of the knee. During an observation and interview on 4/26/2025 at 10:32 AM revealed Resident #1 presented at the hospital asleep in her bed. Resident #1's representative was at the bedside and stated she was not given a report about Resident #1's fall at 4:00 AM on 4/20/2025 until she arrived at the nursing home to visit Resident #1 around 7:00 AM. Resident #1's representative stated she arrived and discovered Resident #1 was confused and had injuries to her knees, Resident #1's representative stated, I reported the injuries to the CNA and the nurse. Resident #1's representative stated after Resident #1's Representative alerted RN B then RN B assessed Resident #1 and called 911 , EMS arrived and took Resident #1 to the hospital where she was discovered with broken ribs and bruises. Resident #1's representative stated she was upset and concerned she was not alerted to the fall and confusion and felt Resident #1 was delayed in receiving care and stated, I don't know if the doctor was called. During an interview on 4/26/2025 at 12:30 PM, RN B stated Resident #1 begun to be confused and hallucinating on 4/19/2025 and reported the change to the physician and the physician had not given any new orders. RN B stated at 10:00 PM, she ended her shift and gave a report to LVN A. RN B stated she returned to work the following morning, 4/20/2025 at 7:20 AM, and received a report from LVN A that Resident #1 had fallen around 4 AM. RN B stated she assessed Resident #1 with Resident #1's representative at the bedside and discovered Resident #1 was confused with bruises and bandages to her knees and called EMS 911 . During an interview on 4/26/25 at 4:15 PM, LVN A stated she was alerted by CNAs Resident #1 was discovered on the floor by her bedside and the CNAs picked her up and placed her back in bed . LVN A stated she assessed Resident #1 in her bed, discovered her knees were red and abraded without bleeding, performed first aid, and applied a small self-adhesive bandages to her knees. LVN A stated Resident #1 could not say how she came to be on her knees next to the bed and no one witnessed the way she became to be on her knees. LVN A stated she had not considered Resident #1's incident a fall and Resident #1 had not complained of pain and was calm and sleepy at 4:00 AM. LVN A stated she documented she reported the incident to Resident #1's physician and her representative but had not reported the incident to the physician nor Resident #1's representative. LVN A stated she documented she reported to the NP and the representative because she had intended to call the NP during business hours. LVN A stated, I called Resident #1's representative and no one answered so I left a message . During an interview on 4/26/2025 at 5:40 PM the Medical Director stated his expectation for unwitnessed falls with injuries was for nursing staff to call and report the finding to a physician and or their Nurse Practitioner within a reasonable time for example an hour after the assessment. The MD stated the risk to residents could have been delayed care. During a joint interview on 4/26/2025 at 5:50 PM, the Administrator and the DON stated they had not recognized LVN A had not followed facility protocols, such as reporting the incident to the physician and to Resident #1's Representative, for Resident #1's unwitnessed fall on 4/20/2025 until early 4/25/2025 and began an investigation and self-reported the incident to the state survey agency. The Administrator and the DON stated they suspended LVN A pending the investigation, assessed all the residents for injuries, developed and implemented in-services for all staff which included fall protocols and reporting to the physician and residents' families. The DON and the Administrator stated their expectations for LVN A was for her to have followed the risk management fall protocol which included a report to the physician and a report to the family. Interviews from 4/26/2025 to 4/27/2025 with 44 of the 69 nursing staff which included all shifts revealed all interviewed were able to confirm they received the in-service which covered unwitnessed falls, assessing residents post falls, documenting the assessments, notifying the physician, and family. A record review of the facility's Risk Management Reporting; Completion Of policy, dated 4/25/2025, revealed The facility will complete an Event report in Risk Management for variances that occur within the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures . All break in planes are considered a fall. All Events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident. Documentation of the notification and subsequent interventions and comments must be recorded in the resident's clinical record and/or on the Event Note. Any physician order should be followed. All unwitnessed falls or head injuries require neuros per facility policy. A record review of the facility's Notifying the Physician of Change in Status policy, dated 3/11/2013, revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 5. The resident's family member or legal guardian should be notified of significant change in resident's status . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions PNC verification The facility identified the deficient practice, took actions to identify residents at risk for the deficiency, and developed and implemented, saftey survey assesments (Quality of Life Rounds) for 88 of 88 residents, in-services for fall protocols and the ANE prevention protocols to the entire staff which included nursing staff. Record review of the facility's nursing roster revealed 113 employees which included 69 nurses and CNAs. A record review of the facility ' s department of social services Quality Life Rounds dated 4/25/2025 revealed 88 of the facility ' s census of 88 residents were assessed for safety with no one evidenced for injuries. Record review of the facility's in-services titled fall protocol and ANE prevention, dated 4/25/2025, revealed 113 staff received the in-service, and the training which included, Falls: all falls require risk management assessments to include reporting to the physician, resident family representative, and immediate supervisor, and SBAR (Situation, Background, Assessment and Recommendation). All unwitnessed falls require neuro checks During an interview on 4/26/2025 at 9:00 PM LVN C stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN C stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:04 PM RN B stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. RN B stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:10 PM LVN D stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN D stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:14 PM LVN E stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN E stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:18 PM RN F stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. RN F stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:20 PM LVN G stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. LVN G stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:22 PM LVN H stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN H stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:24 PM LVN I stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN I stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:29 PM CNA J stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA J stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM CNA K stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA K stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:01 PM CNA L stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA L stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:03 PM CNA M stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA M stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 1:48 PM CNA N stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA N stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 2:38 PM CNA O stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA O stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM RN P stated she worked the 6:00 AM to 10:00 PM shifts on the weekends and on 4/25/2025 she received in-services which included ANE prevention and Fall Protocols, such as assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 2:38 PM CNA Q stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA Q stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:11 PM CNA R stated she worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA R stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:14 PM RN S stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. RN S stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. The facility had corrected the noncompliance before the survey began.

Based on interviews and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of pracxtice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure sores in that: The facility failed to acquire and administer treatment to resident #1's sacral wound when it deteriorated to a Stage 3 on 09/25/2023 until 10/01/2023 and did not send her out of the facility for further care when her pressure sore continued to deteriorate to a Stage 4 and a family member and the resident insisted she be sent out to the hospital on 10/06/2023 where she was treated for an infected Stage 4 sacral wound. An IJ was identified on 12/19/2023 at 5:31 p.m. The IJ template was provided to the facility on [DATE] at 5:31 p.m While the IJ was removed on 12/22/2023 at 5:30 p.m., the facility remained out of compliance at a scope of pattern and severity of actual harm with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This facility failure placed residents at risk of untreated wounds, infection, a decline in health, further surgeries with associated complications. The findings included: Record review of Resident #1's electronic face sheet dated d12/21/2023 reflected she was originally admitted to the facility on [DATE], readmitted on [DATE] and recently admitted on [DATE]. Her diagnoses included: dementia, displaced comminuted fracture of shaft of left femur, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus and neuomuscular dysfunction of bladder. Record review of Resident #1's quarterly MDS assessment with an ARD of 09/20/2023 reflected she had no pressure sores and had MASD which she was being treated with barrier cream. She scored a 6/15 on her BIMS which signified she was moderately cognitively impaired, she couldusually understand and be understood. She had an indwelling urinary catheter and she was always incontinent of bowel. She required extensive assistance with her ADL's. Record review of Resident #1's comprehensive care plan date initiated 06/28/2021 and revised on 11/08/2022 reflected Focus .has MASD to buttocks and sacrum .Interventions .Avoid scratching and keep hands and body parts from excessive moisture .monitor skin rashes for increased spread or signs of infection. Further review reflected Focus .resident has a stage 3 pressure injury tp sacrum revised on 10/01/2023 .Interventions .Administer medications as ordered .assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Record Review of Resident #1's Weekly Skin assessment dated [DATE] reflected Resident #1 did not have a pressure sore and had MASD to the sacrum/buttocks. Record Review of Resident #1's Pressure Ulcer Sheet dated 09/25/2023 revealed that Resident #1 had a Stage 3 pressure injury to the coccyx (2.0cm x2.0 cm x 0.3cm). Record Review of Resident #1's Weekly Skin assessment dated

Based on record review, interview, and review of the facility's policy, the facility failed to safely transfer a resident (R)5 from the bed to the shower chair using a mechanical lift, which resulted in a fall from the lift that required six sutures over her eye and failed to address the potential for R4's feet to slide from the foot rest when in his wheelchair for two of four sampled residents reviewed for supervision to prevent accidents in a total sample of 12 residents. Findings include: 1. Review of the facility's document titled, Task # 774 dated 07/06/21, included general guidelines for mechanical lift inspections that included 12 areas. Item 5 of the Task included, Inspect the swivel bar, check bolts/hooks for damage or wear, check sling hooks for bends or deflection. Item 10 included, .test functionality of lift and proper function of all controls. A review of an undated statement by the former Assistant Maintenance person revealed, .On 07/06/21, I assisted with the inspections of all lifts within the facility. I did not discover any issues or any missing components to the lift involved in the incident. The lift was complete and in good working order. The Admission Record found in the Electronic Medical Record (EMR) revealed R5 was admitted to the facility on [DATE] with a diagnoses included [CONDITION(S)] and malignant neoplasm of the spinal cord. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/18/21 located in the EMR under the MDS tab revealed R5 had a brief interview of mental status (BIMS) score of 15 out of 15, which indicated no cognitive impairment, and required extensive assist of two staff for transfer activities. A review of R5's care plan, located in the EMR under the Care Plan, tab related to risk for falls, dated 01/26/21, included,.staff to assist with transfers and attempt to determine causes of any falls. A review of the Kardex, located in the EMR under the Task tab, revealed the resident required Hoyer lift (mechanical lift) for transfers. Review of the Complaint/Incident Investigation Report, dated 08/11/21, sent by the facility to the State Agency, revealed at 9:00 AM on 08/11/21, two staff were transferring the resident via a mechanical lift, the resident fell forward, sustained an injury to the right eyebrow, and was transferred to the hospital. A review of the hospital CT scans of the spine and head, dated 08/11/21 revealed no acute cervical spine fracture, no evidence of bleeding in the brain, and a right frontal scalp hematoma measuring up to one centimeter in thickness. A review of the Nurse's Note, dated 08/11/21, revealed the resident returned from hospital with a bandage to the top of the right eye with six stitches, bruising and swelling to the site, and was alert and oriented. During an interview with the current Maintenance Director on 09/13/21 at 5:27 PM, he stated he started employment at the facility on 08/23/21. He stated on 08/31/21, he inspected all the lifts at the facility and documented each lift on the facility Safety Inspection Checklist Mechanical Lift Devices. He stated the checklist indicated it was to be completed monthly for each lift. The Maintenance Director stated one lift in the garage, needed servicing, and was not currently being used. He stated one of the bolts on another lift was not the correct bolt, the correct bolt was ordered, and the lift was removed from service at the facility, until the correct bolt was installed on the lift. He stated there were no issues with the other lifts. The Maintenance Director stated he was not able to find any monthly safety inspection checklists, prior to 08/31/21, except for the Task form, dated 07/06/21 and a maintenance invoice, dated 06/07/21, that included inspections of all lifts at the facility. During an interview with R5 on 09/13/21 at 9:27 AM, she stated she recalled the incident that took place on 08/11/21. R5 stated during the transfer with Certified Nurse Assistant (CNA) 5 and Registered Nurse (RN)1, she observed the strap come off the hook, she fell forward, and hit her face and eye on the lift. R5 stated she had a lot of pain and her eye and was bleeding. During an interview with RN1 on 09/13/21 at 11:30 AM, she stated R5 was alert and oriented. RN1 stated she was familiar with the lift used on R5. RN1 stated a mesh sling is used when showering a resident. RN1 stated the slings have color coded straps on the top of the sling and the strap color is determined by the size of the resident. RN1 stated when she has transferred a resident, there has never been an issue with the color of strap chosen by the staff member. RN1 stated on 08/11/21 prior to 9:00 AM, CNA5 asked her to assist her with transferring R5 from her bed to shower chair, which was in the locked position, using a mechanical lift. RN1 stated she noted nothing unusual about the lift. RN5 stated the sling and straps had no wear, were not frayed, and were in good condition. RN1 stated she could not recall the color of the strap used on the top portion of the sling but stated the same color was used on both sides. RN1 stated she and CNA5 placed the straps on the hooks and ensured they were on the middle of the hooks, were secure, and correctly placed. RN1 stated during the transfer, the base of the lift was in the wide position. RN1 stated she was in front of the lift, using the control to move the resident up, off the bed and the CNA5 was next to the resident. RN1 stated CNA5 moved the resident's legs off the bed, turned the resident, she moved the lift away from the bed, and CNA5 moved behind the resident. RN1 stated the resident was sitting upright and was secure in the lift. RN1 stated CNA5 was guiding the resident to the shower chair from behind her with her two hands on the sling and resident. RN1 stated as CNA5 guided R5 toward the shower chair, R5 leaned very slightly to her left side, immediately one of the straps slid off the hook, and the resident fell on the base of the lift, hitting her right eye on the base of the lift. RN1 stated the resident had bleeding on her face over her eye and was transferred to the Emergency Department (ED). RN1 stated the sling and straps were evaluated and there were no tears or rips noted. RN1 stated someone from the Maintenance department evaluated the lift. RN1 stated she was told there was a piece that went over the hooks that was missing on one side. During an interview with Licensed Vocational Nurse (LVN) 2 on 09/14/21 at 5:01 PM, she stated the resident returned to the facility during the evening shift, her right eye had swelling and bruising, and she had no complaints of visual issues. During an interview with the Administrator on 09/15/21 at 9:15 AM, he stated on 07/05/21 Task # 774 was sent to the facility by the facility corporation and all mechanical lifts at the facility were to be inspected and tested . The Administrator stated the form was a general guide to evaluate and test mechanical lifts. The Administrator stated the former Assistant Maintenance person told him, he evaluated and checked the functioning of all lifts on 07/06/21 per the Task form, and no issues were noted. The Administrator stated the lift used during the fall of R5 on 08/11/21 was one of the lifts evaluated on 07/05/21 and the lift had no issues. The Administrator confirmed the Task form was not signed and there was no documentation on the form that indicated what lifts were evaluated, and no notations about the evaluations. Further interview with the Administrator on 09/15/21 at 9:15 AM, he stated he initiated an investigation on 08/11/21. The final investigation, dated 08/17/21, revealed that on 08/11/21, the former Assistant Maintenance person evaluated the lift involved with R5 and noted the lift was missing one black washer and the sling was serviceable. The black washer is used as a secondary safety measure to ensure the sling does not come undone. The lift was rendered inoperable due to the severity of the incident, and a new lift was ordered to replace that lift. The investigation revealed that the facility performs routine monthly inspections on equipment to ensure safety and serviceability. The investigation revealed all lifts were inspected that day and there were no concerns with the other lifts. The mechanical lift used at the time of the incident was no longer at the facility, they no longer had the manufacturer's instructions, they did not know the exact type of lift used, and the Surveyor was not able to view the lift. During an interview with CNA5 on 09/15/21 at 9:59 AM, she stated R5 was alert and oriented. CNA5 stated she had transferred R5 from the bed to the wheelchair or shower chair with RN1, prior to the incident, and there were no issues. CNA5 stated they always used the same sling for R5 and the same color tabs, when using that lift. CNA5 stated the sling and straps were in good condition. CNA5 stated RN1 came to the resident's room, and she (CNA5) brought the lift into the room. CNA5 stated there were four hooks on the lift, two in the front and two in the back. CNA5 stated she placed the straps on the lift hooks, which faced away from the resident, and ensured they were secure. CNA5 stated the base of the lift was in the wide position and the shower chair was next to the bed. CNA5 stated RN1 was using the control and was facing the resident and she was next to the resident. CNA5 stated the nurse raised the resident from the bed with the lift, the resident was sitting in a safe position, and she guided, and turned R5's legs off the bed. CNA5 stated she placed both hands on the sling and resident from behind the resident and was guiding the resident to the shower chair. CNA5 stated as they neared the shower chair, R5's position shifted very slightly forward, and she was secure in the sling. CNA5 stated in the next second, the right strap came off the hook and the resident fell forward. CNA5 stated she was not able to secure the resident and prevent her fall. During further interview with the Administrator on 09/15/21 at 11:42 AM, he confirmed he was not able to provide the Surveyor with any additional monthly audits on mechanical lifts, except as indicated in this report. A review of the facility's policy titled, Hydraulic Lift, dated 11/08/18, revealed, The resident will achieve safe transfer to bed or chair via a mechanical lift device .Follow manufacturer recommendations for routine maintenance . 2. The Admission Record, located in the EMR, revealed R4 was admitted to the facility on [DATE] with a diagnoses that included [CONDITION(S)] affecting left nondominant side and dementia. Review of R4's quarterly MDS with an ARD of 07/18/21 revealed R4 had a BIMS score of 14 out of 15, which indicated intact cognition, and required assist of two for positioning, transfer activities, and dressing. A review of R4's care plans related to a history of a fall in 2019 and [CONDITION(S)] and [CONDITION(S)], dated 04/26/21, included, ensure resident is wearing appropriate footwear when mobilizing in wheelchair. The goal listed under [CONDITION(S)] and [CONDITION(S)] revealed the resident will remain free of complications or discomfort related to [CONDITION(S)]/[CONDITION(S)]. During an interview with CNA4 on 09/14/21 at 5:19 PM, she stated she was the staffing coordinator, arranged appointments for residents, and picked up assignments as a CNA. CNA4 stated R4 was not able to self-propel his wheelchair. CNA4 stated R4 had many appointments and she accompanied him to the appointments. CNA4 stated during a previous appointment, R4 asked her to get him elastic bands to place around his shoe and the footrest to keep his feet from sliding off the wheelchair. CNA4 stated she explained why she was not able to assist him with the placement of the elastic bands and he became upset and agitated. CNA4 stated she told him, she was accompanying him to the appointment, and she would ensure his feet did not slide off the footrest. CNA4 stated the resident was agreeable and there were no issues with his feet. CNA4 stated she did not report the issue to anyone as the issue was resolved. During an interview with CNA5 on 09/15/21, at 9:59 AM, CNA5 stated R4 rarely wanted to be out of bed, except for his appointments and showers. CNA5 stated R4's feet were sometimes difficult to keep on the footrest. She stated on one occasion, the resident asked her to use a sheet around his legs and the wheelchair to keep his legs on the footrest. CNA5 stated she told the resident it was not safe to do this, and she suggested the use of a pillow. CNA5 stated the pillow worked well. CNA5 stated she did not notify the nurse as R4 was satisfied with using the pillow. There was no evidence in the clinical record of information related to the resident requesting or wearing elastics around his shoe and footrests or issues with his feet sliding off the wheelchair rest. During an interview with the Compliance Nurse on 09/15/21 at 11:08 AM, she stated the clinical record had no documentation related to R4 having an issue with his feet staying on the footrest or the need to use elastics or a pillow to keep his feet on the footrest. She stated the nurses were not aware the resident had an issue with his foot sliding off the footrests, therefore when being treated by the physical therapist the resident was not evaluated for this issue. A review of the Grievance Report Form dated 07/30/21, completed by the Administrator revealed R4's Family Member reported the staff used a rubber band to hold the resident's feet in place to the footrest. During an interview with the Veterans Care Coordinator (Care Coordinator), who is employed by the facility on 09/13/21 at 4:26 PM, she stated the resident is under the Veteran's contract at the facility and she monitors him at the facility. She stated on the day of the resident's appointment, on 07/23/21, R4's Wife called the facility and reported the resident had a rubber band attached around his shoe and the footrest. The Care Coordinator stated she reported the incident to the Administrator and the Director of Nurses (DON). The Care Coordinator stated she was not aware the resident had any issues with his foot sliding off the wheelchair, prior to 07/23/21. The Care Coordinator stated she reviewed the 07/23/21 schedule, interviewed the staff involved, and had the staff write statements regarding the incident. She stated the three staff reported the resident, who is alert an oriented requested the staff place the elastic around his shoe and wheelchair rest and he stated he would not go to the appointment unless this was done. She stated one of the resident's arms was contracted and he had full functioning capacity of the other hand and arm. The Care Coordinator stated the resident would have been able to remove the elastic if he chose. The Care Coordinator stated the three staff told her the resident had not requested this in the past and there were no known issues with his wheelchair or footrests. She stated during the appointment, it was discovered the resident had abnormal laboratory studies, he was transferred to the Emergency Department, and admitted to the hospital. She stated she provided education to Licensed Vocational Nurse (LVN) 3 related to facility practice and the potential for injury to a resident with elastics around his shoe and footrest. A review of LVN2's undated written statement revealed, On morning of 07/23/21, this nurse witnessed/heard resident asked another nurse for rubber bands. The nurse responded and told resident she did not have any rubberbands but she could find some for him. Nurse asked what did he need rubber bands for and the resident stated to put on his feet to keep them from falling off the foot petal. Nurse assisted resident with his request and resident insisted he wanted the rubberbands on his feet. Resident was leaving for an appointment on this day. During an interview with LVN2 on 09/14/21 at 5:01 PM, she stated the resident was alert, oriented, and occasionally confused. She stated R4 had lower extremity paralysis, had limited ability in his right arm and hand, and no issues with his left arm and hand. LVN2 stated the resident was not able to self-propel his wheelchair. LVN2 stated the staff at facility went with resident for his appointments and the family usually met them at the appointment. LVN2 stated she heard LVN3 tell the resident he shouldn't use the rubber bands, and the resident replied he had used them before, and wanted to use them. During further interview with CNA4 on 09/14/21 at 5:19 PM she stated on the day of this appointment (07/23/21), no one was assigned to go with the resident, and she could not recall the reason. CNA4 stated his family was to meet him at the appointment. CNA4 stated the transport company person was scheduled to drop R4 off at his appointment at the clinic. CNA4 stated she heard the resident screaming and insisting the nurse get him elastics. CNA4 stated she was not aware if elastics were placed on the resident's feet. During an interview with LVN3 on 09/15/21 at 11:23 AM she stated the resident could partially use his right leg and foot to somewhat control his left leg and he had no issues with his right arm and hand. LVN3 stated prior to the incident, she had never observed the resident out of bed and had not been involved in his previous appointments. She stated on 07/23/21, the resident had an early appointment and she had packed a breakfast for him to take with him. She stated she had finished her night shift and was leaving the facility. LVN3 stated the resident was in his wheelchair and was yelling and agitated. She stated she asked him what was wrong, and he told her he needed her to place an elastic band around his shoes and the footrest. She stated the resident told her he had done this in the past. LVN3 stated the resident told her he needed the elastics placed around his feet, as he had sustained an injury to his toe in the past, when he was transported to the clinic for an appointment, and his foot slid off the footrest. LVN3 stated she told him this was not a good idea, and she would try to find something else. LVN3 stated the resident told her he was not moving until the elastics were placed and he needed to go to the appointment. LVN3 stated the resident instructed her on how to place the elastic bands, which she did. LVN3 stated CNA4 went to the appointments with the resident and had heard the conversation about the elastics. LVN3 stated she was not aware no one was going with the resident to his appointment. LVN3 stated she did not report the issue to management prior to leaving the facility and did not document the incident. During an interview with the Administrator on 09/13/21 at 4:30 PM, he stated the resident was admitted to the hospital on 07/23/21 and did not return to the facility. He stated he did not believe the resident was restrained as he was not able to stand and was not ambulatory. The Administrator stated if the information regarding the resident's feet not staying on the footrests had been reported, a safer option would have been provided for the resident. He stated the Care Coordinator educated LVN3 regarding the use of elastics. He stated elastics were put on resident per resident's request. Not aware that resident had requested prior, not aware had ever used. No staff ever observed resident with elastics except on day of appointment

Based on observation, interview, and record review the facility failed to provide routine and emergency drugs and pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident for 5 of 17 residents (#1, #2, #3, #16 & #17) whose medications were reviewed in that: 1. Staff did not know if there was any glucagon available for 3 Diabetic residents, #1, #16, & #17, who had a prescription for glucagon (used for [DIAGNOSES REDACTED]; low blood sugar <60) to be used PRN, as needed, in an emergency situation. When located, the glucagon pen was not stored in the Pyxis machine (automated medication dispensing system); the facility designated location. 2. LVN M administered an expired dose of glucagon to Resident #3 after her blood glucose fell under 60. 3. LVN H did not wrap Resident #2's arm with saran wrap after applying lidocane per physician orders. This deficient practice could affect 18 Diabetic residents either with a PRN order or with the potential use of glucagon in an emergency basis and 1 resident with an order for [REDACTED]. The findings were: According to the American Diabetes Association "Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia. [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood levels, usually less than 70 mg/dl. Injectable glucagon kits are used as a medication to treat someone with diabetes that has become unconscious". 1. a. Review of Resident #1's medical face sheet dated 1/26/15 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order for Resident #1 dated 2/16/15 read "glucagon PRN for BS < 60 then notify MD". Review of a telephone order for Resident #1, undated, but filed under another telephone order dated 3/2/15 read "Glucagon Kit DX D.M". Review of Resident #1's admission MDS dated [DATE] revealed she had a [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plan, "undated" confirmed she had a [DIAGNOSES REDACTED]. b. Review of Resident #16's medical face sheet dated 3/13/15 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order for Resident #16 dated 3/2/15 read "Glucagon Kit." Review of Resident #16's admission MDS dated [DATE] confirmed she had a [DIAGNOSES REDACTED]. Review of Resident #16's comprehensive care plan, undated, did not address her diagnosis, diabetes mellitus. c. Review of Resident #17's medical face sheet, undated, revealed he was admitted into the facility on [DATE]. Review of a telephone order for Resident #17 dated 3/2/15 read "Glucagon Kit." Review of Resident #17's most current MDS dated [DATE] revealed he had a [DIAGNOSES REDACTED]. Review of Resident #17's comprehensive care plan, undated, confirmed he had a [DIAGNOSES REDACTED]. Interview on 3/2/15 at 1:05 p.m. with the Interim DON revealed the Pyxis which was also the facility emergency kit (E-kit) had not been working properly for at least 1 week and stated she had called in a ticket to the pharmacy to have it repaired. The Interim DON stated typically the pharmacy was able to electronically read what medications were available in the Pyxis and they would deliver medications as needed on the next delivery date which was done weekly. The Interim DON stated there were no other E-kits. She further stated any available glucagon would be stored in the nursing carts if any resident had a physician order [REDACTED]. She stated there were only 2 super users (had the ability to access the entire inventory in the Pyxis), her and ADON D,. Observation on 3/2/15 at 1:07 p.m. revealed glucagon was not available in the Pyxis. Interview at this same time with the Interim DON confirmed there was no glucagon in the Pyxis. Observation on 3/2/15 at 1:10 p.m. revealed glucagon was not available in 2 nurse's carts located in the rehabilitation wing. Interviews at this same time with LVN H and LVN O revealed they were each assigned a nursing cart and they confirmed they did not have glucagon in their carts. LVN H and LVN O stated glucagon would not be stored in a medication cart because only licensed staff could administer glucagon. LVN H and LVN O stated they would obtain glucagon as needed from the Pyxis and were not aware if any was available. Observation on 3/2/15 at 1:19 p.m. revealed glucagon was not stored in the rehabilitation medication cart. Interview at this same time with Medication Aide (MA) P confirmed this finding. MA P stated she was assigned to the cart and confirmed glucagon would not be stored in her cart because only licensed staff could administer glucagon. Observation on 3/2/15 at 1:20 p.m. revealed glucagon was not stored in the LTC (long term care) medication cart. Interview at this same time with MA Q confirmed this finding. MA Q stated she was assigned to the cart and also confirmed glucagon would not be stored in her cart because only licensed staff could administer glucagon. Observation on 3/2/15 at 1:22 p.m. revealed glucagon was not stored in a nursing cart or in a treatment cart in the LTC wing. Interview at this same time with charge nurse/LVN R confirmed these findings. LVN R stated she was assigned the nursing cart and would look in the Pyxis for emergency use of glucagon. She stated there should be a house stock of glucagon in the Pyxis. Observation on 3/2/15 at 1:25 p.m. revealed glucagon was not stored in a second LTC nursing cart. Interview at this same time with LVN S confirmed this finding. LVN S stated she was assigned the nursing cart and stated she had been out of glucagon for at least 2 weeks. She stated she should have glucagon in her cart and should have ordered it because she had at least 4 diabetic residents and if their blood glucose dropped she would need the medication to administer on an emergency basis. LVN S stated she would look for glucagon in the Pyxis and if it was not available a resident could have seizures; multiple medical problems including death. LVN S stated she would not look for glucagon anywhere other than the Pyxis. LVN S further stated she was not sure if glucagon was available in the Pyxis. Interview on 3/2/15 at 1:28 p.m. with the Interim DON revealed she did not know they were out of glucagon and confirmed technically glucagon would only be stored in nursing carts and in the Pyxis. Observation on 3/2/15 at 1:30 p.m. revealed the Interim DON, ADM, and ADON D were meeting in the Administrator's office. The Interim DON was on the phone and the ADM was on the computer. Surveyor asked if they had identified the problem. Interview at this same time with the Interim DON, ADM and ADON D revealed they had a sense of urgency to obtain glucagon for emergency use after Surveyor intervention. The Interim DON stated she understood the importance of having glucagon available and had ordered some and it was on its way to the facility on this date. She then stated there were other E-kits she could also look in for glucagon. The ADON D stated the last glucagon pen used that he knew of was 1 or 2 days ago. The Interim DON and ADON D were asked for the last medication requisition list ordered from the pharmacy and the date the last glucagon was used. This was never provided. Observation on 3/2/15 at 1:40 p.m. revealed glucagon was not stored in other areas of the facility such as in the insulin emergency kit, in the refrigerator and in another box labeled emergency kit in the rehabilitation medication room. Interview at this same time with the Interim DON confirmed this finding. Interview on 3/2/15 at 2:15 p.m. with ADON D revealed he had just now found a glucagon pen in a cabinet where the over the counter medications were stored in the rehabilitation medication room. He stated it was normally stored in the Pyxis and that he did not know they were out of glucagon. Observation on 3/2/15 at 2:20 p.m. revealed glucagon was not stored in the LTC medication room. Interview at this same time with ADON D confirmed this finding. He stated he learned "about 20 minutes ago" the Pyxis was not communicating electronically with the pharmacy. ADON D stated he was promoted as the ADON about 1 week ago and stated about 2 weeks ago he counted all medications manually but had not checked the Pyxis inventory since that time. He did not know if there was one specific staff designated to count inventory and staff responsible for re-ordering medications as needed. ADON D further stated in the event he found a resident to be unresponsive he would administer glucagon and would call 911 at the same time. He stated he would try and stabilize the resident's blood sugar. ADON D stated he would not think to look for the glucagon in the cabinet where the over the counter medications were stored because it was not where it should be stored. Interview on 3/2/15 at 2:50 p.m. with the Interim DON revealed ultimately the pharmacy was responsible for ensuring their equipment was operating correctly and that medications were available for the residents. Surveyor then asked who in the facility was responsible to ensure medications were available especially emergency medications once used due to the fact the Pyxis was not working: The Interim DON reiterated the Pyxis was not working properly, but was not able to identify the system in place which identified staff responsible for re-ordering emergency medications, including glucagon once used to ensure glucagon was available for identified residents. Interview on 3/2/15 at 3:15 p.m. with the Interim DON revealed only residents on regular insulin would have a PRN standing order for glucagon. She provided a document dated 3/2/15 naming 35 residents on antidiabetic medications. She further stated only residents on high doses of insulin would need a standing order for glucagon. There were 18 highlighted residents on the list but only 2 residents, #16 and #17, had an order "Glucagon Emergency 1 mg". The Interim DON stated she would find out what the "PAR level" (house stock available) for glucagon was for the facility. She further stated the pharmacy and nursing staff were responsible for ensuring medications were available for resident use. However, she was not able to elaborate on the system in place for the requisition of medications and staff responsible for stocking medications upon delivery. Interview on 3/2/15 at 3:45 p.m. with the Interim DON confirmed Resident #1 also had a standing order for glucagon. She stated Resident #1 was administered glucagon on 2/23/15 because she was hypoglycemic. She stated prior to that Resident #3 was administered glucagon on 2/8/15 for the same reason. The Interim DON again stated staff would be most concerned about residents on high levels of insulin because they could "bottom out" and glucagon would be needed. She stated additional glucagon pens would be delivered at 6:00 p.m. on this date even though they had the 1 glucagon pen. Interview on 3/2/15 at 4:15 p.m. with the Interim DON revealed the facility "PAR level" for glucagon was 1. She stated they had the 1 glucagon pen but ordered more because the 1 glucagon pen was not enough in comparison to the number of diabetic residents in the facility. The Interim DON provided a document titled, "Consolidated Delivery Sheets" faxed from the pharmacy on 3/2/15 at 4:01 p.m. The document indicated 1 glucagon kit was delivered on 2/9/15 for Resident #3. Review of a Discharge Notice revealed Resident #3 was discharged home on[DATE]. There were no glucagon pens listed on the document for Resident #1, #16, or #17. The Interim DON stated there was not a policy for the use of Glucagon. An IJ was identified on 3/2/15 at 4:50 p.m. The ADM and Interim DON were notified and informed an IJ was identified due to the above mentioned findings. They were informed they would have to develop a plan of removal to address all failures and the region would review and approve it before the IJ was removed. Observation on 3/2/15 at 5:10 p.m. revealed the glucagon pen found by ADON D was not stored in the Pyxis. Interview at this same time with the Interim DON confirmed this finding and she commented it might be in one of the nurse's carts. Further observation revealed a brown paper bag on top of the counter with medications in it. The Interim DON stated it was a delivery from the pharmacy. She stated she did not know when it was delivered. She could not identify staff responsible for restocking the medications when asked the question. Observation on 3/2/15 at 5:15 p.m. revealed the glucagon pen was in a nursing cart assigned to LVN T. The expiration date was 6/2015. Interview at this same time with the Interim DON confirmed their "system was broken." Interview on 3/2/15 at 7:20 p.m. with CPT U revealed they had received a request for a glucagon kit for Resident #16 on this date. He stated they had not received any other requests for glucagon kits for any other residents at the facility. Interview on 3/2/15 at 8:20 p.m. with the ADM, DON, and ADON D confirmed they had developed a plan of removal. Review of the finalized Plan of Removal dated 3/3/15 read: "Immediate Action: Glucagon is stored in the Pyxis and/or medication room and is available in the facility. We had at least one glucagon kit in the facility prior to this but due to the potential concern we will get glucagon for residents with orders + 1 extra. Correction Action: DON and/or ADON will continue to monitor the Pyxis weekly and as needed to ensure emergency medications are replenished as needed via attached monitoring tool. As an extra measure, all licensed nursing staff will be in-serviced regarding replenishing emergency medications upon usage by completing the medication usage slip and fax to the pharmacy to be completed by 3/4/15. Nurses who have not been inserviced by then will not be allowed to work until in-serviced by the DON or designee. Monitoring: DON or designee will monitor glucagon availability daily to ensure it is available for residents that have it ordered. DON or designee will ask 3 nurses daily what they would do if they used the emergency supply of glucagon. Glucagon availability usage, and replenishing will be discussed in facility QA for no less than 90 days or until substantial complaince has been achieved and sustained. Our physicians and nurse practitioners round frequently and review accu checks, although we can have each individual diabetic reviewed by their MD as soon as possible for the potential need. After hours and on weekends, Charge Nurses are responsible for signing off on meds. And then meds are put on medication carts unless it's a stock/emergency supply, and those are kept in the med room. DON or designee will be responsible for restocking the replacement meds in the Pyxis the day after they are delivered. Reordering stock is the charge nurses responsibility to fill out a slip and fax to the pharmacy when used." Review of an in-service training initiated on 3/2/15 provided by ADON D revealed 7 nurses who worked full time, PRN, and who worked all shifts were trained regarding the new facility medication protocol. Review of the same in-service training completed on 3/3/15 revealed an additional 12 nurses completed this training. Further review revealed a document attached which read, "Effective 3/2/15 all diabetic patients requiring insulin will have a glucagon emergency kit ordered for them upon admit" and their kit will be kept in "the nurse's treatment cart". Also attached was a form titled, "Emergency Medication Kit Usage Slip." Further review revealed that on 3/3/15 it was verified that each Resident #1, #16, and #17 had 1 dose of Glucagon available to them and 3 nurses were asked what they would do if they used the dose of Glucagon. Interview on 3/3/15 at 9:45 a.m. with the previous DON V and nurse consultant C revealed the Pyxis had not been working since mid-January 2015. They stated the system that had been in place for ordering/re-ordering medications since that time was as follows: the previous ADON/LVN H would check inventory in the Pyxis every Monday and send a fax request of medications needed to the pharmacy. The pharmacy would deliver the ordered medications every week. DON V and nurse consultant C stated nurses would notify the DON and ADON when a medication was low. A medication request would be faxed to the pharmacy and the ordered medications would be delivered on the next schedule delivery date. They stated every nurse had access to the Pyxis but only 2 super users had access to do inventory; the DON and ADON. They stated ADON D set up the user identification for the nurse's and confirmed he had been the ADON about 1 week. They further stated the Interim DON and ADON D would be responsible for ordering/re-ordering medications. DON V stated she had trained the Interim DON prior to her leaving her position and they talked on the phone last week about the process as stated above. Interview on 3/3/15 at 11:16 a.m. with LVN H confirmed she was the previous ADON for the rehabilitation wing and confirmed the system that had been in place identified by DON V and nurse consultant C. She stated only 1 glucagon pen was kept in stock. She stated she had not taken inventory or ordered any medications for about 3 weeks. LVN H stated Interim DON did not confer with her yesterday, 3/2/15, about the facility's requisition of medications. She stated as a floor nurse she would report when a medication "ran out" to the Interim DON or ADON D. LVN H stated ADON D provided training yesterday on the new system for ordering medications. She stated upon admission nurses would order a glucagon kit for every diabetic resident. She was trained to fill out the form located by the Pyxis every time she took a medication from the Pyxis and then she was supposed to fax the form to the pharmacy the same date as she used the medication. LVN H stated she was never trained before on the use of the Pyxis. Interview on 3/3/15 at 12:10 p.m. with nurse consultant C revealed the medication requisition history for the facility. Nurse consultant C stated staff who accepted the medications checked off the medication on the fax request list when the pharmacy delivered the medications. This was the facility consolidation of medications ordered and received. The nurse checking the medications would fax in another request if a medication was not delivered according to the faxed list. Nurse consultant C provided inventory sheets dated 2/2/15, 2/11/15, 2/16/15 and 2/23/15 which revealed glucagon was delivered on 2/16/15. According to a "Consolidated Delivery Sheets" previously provided by the Interim DON revealed 1 glucagon kit was delivered on 2/9/15 for Resident #3 making it a total of 2 glucagon pens delivered to the facility during February 2015. However, review of Resident #1's medical chart revealed she was administered glucagon on 2/16/15 and on 2/23/15. Review of Resident #3's medical chart revealed she was administered glucagon on 2/8/15. The result was the use of 3 total glucagon pens during February 2015. This confirmed the facility requisition and consolidation of medications was not accurately capturing glucagon kits used and kits available in the facility. Interview on 3/3/15 at 1:50 p.m. with LVN O revealed she was able to identify the protocol followed when a diabetic resident was found to be unresponsive. She stated she would check the nursing cart to check if a glucagon pen was available for the individual in question if not she would go to the Pyxis for an emergency kit. Observation on 3/3/15 at 1:56 p.m. revealed 7 glucagon emergency pens in the Pyxis. Interview at this same time with LVN O confirmed this finding. LVN O stated she was trained to complete the medication form when she took a medication from the Pyxis. She was then to fax it to the pharmacy each time she took a medication from the Pyxis. LVN O stated she had not received training on the use of the Pyxis. Interview on 3/3/15 at 5:11 p.m. with LVN M revealed she received training yesterday regarding medication usage and storage of the glucagon emergency pens. LVN M stated she was to document any medication used from the Pyxis and then fax it to the pharmacy. She stated the glucagon emergency pens would be stored in the Pyxis. Interview on 3/3/15 at 5:15 p.m. with LVN T revealed she received training regarding medication usage and storage of the glucagon emergency pens. LVN T stated she was to document any medication used from the Pyxis and then fax it to the pharmacy. She stated the glucagon emergency pens would be stored in the Pyxis. Interview on 3/3/15 at 5:26 p.m. with LVN W revealed she received training today regarding medication usage and storage of the glucagon emergency pens. LVN M stated she was to document any medication used from the Pyxis and then fax it to the pharmacy. She stated the glucagon emergency pens would be stored in the Pyxis. Review of the facility medication policy dated 2003 revealed "Ordering medications: [REDACTED]. Such medications need to be delivered and administered within(one (1) hour. If available, obtain the initial dose from the emergency kit when necessary. After scheduled business hours, require pharmacy to deliver emergency or stat medications so they can be administered within ONE (1) hour. If available, obtain the initial dose from the emergency kit when necessary. Receiving medications: [REDACTED]. 4. These delivery records are retained for (one year). Operation of the Emergency Medication Kit: 1. Stocking or replacing items to the emergency medication kit shall be completed in the provider pharmcy or in the facility by a pharmacist or certified pharmacy technician under the direct supervision of a pharmacist. Emergency Kit Medication Utilization: 2. When removing medications from the emergency kit the nurse must record this entry on the appropriate form. 3. The pharmacy will be notified of the removed medications so a replacement emergency kit can be obtained, or so the pharmacist may replace the item removed. 4. The nurse will order the medication from the pharmacy so a Rx supply can be delivered by the pharmacy. Recordkeeping and Accountability of medications: [REDACTED]." The facility Plan of Removal provided by the ADM was accepted on 3/3/15 at 5:50 p.m. and the IJ was removed. While the IJ was removed the facility remained out of compliance at no actual harm with potential for more than minimal harm that was not immediate jeopardy and the scope was a pattern. 2. Record review of Resident #3's medical face sheet dated 2/12/15 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order dated 2/8/15 read, glucagon injection PRN if blood glucose <60. Review of a medication error form dated 2/8/15 revealed LVN administered an expired Glucagon kit to Resident #3. Review of nurses note dated 2/8/15 at 1135 read, "checked rsd blood glucose 88 @ 1215 when she (Resident #3) received hall tray rsd was acting differently & not responding appropriately. Rechecked BS. 35. 0 glucagon in cart. called 911. LVN M Longterm LVN admin glucagon from pyxsis. EMS arrive & monitor vs. rsd out @ 1235 for [DIAGNOSES REDACTED]. Arrived back @ facility @ 1450p. (2:50 p.m.) @ 1630 (4:30 p.m.) BS. 243 held insulin d/t hypoglycemic (low blood sugar) incident earlier in day." Review of a Discharge Notice revealed Resident #3 was discharged home on[DATE] between 10:00 and 11:00 a.m. Interview on 3/5/15 at 12:40 p.m. with RN I revealed she was the weekend supervisor on the weekend of 2/8/15. She stated a medication aid alerted the charge nurse that Resident #3 was cool and clammy and the accucheck reading was 35. Resident #3 was not responding. RN stated she and 2 other nurses went looking for glucagon and could not find any. She stated one of the nurse's finally found one in the pyxsis and LVN M administered Resident #3 with it. RN stated she read the glucagon wrapper and it had expired either 10/14 or 12/14. She stated Resident #3 was transferred to the hospital 10 minutes after the medication was administered. 3. Record review of Resident #2's medical face sheet dated 2/6/15 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's admission orders [REDACTED]. Review of Resident #2's most recent physician orders [REDACTED]. Apply to access site right upper arm 1 hour priort to dialysis and wrap with plastic. Review of Resident #2's comprehensive care plan dated 1/27/15 revealed to apply licocaine/prilocaine 2/5% topically to shunt site and wrap with cling (prior to p/u on dialysis). Date initiated was 1/30/15. Review of Resident #2's TAR, treatment administration record, dated March 2015 read: "lidocaine-prilocaine- transdermal dose: 2.5%-2/5% QD apply 1 hr before dialysis". Interview on 3/4/15 at 3:05 p.m. with LVN G confirmed Resident #2's TAR dated March 2015 read "lidocaine-prilocaine- transdermal dose: 2.5%-2/5% QD apply 1 hr before dialysis." LVN G stated the ointment was used for pain and stated the site was not wrapped so the lidocaine could penetrate into the skin. Interview on 3/4/15 at 3:35 p.m. with Resident #2's RP revealed he met Resident #2 at dialysis. He noted Resident #2 was making facial gestures like she was in a great deal of pain when the technician removed the needle from her shunt site. The RP stated he asked the technician if the lidocaine had not been effective. The technician stated he did not believe the lidocaine had been applied because the site was not wrapped with saran wrap when she arrived for her dialysis appointment. Interview on 3/4/15 at 4:25 p.m. with LVN H confirmed she did not wrap Resident #2's shunt site after applying the lidocaine on the same date prior to going to dialysis. LVN H stated the TAR did not reflect to wrap the site with saran wrap. She further stated she knew it was the RP's preference but stated an order was not in place. Review of a policy titled, Pain Management, Assessment Scale dated 2/13/107 read: "2. Administer pain medications as prescribed." Review of a policy titled, Dialysis dated November 2013 read."Procedure 1. Review and confirm the physician's orders [REDACTED]. Review of a document provided by the facility on 3/5/15 revealed there was 1 resident who had an order for [REDACTED]. Review of a document dated 3/2/15 revealed 18 highlighted Diabetic residents who had the potential to need glucagon on an emergency basis.

Based on observation, interview, and record review the facility failed to provide necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for 3 of 3 Diabetic residents (#1, 16, & #17) who required [MEDICATION NAME] on an as needed basis. 1. Staff did not know if there was any [MEDICATION NAME] available for 3 Diabetic residents, #1, #16, & #17, who had a prescription for [MEDICATION NAME] (used for [DIAGNOSES REDACTED]; low blood sugar <60) to be used PRN, as needed, in an emergency situation. When located, the [MEDICATION NAME] pen was not stored in the Pyxis machine (automated medication dispensing system); the facility designated location. 2. LVN M administered expired [MEDICATION NAME] to Resident #3 when she became hypoglycemic. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that was not immediate jeopardy and the scope was a pattern. All staff had not been trained on: the reacquisition of medications; the designated storage of the [MEDICATION NAME] pens during off hours and on weekends; designated nursing staff responsible for storing the [MEDICATION NAME] in the Pyxis after the receipt of the medication during off hours and on weekends to ensure all nursing staff knew where to obtain the [MEDICATION NAME]. These deficient practices could affect 18 residents with a [DIAGNOSES REDACTED]. The findings were: According to the American Diabetes Association "Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called [MEDICAL CONDITION]. [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood levels, usually less than 70 mg/dl. Injectable [MEDICATION NAME] kits are used as a medication to treat someone with diabetes that has become unconscious". 1. a. Review of Resident #1's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order for Resident #1 dated [DATE] read "[MEDICATION NAME] PRN for BS < 60 then notify MD". Review of a telephone order for Resident #1, undated, but filed under another telephone order dated [DATE] read "[MEDICATION NAME] Kit DX D.M". Review of Resident #1's admission MDS dated [DATE] revealed she had a [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plan, "undated" confirmed she had a [DIAGNOSES REDACTED]. b. Review of Resident #16's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order for Resident #16 dated [DATE] read "[MEDICATION NAME] Kit." Review of Resident #16's admission MDS dated [DATE] confirmed she had a [DIAGNOSES REDACTED]. Review of Resident #16's comprehensive care plan, undated, did not address her diagnosis, diabetes mellitus. c. Review of Resident #17's medical face sheet, undated, revealed he was admitted into the facility on [DATE]. Review of a telephone order for Resident #17 dated [DATE] read "[MEDICATION NAME] Kit." Review of Resident #17's most current MDS dated [DATE] revealed he had a [DIAGNOSES REDACTED]. Review of Resident #17's comprehensive care plan, undated, confirmed he had a [DIAGNOSES REDACTED]. Interview on [DATE] at 1:05 p.m. with the Interim DON revealed the Pyxis which was also the facility emergency kit (E-kit) had not been working properly for at least 1 week and stated she had called in a ticket to the pharmacy to have it repaired. The Interim DON stated typically the pharmacy was able to electronically read what medications were available in the Pyxis and they would deliver medications as needed on the next delivery date which was done weekly. The Interim DON stated there were no other E-kits. She further stated any available [MEDICATION NAME] would be stored in the nursing carts if any resident had a physician order [REDACTED]. She stated there were only 2 super users (had the ability to access the entire inventory in the Pyxis), her and ADON D,. Observation on [DATE] at 1:07 p.m. revealed [MEDICATION NAME] was not available in the Pyxis. Interview at this same time with the Interim DON confirmed there was no [MEDICATION NAME] in the Pyxis. Observation on [DATE] at 1:10 p.m. revealed [MEDICATION NAME] was not available in 2 nurse's carts located in the rehabilitation wing. Interviews at this same time with LVN H and LVN O revealed they were each assigned a nursing cart and they confirmed they did not have [MEDICATION NAME] in their carts. LVN H and LVN O stated [MEDICATION NAME] would not be stored in a medication cart because only licensed staff could administer [MEDICATION NAME]. LVN H and LVN O stated they would obtain [MEDICATION NAME] as needed from the Pyxis and were not aware if any was available. Observation on [DATE] at 1:19 p.m. revealed [MEDICATION NAME] was not stored in the rehabilitation medication cart. Interview at this same time with Medication Aide (MA) P confirmed this finding. MA P stated she was assigned to the cart and confirmed [MEDICATION NAME] would not be stored in her cart because only licensed staff could administer [MEDICATION NAME]. Observation on [DATE] at 1:20 p.m. revealed [MEDICATION NAME] was not stored in the LTC (long term care) medication cart. Interview at this same time with MA Q confirmed this finding. MA Q stated she was assigned to the cart and also confirmed [MEDICATION NAME] would not be stored in her cart because only licensed staff could administer [MEDICATION NAME]. Observation on [DATE] at 1:22 p.m. revealed [MEDICATION NAME] was not stored in a nursing cart or in a treatment cart in the LTC wing. Interview at this same time with charge nurse/LVN R confirmed these findings. LVN R stated she was assigned the nursing cart and would look in the Pyxis for emergency use of [MEDICATION NAME]. She stated there should be a house stock of [MEDICATION NAME] in the Pyxis. Observation on [DATE] at 1:25 p.m. revealed [MEDICATION NAME] was not stored in a second LTC nursing cart. Interview at this same time with LVN S confirmed this finding. LVN S stated she was assigned the nursing cart and stated she had been out of [MEDICATION NAME] for at least 2 weeks. She stated she should have [MEDICATION NAME] in her cart and should have ordered it because she had at least 4 diabetic residents and if their blood glucose dropped she would need the medication to administer on an emergency basis. LVN S stated she would look for [MEDICATION NAME] in the Pyxis and if it was not available a resident could have [MEDICAL CONDITION]; multiple medical problems including death. LVN S stated she would not look for [MEDICATION NAME] anywhere other than the Pyxis. LVN S further stated she was not sure if [MEDICATION NAME] was available in the Pyxis. Interview on [DATE] at 1:28 p.m. with the Interim DON revealed she did not know they were out of [MEDICATION NAME] and confirmed technically [MEDICATION NAME] would only be stored in nursing carts and in the Pyxis. Observation on [DATE] at 1:30 p.m. revealed the Interim DON, ADM, and ADON D were meeting in the Administrator's office. The Interim DON was on the phone and the ADM was on the computer. Surveyor asked if they had identified the problem. Interview at this same time with the Interim DON, ADM and ADON D revealed they had a sense of urgency to obtain [MEDICATION NAME] for emergency use after Surveyor intervention. The Interim DON stated she understood the importance of having [MEDICATION NAME] available and had ordered some and it was on its way to the facility on this date. She then stated there were other E-kits she could also look in for [MEDICATION NAME]. The ADON D stated the last [MEDICATION NAME] pen used that he knew of was 1 or 2 days ago. The Interim DON and ADON D were asked for the last medication requisition list ordered from the pharmacy and the date the last [MEDICATION NAME] was used. This was never provided. Observation on [DATE] at 1:40 p.m. revealed [MEDICATION NAME] was not stored in other areas of the facility such as in the insulin emergency kit, in the refrigerator and in another box labeled emergency kit in the rehabilitation medication room. Interview at this same time with the Interim DON confirmed this finding. Interview on [DATE] at 2:15 p.m. with ADON D revealed he had just now found a [MEDICATION NAME] pen in a cabinet where the over the counter medications were stored in the rehabilitation medication room. He stated it was normally stored in the Pyxis and that he did not know they were out of [MEDICATION NAME]. Observation on [DATE] at 2:20 p.m. revealed [MEDICATION NAME] was not stored in the LTC medication room. Interview at this same time with ADON D confirmed this finding. He stated he learned "about 20 minutes ago" the Pyxis was not communicating electronically with the pharmacy. ADON D stated he was promoted as the ADON about 1 week ago and stated about 2 weeks ago he counted all medications manually but had not checked the Pyxis inventory since that time. He did not know if there was one specific staff designated to count inventory and staff responsible for re-ordering medications as needed. ADON D further stated in the event he found a resident to be unresponsive he would administer [MEDICATION NAME] and would call 911 at the same time. He stated he would try and stabilize the resident's blood sugar. ADON D stated he would not think to look for the [MEDICATION NAME] in the cabinet where the over the counter medications were stored because it was not where it should be stored. 2. Interview on [DATE] at 2:50 p.m. with the Interim DON revealed ultimately the pharmacy was responsible for ensuring their equipment was operating correctly and that medications were available for the residents. Surveyor then asked who in the facility was responsible to ensure medications were available especially emergency medications once used due to the fact the Pyxis was not working: The Interim DON reiterated the Pyxis was not working properly, but was not able to identify the system in place which identified staff responsible for re-ordering emergency medications, including [MEDICATION NAME] once used to ensure [MEDICATION NAME] was available for identified residents. Interview on [DATE] at 3:15 p.m. with the Interim DON revealed only residents on regular insulin would have a PRN standing order for [MEDICATION NAME]. She provided a document dated [DATE] naming 35 residents on antidiabetic medications. She further stated only residents on high doses of insulin would need a standing order for [MEDICATION NAME]. There were 18 highlighted residents on the list but only 2 residents, #16 and #17, had an order "[MEDICATION NAME] Emergency 1 mg". The Interim DON stated she would find out what the "PAR level" (house stock available) for [MEDICATION NAME] was for the facility. She further stated the pharmacy and nursing staff were responsible for ensuring medications were available for resident use. However, she was not able to elaborate on the system in place for the requisition of medications and staff responsible for stocking medications upon delivery. Interview on [DATE] at 3:45 p.m. with the Interim DON confirmed Resident #1 also had a standing order for [MEDICATION NAME]. She stated Resident #1 was administered [MEDICATION NAME] on [DATE] because she was hypoglycemic. She stated prior to that Resident #3 was administered [MEDICATION NAME] on [DATE] for the same reason. The Interim DON again stated staff would be most concerned about residents on high levels of insulin because they could "bottom out" and [MEDICATION NAME] would be needed. She stated additional [MEDICATION NAME] pens would be delivered at 6:00 p.m. on this date even though they had the 1 [MEDICATION NAME] pen. Interview on [DATE] at 4:15 p.m. with the Interim DON revealed the facility "PAR level" for [MEDICATION NAME] was 1. She stated they had the 1 [MEDICATION NAME] pen but ordered more because the 1 [MEDICATION NAME] pen was not enough in comparison to the number of diabetic residents in the facility. The Interim DON provided a document titled, "Consolidated Delivery Sheets" faxed from the pharmacy on [DATE] at 4:01 p.m. The document indicated 1 [MEDICATION NAME] kit was delivered on [DATE] for Resident #3. Review of a Discharge Notice revealed Resident #3 was discharged home on [DATE]. There were no [MEDICATION NAME] pens listed on the document for Resident #1, #16, or #17. The Interim DON stated there was not a policy for the use of [MEDICATION NAME]. An IJ was identified on [DATE] at 4:50 p.m. The ADM and Interim DON were notified and informed an IJ was identified due to the above mentioned findings. They were informed they would have to develop a plan of removal to address all failures and the region would review and approve it before the IJ was removed. Observation on [DATE] at 5:10 p.m. revealed the [MEDICATION NAME] pen found by ADON D was not stored in the Pyxis. Interview at this same time with the Interim DON confirmed this finding and she commented it might be in one of the nurse's carts. Further observation revealed a brown paper bag on top of the counter with medications in it. The Interim DON stated it was a delivery from the pharmacy. She stated she did not know when it was delivered. She could not identify staff responsible for restocking the medications when asked the question. Observation on [DATE] at 5:15 p.m. revealed the [MEDICATION NAME] pen was in a nursing cart assigned to LVN T. The expiration date was ,[DATE]. Interview at this same time with the Interim DON confirmed their "system was broken." Interview on [DATE] at 7:20 p.m. with CPT U revealed they had received a request for a [MEDICATION NAME] kit for Resident #16 on this date. He stated they had not received any other requests for [MEDICATION NAME] kits for any other residents at the facility. Interview on [DATE] at 8:20 p.m. with the ADM, DON, and ADON D confirmed they had developed a plan of removal. Review of the finalized Plan of Removal dated [DATE] read: "Immediate Action: [MEDICATION NAME] is stored in the Pyxis and/or medication room and is available in the facility. We had at least one [MEDICATION NAME] kit in the facility prior to this but due to the potential concern we will get [MEDICATION NAME] for residents with orders + 1 extra. Correction Action: DON and/or ADON will continue to monitor the Pyxis weekly and as needed to ensure emergency medications are replenished as needed via attached monitoring tool. As an extra measure, all licensed nursing staff will be in-serviced regarding replenishing emergency medications upon usage by completing the medication usage slip and fax to the pharmacy to be completed by [DATE]. Nurses who have not been inserviced by then will not be allowed to work until in-serviced by the DON or designee. Monitoring: DON or designee will monitor [MEDICATION NAME] availability daily to ensure it is available for residents that have it ordered. DON or designee will ask 3 nurses daily what they would do if they used the emergency supply of [MEDICATION NAME]. [MEDICATION NAME] availability usage, and replenishing will be discussed in facility QA for no less than 90 days or until substantial complaince has been achieved and sustained. Our physicians and nurse practitioners round frequently and review accu checks, although we can have each individual diabetic reviewed by their MD as soon as possible for the potential need. After hours and on weekends, Charge Nurses are responsible for signing off on meds. And then meds are put on medication carts unless it's a stock/emergency supply, and those are kept in the med room. DON or designee will be responsible for restocking the replacement meds in the Pyxis the day after they are delivered. Reordering stock is the charge nurses responsibility to fill out a slip and fax to the pharmacy when used." Review of an in-service training initiated on [DATE] provided by ADON D revealed 7 nurses who worked full time, PRN, and who worked all shifts were trained regarding the new facility medication protocol. Review of the same in-service training completed on [DATE] revealed an additional 12 nurses completed this training. Further review revealed a document attached which read, "Effective [DATE] all diabetic patients requiring insulin will have a [MEDICATION NAME] emergency kit ordered for them upon admit" and their kit will be kept in "the nurse's treatment cart". Also attached was a form titled, "Emergency Medication Kit Usage Slip." Further review revealed that on [DATE] it was verified that each Resident #1, #16, and #17 had 1 dose of [MEDICATION NAME] available to them and 3 nurses were asked what they would do if they used the dose of [MEDICATION NAME]. Interview on [DATE] at 9:45 a.m. with the previous DON V and nurse consultant C revealed the Pyxis had not been working since mid-[DATE]. They stated the system that had been in place for ordering/re-ordering medications since that time was as follows: the previous ADON/LVN H would check inventory in the Pyxis every Monday and send a fax request of medications needed to the pharmacy. The pharmacy would deliver the ordered medications every week. DON V and nurse consultant C stated nurses would notify the DON and ADON when a medication was low. A medication request would be faxed to the pharmacy and the ordered medications would be delivered on the next schedule delivery date. They stated every nurse had access to the Pyxis but only 2 super users had access to do inventory; the DON and ADON. They stated ADON D set up the user identification for the nurse's and confirmed he had been the ADON about 1 week. They further stated the Interim DON and ADON D would be responsible for ordering/re-ordering medications. DON V stated she had trained the Interim DON prior to her leaving her position and they talked on the phone last week about the process as stated above. Interview on [DATE] at 11:16 a.m. with LVN H confirmed she was the previous ADON for the rehabilitation wing and confirmed the system that had been in place identified by DON V and nurse consultant C. She stated only 1 [MEDICATION NAME] pen was kept in stock. She stated she had not taken inventory or ordered any medications for about 3 weeks. LVN H stated Interim DON did not confer with her yesterday, [DATE], about the facility's requisition of medications. She stated as a floor nurse she would report when a medication "ran out" to the Interim DON or ADON D. LVN H stated ADON D provided training yesterday on the new system for ordering medications. She stated upon admission nurses would order a [MEDICATION NAME] kit for every diabetic resident. She was trained to fill out the form located by the Pyxis every time she took a medication from the Pyxis and then she was supposed to fax the form to the pharmacy the same date as she used the medication. LVN H stated she was never trained before on the use of the Pyxis. Interview on [DATE] at 12:10 p.m. with nurse consultant C revealed the medication requisition history for the facility. Nurse consultant C stated staff who accepted the medications checked off the medication on the fax request list when the pharmacy delivered the medications. This was the facility consolidation of medications ordered and received. The nurse checking the medications would fax in another request if a medication was not delivered according to the faxed list. Nurse consultant C provided inventory sheets dated [DATE], [DATE], [DATE] and [DATE] which revealed [MEDICATION NAME] was delivered on [DATE]. According to a "Consolidated Delivery Sheets" previously provided by the Interim DON revealed 1 [MEDICATION NAME] kit was delivered on [DATE] for Resident #3 making it a total of 2 [MEDICATION NAME] pens delivered to the facility during February 2015. However, review of Resident #1's medical chart revealed she was administered [MEDICATION NAME] on [DATE] and on [DATE]. Review of Resident #3's medical chart revealed she was administered [MEDICATION NAME] on [DATE]. The result was the use of 3 total [MEDICATION NAME] pens during February 2015. This confirmed the facility requisition and consolidation of medications was not accurately capturing [MEDICATION NAME] kits used and kits available in the facility. Interview on [DATE] at 1:50 p.m. with LVN O revealed she was able to identify the protocol followed when a diabetic resident was found to be unresponsive. She stated she would check the nursing cart to check if a [MEDICATION NAME] pen was available for the individual in question if not she would go to the Pyxis for an emergency kit. Observation on [DATE] at 1:56 p.m. revealed 7 [MEDICATION NAME] emergency pens in the Pyxis. Interview at this same time with LVN O confirmed this finding. LVN O stated she was trained to complete the medication form when she took a medication from the Pyxis. She was then to fax it to the pharmacy each time she took a medication from the Pyxis. LVN O stated she had not received training on the use of the Pyxis. Interview on [DATE] at 5:11 p.m. with LVN M revealed she received training yesterday regarding medication usage and storage of the [MEDICATION NAME] emergency pens. LVN M stated she was to document any medication used from the Pyxis and then fax it to the pharmacy. She stated the [MEDICATION NAME] emergency pens would be stored in the Pyxis. Interview on [DATE] at 5:15 p.m. with LVN T revealed she received training regarding medication usage and storage of the [MEDICATION NAME] emergency pens. LVN T stated she was to document any medication used from the Pyxis and then fax it to the pharmacy. She stated the [MEDICATION NAME] emergency pens would be stored in the Pyxis. Interview on [DATE] at 5:26 p.m. with LVN W revealed she received training today regarding medication usage and storage of the [MEDICATION NAME] emergency pens. LVN M stated she was to document any medication used from the Pyxis and then fax it to the pharmacy. She stated the [MEDICATION NAME] emergency pens would be stored in the Pyxis. Review of the facility medication policy dated 2003 revealed "Ordering medications: [REDACTED]. Such medications need to be delivered and administered within(one (1) hour. If available, obtain the initial dose from the emergency kit when necessary. After scheduled business hours, require pharmacy to deliver emergency or stat medications so they can be administered within ONE (1) hour. If available, obtain the initial dose from the emergency kit when necessary. Receiving medications: [REDACTED]. 4. These delivery records are retained for (one year). Operation of the Emergency Medication Kit: 1. Stocking or replacing items to the emergency medication kit shall be completed in the provider pharmcy or in the facility by a pharmacist or certified pharmacy technician under the direct supervision of a pharmacist. Emergency Kit Medication Utilization: 2. When removing medications from the emergency kit the nurse must record this entry on the appropriate form. 3. The pharmacy will be notified of the removed medications so a replacement emergency kit can be obtained, or so the pharmacist may replace the item removed. 4. The nurse will order the medication from the pharmacy so a Rx supply can be delivered by the pharmacy. Recordkeeping and Accountability of medications: [REDACTED]." The facility Plan of Removal provided by the ADM was accepted on [DATE] at 5:50 p.m. and the IJ was removed. While the IJ was removed the facility remained out of compliance at no actual harm with potential for more than minimal harm that was not immediate jeopardy and the scope was a pattern. 3. Record review of Resident #3's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order dated [DATE] read, [MEDICATION NAME] injection PRN if blood glucose <60. Review of a medication error form dated [DATE] revealed LVN M administered an expired [MEDICATION NAME] kit to Resident #3. Review of a Discharge Notice revealed Resident #3 was discharged home on [DATE] between 10:00 and 11:00 a.m. Interview on [DATE] at 12:40 p.m. with RN I revealed she was the weekend supervisor on the weekend of [DATE]. She stated a medication aide alerted the charge nurse that Resident #3 was cool and clammy and the accu-check reading was 35. Resident #3 was not responding. RN stated she and 2 other nurses went looking for [MEDICATION NAME] and could not find any. She stated one of the nurses finally found one in the Pyxis and LVN M administered the [MEDICATION NAME] to Resident #3. RN stated she read the [MEDICATION NAME] wrapper and it had expired either ,[DATE] or ,[DATE]. She stated Resident #3 was transferred to the hospital 10 minutes after the medication was administered. Review of a document dated [DATE] listed 18 highlighted diabetic residents who would potentially need a [MEDICATION NAME] emergency kit.