Every finding on record at South River Rehabilitation and Wellness Center

Based on complaint investigation, a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to monitor residents' nutritional status regarding body weight and failed to timely address significant weight loss. This was evident for one (Resident #1) of two residents reviewed for nutrition during this Change of Ownership (CHOW) and complaint survey.The findings include:On 5/26/26 at 11:33 AM, the surveyor reviewed complaint #3015772. It was noted that the complainant expressed concern regarding Resident #1's significant weight loss.A further review of Resident #1's medical records revealed that the resident was initially admitted on [DATE], transferred to the hospital on 1/17/26, readmitted on [DATE], transferred again on 2/24/26, and readmitted on [DATE].During a review of Resident #1's body weight on 5/26/26 at 1:00 PM, the resident's weight was noted and documented as follows:2/06/26: 171.0 lbs (pounds)3/26/26: 156.2 lbs3/27/26: 153.2 lbs4/07/26: 144.6 lbsResident #1's body weight documented on 3/26/26 was recorded 23 days after their readmission, following a 7-day hospitalization. Additionally, the weight documented on 4/07/26 reflected an 8.6 lbs loss (5.6%) within a 10-day period.During an interview with the Dietitian on 5/26/26 at 1:15 PM, she explained that facility staff are required to assess and monitor newly admitted residents' body weights weekly for four weeks, and monthly thereafter. The surveyor reviewed Resident #1's weight records with the Dietitian, who verified that there was a lack of body weight documentation following the resident's most recent readmission on [DATE]. Furthermore, the Dietitian confirmed that no interventions or follow-up care were provided regarding the significant weight loss noted on 4/07/26.On 5/26/26 at 1:50 PM, the surveyor shared concerns with the Director of Nursing (DON) regarding the lack of monitoring of Resident #1's nutritional status and body weight, as well as the lack of interventions for the significant weight loss. The DON validated the findings and acknowledged that the facility was aware of the issue.

Based on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to ensure appropriate wound assessment and timely specialist consultation. This was evident for one of one resident (Resident #1) reviewed for pressure ulcers during this Change of Ownership (CHOW) and complaint survey. The findings include:On 5/26/26 at 11:33 AM, the surveyor reviewed complaint #3015772. It was revealed that the complainant expressed concern regarding Resident #1's wound care.A review of Resident #1's medical records revealed a history of multiple transfers and readmissions: the resident was initially admitted on [DATE], transferred to the hospital on 1/17/26, readmitted on [DATE], transferred again on 2/24/26, and readmitted on [DATE].The medical record review further revealed the following documentation gaps and discrepancies:-Initial admission [DATE] - 1/17/26): The Nursing admission Evaluation dated 1/08/26 documented that Resident #1 had pressure ulcers on the sacrum, coccyx, and groin. However, there was no follow-up documentation regarding these wounds from the contracted wound specialist (Nurse Practitioner) until the resident was transferred to the hospital on 1/17/26.-First readmission [DATE] - 2/24/26): Following readmission on [DATE], the contracted wound specialist assessed the resident on 1/27/26, with a follow-up assessment on 2/10/26. There were no wound care records for the first week of February.-Subsequent readmission and April/May Assessments: On 5/28/26 at 7:30 AM, a review of the medical records showed the wound NP evaluated the resident on 5/01/26. The NP documented a left buttock unstageable pressure ulcer measuring 4 x 4.5 x 0.3 cm and a right buttock unstageable pressure ulcer measuring 1.5 x 2.5 x 0.2 cm. Despite these severe findings, there was a total lack of specialized wound assessments during the last week of April.-Facility Assessment Discrepancies: A review of the facility's internal weekly skin assessments revealed conflicting data. The facility recorded no new skin area noted on 4/29/26, a non-pressure new area noted on 4/30/26, and no new skin issue noted on 5/07/26.During an interview with Resident #1's family member on 5/26/26 at 12:47 PM, the family member stated, [Resident #1] did not have a buttock wound during the hospital stay. No one updated us about his/her new wound.During an interview with the Director of Nursing (DON) on 5/26/26 at 1:50 PM, she explained that the facility utilizes a contracted wound care company whose Nurse Practitioner (NP) visits twice a week: on Thursdays to evaluate all new admissions (regardless of whether they have an existing wound) and on Tuesdays to follow up on residents with existing wounds. The DON also stated that the facility has a designated internal wound care nurse.The surveyor reviewed Resident #1's medical records with the DON, who validated the findings and acknowledged the lack of required wound assessments.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's comprehensive care plan specified the level of assistance the resident required for bathing and the resident's frequent refusals of showers for 1 (Resident #2) of 3 sampled residents reviewed for activities of daily living. Findings included: A facility policy titled, Refusal of Care, dated 04/2026, indicated, It is the policy of [facility name] to respect and uphold each resident's right to refuse treatment, medication, or any aspect of care. The policy specified, The care plan will be updated to reflect the refusal pattern. An admission Record revealed the facility admitted Resident #2 on 03/29/2026. According to the admission Record, the resident had a medical history that included a diagnosis of primary osteoarthritis of the right shoulder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/31/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #2's Care Plan Report included a focus area initiated 03/29/2026, that indicated the resident had activity of daily living self-care performance. There was no evidence on the Care Plan Report to specify the level of assistance the resident required for bathing or refusal of care. Resident #2's shower sheets dated 04/01/2026, 04/04/2026, 04/08/2026, 04/11/2026, 04/15/2026, 04/18/2026, 04/22/2026, 04/25/2026, and 04/29/2026 revealed Resident #2 refused their shower but accepted a bed bath on all days, with the exception of 04/18/2026. During an interview on 05/14/2026 at 11:03 AM, Certified Nursing Assistant #2 stated he cared for Resident #2 a couple of times, and the resident refused care frequently. During an interview on 05/15/2026 at 11:51 AM, Licensed Practical Nurse (LPN) #1 stated Resident #2 refused showers. LPN #1 stated she would expect refusals to be care planned if it became a pattern. During an interview on 05/15/2026 at 12:21 PM, the Unit Manager (UM) stated a resident's refusals should be care planned. The UM confirmed Resident #2 refused showers and confirmed the resident's care plan did not include the resident's refusal. During an interview on 05/15/2026 at 1:16 PM, the MDS Coordinator stated if a resident refused care or showers, it should be added to the resident's care plan. Per the MDS Coordinator, if Resident #2 refused care offered by the floor staff, they would have been responsible for updating the resident's care plan with that information. During an interview on 05/15/2026 at 2:09 PM, the [NAME] President of Clinical Operations (VPCO) confirmed she was filling in for the Director of Nursing. The VPCO stated she would expect refusals to be care planned and the nursing team was responsible for updating the resident's care plan. During an interview on 05/15/2026 at 2:15 PM, the Administrator stated refusals of care should be care planned by the nursing department.

Based on observation and interviews, it was determined that the staff failed to perform consistent hand hygiene in between resident interactions. This was evident for 2 (Staff #19 and #20) out of 2 staff observed during the medication administration task. The findings include: On 03/11/2026 at 7:25 AM, the surveyor observed LPN #19 administering medications to Rooms 121, 122 and 129. The surveyor noted that Staff #19 only performed hand hygiene after leaving room [ROOM NUMBER]. On 03/11/26 at 7:36 AM, the surveyor observed LPN #20 administering medications to rooms [ROOM NUMBERS]. The surveyor noted that Staff #20 only performed hand hygiene after leaving rooms [ROOM NUMBERS]. On 03/13/26 at 9:55 AM, [NAME] President of Infection Preventionist acknowledged the concerns.

Based on observations, staff interviews and surveyor record review it was determined that the facility failed to maintain sanitation practices in the kitchen and in the nursing unit nourishment refrigerator. This finding was found to be evident in review of the kitchen, service area and the nourishment refrigerator on the nursing unit. The findings include: On the initial tour of the kitchen and service area at 7:45 AM on 3/9/2026 with the Food Services Director (FSD) and District Manager the following were observed: in the dry storage room was a pair of shoes in a plastic recycle bag and 4 boxes of disposable gloves in a cardboard box under the storage rack in the corner on the floor in the walk-in freezer was a personal bag of lunch including a frozen entrée in the corner on the top shelf items on both sides of the service hall outside the kitchen – wheelchair, metal cart, maintenance cart and 3 cardboard boxes with bottles of chemicals directly on the floor The FSD on 3/9/2026 during this initial tour removed the shoes, boxes of gloves and personal bag of lunch from the kitchen walk-in freezer and the dry storage room. At 8:10 AM on 3/10/2026 with the Director of Nursing (DON) in attendance the nourishment refrigerator and freezer were observed on station 2 nursing unit. The following items were stored in the nourishment refrigerator not dated: take-out pizza box, plastic container of fruit, paper bag with food items inside, and disposable paper bowl with vegetables. The following items were stored in the nourishment freezer not labeled with name and date: a large chick filet milkshake cup with lid full of frozen substance, and a large McDonald's plastic cup with straw and lid 1/4 full of frozen substance. In an interview on 3/10/2026 with the DON during this observation, the surveyor asked what the expectation was for food items in the nourishment refrigerator and freezer. DON stated that the food items should be labeled with Resident name and dated. Additionally, the DON confirmed with the surveyor that only Resident food items were to be stored in the nourishment refrigerator and freezer. The surveyor reviewed the facility's Storage of Resident Food policies and standard procedures on 3/10/2026 at 9:25 AM. The policy indicated that refrigerators / freezers for storage of foods brought in by visitors will be properly maintained, daily monitoring for refrigerated storage duration and discard of any food items that have been stored for equal to or > than 7 days, and food not for immediate consumption will be properly contained and labeled for storage to be consumed at a later time. Additionally, the dietary staff will monitor refrigerator contents for food safety and reserve the right to dispose of outdated, expired, unsafe foods or otherwise foods unfit for consumption. No additional information was provided by the facility at the time of the survey exit.

Based on record review and interview, it was determined that the facility failed to perform accurate Minimum Data Set (MDS) assessments. This was found to be evident for 3 (#3, #45, and #107) of 18 residents observed for coding accuracy of MDS assessments.The findings include:The MDS, is a federally mandated assessment tool, that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. Accurate MDS assessments ensure each resident receives necessary care. 1) On 3/9/2026 at 11:30 AM the surveyor observed Resident #45 who was sitting in wheelchair in Resident room with left arm in a sling. Resident #45 stated that he/she was going to physical therapy here at the facility because he/she fell at home and broke shoulder. The surveyor conducted a record review of Resident #45's medical record on 3/10/2026 at 2:20 PM. Review of the medical record revealed that Resident #45 fell in the walk-in closet at home and sustained a closed left scapular fracture. Further review of the medical record revealed that the 2/13/2026 Admission/Medicare – 5 Day Minimum Data Set (MDS) assessment Section J1800/1900 was coded that Resident #45 had falls since admission and that one fall was coded as no injury and that another fall was coded as major injury. Continued review of the medical record revealed that Resident #45 did not have any falls in the facility. In an interview with the Director of Nursing (DON) at 2:35 PM on 3/10/2026 the surveyor asked if Resident #45 had fallen in the facility and the DON stated that the Resident did not have any falls in the facility since admission. Resident #45 was admitted to facility from the hospital on 2/9/2026 with a fractured scapula. The DON was notified that Resident #45's Admission/Medicare – 5 Day MDS assessment was inaccurately coded for falls. The surveyor conducted an interview with the Lead Registered Nurse MDS Coordinator at 2:45 PM on 3/10/2026. The surveyor conveyed to the MDS Coordinator that Resident #45 did not fall in the facility since admission on [DATE] and that Resident was admitted with a fractured shoulder due to a fall at home. The surveyor reviewed Resident #45's 2/13/2026 Admission/Medicare – 5 Day MDS assessment with the MDS Coordinator and stated that the MDS assessment was coded that the Resident had 2 falls in the facility since admission, one fall with no injury and one fall with major injury. The MDS Coordinator acknowledged the surveyor and stated that the 2/13/2026 Admission/Medicare – 5 Day MDS was coded inaccurately for falls as Resident #45 did have any falls in the facility and further stated that she would complete a correction to the admission MDS as that was the facility's policy for inaccurate coding of MDS assessments. In a follow-up review of Resident #45's medical record on 3/10/2026 at 3:20 PM it revealed that there was a 2/13/2026 Modification of Admission/Medicare – 5 Day MDS assessment completed on 3/10/2026 at 2:52 PM Section J1800/1900 which was coded that Resident had no falls since admission. On 3/12/2026 at 7:52 AM the surveyor conducted a record review of Resident #107's closed medical record. Review of the medical record revealed that Resident #107 had 2 falls in the facility, one on 2/11/2026 with no injury and one on 2/16/2026 with injury (except major). Further review of the medical record revealed that there were the following MDS assessments completed: 2/1/2026 Admission/Medicare – 5 Day, 2/20/2026 End of PPS Part A Stay, 2/25/2026 Quarterly – None PPS, and 2/28/2026 Discharge Return Anticipated. The 2/20/2026 End of PPS Part A Stay MDS Section J1800/1900 was coded that Resident #107 had a fall with no injury and had a fall with injury (except major) which would include the 2 falls on 2/11/2026 and 2/16/2026. However, further review of the MDS assessments revealed that the 2/28/2026 Discharge MDS was coded that Resident #107 had one fall with no injury and one fall with injury (except major). There was no documentation that Resident #107 had any additional falls in the facility. In an interview with the Director of Nursing (DON) at 11:30 AM on 3/12/2026 the surveyor reviewed Resident #107's falls. The DON confirmed that Resident #107 had only 2 falls, one on 2/11/2026 with no injury and one on 2/16/2026 with injury (except major). Additionally, the surveyor conveyed that the 2/28/2026 Discharge MDS was coded that Resident had 2 falls, however, these falls were already coded on the 2/20/2026 End of PPS Part A Stay MDS assessment. In a follow-up review of Resident #107's medical record on 3/12/2026 at 1:50 PM it revealed that there was a 2/28/2026 Modification of Discharge Return Anticipated MDS assessment completed on 3/12/2026 at 12:02 PM Section J1800/1900 which was coded that Resident had no falls since prior MDS assessment. At 3:10 PM on 3/12/2026 the surveyor reviewed with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA) and the Regional Director of Clinical Services the concern with Resident #107's falls and inaccurate coding on the 2/28/2026 Discharge Return Anticipated MDS assessment. 2) On 03/11/2026 at 9:11 AM, the surveyor reviewed Resident #3's Quarterly MDS assessment dated [DATE]. The assessment read: Section N - N0350 Insulin, A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. The number was 7. The electronic medical record did not contain any orders for insulin. The surveyor interviewed the MDS Coordinator on 03/11/2026 at 9:37 AM. When the surveyor questioned the coding, the Coordinator stated, I coded Ozempic as an insulin, but that is an error. I will prepare a modification now. On 03/11/2026 at 9:42 AM, the Administrator acknowledged the incorrect coding and stated it would be corrected.

Based on observations and facility staff interviews it was determined that the facility failed to maintain a safe clean comfortable homelike environment for Residents. This finding was found to be evident in review of Resident rooms on station 2 nursing unit of the facility during the annual recertification survey.The findings include:On 3/9/2026 at 8:30 AM during the initial tour of station 2 nursing unit several Resident rooms were observed with walls, doors, door frames, and sink counters in disrepair and in need of maintenance and repair. Observations included the following rooms: 211 - door/ doorframe marred, 212 - door/doorframe marred, 213 - wall/door marred, 214 - door marred, 215 - tile loose from wall around sink, 216 - door marred, sink counter warped, 217 - doors marred, 218 - tile missing around sink, marred door, no remote for television, 220 - door marred, 221 - wall marred, door marred with chipped wood, 222 - doorframe/ door marred, 225 - doors marred, 226 - doors marred, 227 - doors/walls marred, bedside dresser 2nd drawer not aligned on track, 228 - bathroom wall and door marred, and 230 - bathroom door marred with 2 holes in the wood, and peeling paint on the bathroom wall adjacent to the sink. The surveyor interviewed the Maintenance Director at 3:15 PM on 3/11/2026. The surveyor conveyed that several Resident rooms on station 2 nursing unit had doors and walls that were marred and chipped, sink counters that were warped and with loose tiles, and doors with chipped wood and holes in the wood. The Maintenance Director stated that he had a plan to repair the marred doors with some type of panel/plate guard on the lower half of the doors, but it takes money to repair the doors and there was a budget. The Maintenance Director accompanied the surveyor to station 2 nursing unit and observed several of the Resident rooms that were in disrepair and in need of repair and maintenance.On 3/13/2026 at 7:35 AM the Licensed Nursing Home Administrator was notified of the physical environment concerns (marred/wood chipped doors) that were observed on station 2 nursing unit.

Based on observations and facility staff interviews it was determined that the facility failed to have call lights accessible for Residents. This finding was found to be evident in 2 (Resident #18 and Resident #75) out of 28 Residents reviewed for accessibility of Resident Call System.The findings include:Resident Call System (or nurse call systems) are essential safety communication tools in nursing homes, enabling Residents and families to alert staff via push-button stations or pull cords. The call station is fixed units in rooms, bathrooms or common areasDuring tour of station 2 nursing unit on 3/9/2026 at 10:15 AM the surveyor observed the attached pull cord/string to the call light device panel next to the toilet in Resident #18's shared bathroom that was short in length. The call light device was not accessible to Resident #18 if he/she was on the floor. Resident #18 was not in his/her room or the bathroom.Additionally, on 3/9/2026 at 12:30 PM the surveyor observed that there was no pull cord/string attached to the call light device panel next to the toilet in Resident #75's shared bathroom. Resident #75 was asleep in bed. In an interview with the Maintenance Director on 3/11/2026 at 3:15 PM the surveyor toured station 2 nursing unit with the Maintenance Director. The surveyor asked what the expectation was for call lights in the Resident bathroom and he stated that the Resident bathrooms should have a call light accessible for the Residents. The Maintenance Director observed the short cord for the call light device in Resident #18's shared bathroom, and no cord for the call light device in Resident #75's shared bathroom. The Maintenance Director stated that he would replace the short cord on the call light device in Resident #18's bathroom, and that he would attach a cord to the call light device in Resident #75's bathroom.On 3/13/2026 at 8:15 AM the surveyor toured station 2 nursing unit and observed that Resident #18 and Resident #75 had accessible pull cords to the call light device panels in each of their bathrooms.

Based on observations and facility staff interviews it was determined that the facility failed to ensure that garbage and refuse was maintained in a proper manner. This finding was found to be evident during the review of the outside dumpster area adjacent to the service hall during the annual recertification survey. The findings include: During the initial tour of the kitchen and the outside dumpster area of the facility on 3/9/2026 at 7:45 AM the surveyor with the Food Services Director (FSD) and District Manager in attendance observed the outside dumpster area. There were 2 trash dumpsters outside. One of the trash dumpsters did not have the attached lid closed on the dumpster. In an interview with the FSD on 3/9/2026 the surveyor asked what the expectation was for the lid being closed on the trash dumpster. The FSD stated that the dumpster should have the lid closed. The FSD closed the lid to the trash dumpster. At 2:10 PM on 3/11/2026 the surveyor observed that the door to one of the trash dumpsters outside the facility was opened. There were no staff in attendance at the outside dumpster area. On 3/11/2026 at 3:10 PM the surveyor observed with the Maintenance Director the door opened to one of the outside trash dumpsters. The Maintenance Director called out to the FSD who was outside to close the trash dumpster door. The Maintenance Director stated that the staff recently took trash out to the dumpster and did not close the trash dumpster door.

Based on facility staff interviews and surveyor record review it was determined that the facility failed to provide notification of room change when a Resident was transferred to another room in the facility. This finding was found to be evident in 1 (Resident #107) out of 10 Residents reviewed for notification of room change.The findings include:The surveyor conducted a record review of the closed medical record for Resident #107 on 3/13/2026 at 6:50 AM related to a complaint that was submitted online to the Office of Healthcare Quality (OHCQ). Review of the medical record revealed that Resident #107 was transferred from room [ROOM NUMBER]-A on station 2 nursing unit to room [ROOM NUMBER]-B on station 1 nursing unit on 2/4/2026. Further review of the medical record revealed that there was no documentation that indicated that Resident #107 and/or Responsible Party were notified of the room change.In an interview with the Director of Nursing (DON) at 8:38 AM on 3/13/2026 the surveyor conveyed that Resident #107 was transferred from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B on 2/4/2026, and that there was no documentation in the medical record that Resident #107 and/or Responsible party were notified of the room change. The DON stated that she would look for the room change notification for Resident #107.In a follow-up interview with the DON at 9:20 AM on 3/13/2026 the DON stated that she was unable to locate documentation of notification of room change for Resident #107, but she was still looking for it. The surveyor asked what the expectation was for the facility to document notification of a room change to the Resident and/or Responsible Party. The DON stated that it was the expectation of the facility to notify the Resident and/or Responsible party of the room change and to document in the medical record the notification of room changes.At the time of survey exit no information was provided by the facility for notification of room change for Resident #107.

Based on record review and interviews, it was determined that the facility failed to ensure that physicians and Responsible Party (RP)'s were notified of changes in a resident's condition. This was evident for 1 (Resident #6) of 1 resident reviewed for nutrition. The findings include: Center for Medicare and Medicaid (CMS) defines a significant unintentional weight loss as a loss of 5% of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days On 3/9/26 at 8:21 AM, the surveyor interviewed Resident #6. During the interview Resident #6 stated that he/she was not interested in his/her breakfast and only consumed the drinks. On 3/10/26 at 12:45 PM, the surveyor observed that Resident #6 did not eat his/her lunch but only drank the two juices. On interview Resident #6 stated that he/she did not like what was served for lunch. On 3/11/26 at 11:01 AM, the surveyor reviewed Resident #6's medical record. The review revealed that Resident #6 had been admitted to the facility in May of 2025 and on 6/2/25 Resident #6' attending physician assessed that Resident #6 lacked adequate decision making capacity. On further review it was noted that Resident #6 weighed 173 pounds (lbs) on 1/5/26 and weighed 155 lbs on 3/2/26. This was an 18 pound loss in less than three months, a 10.4 % weight loss. Next the surveyor reviewed a progress note written by a Dietitian that noted the weight loss and increased Resident #6's med pass (fortified nutritional shakes that provide supplemental calories and protein) from twice a day to three times per day along with increasing weights from monthly to weekly. The note stated that the interdisciplinary team was aware and that laboratory orders were done per providers. The surveyor reviewed the last provider note written on 2/20/26. There was no mention of monitoring weight loss, only a comment of, eating well, and a noted weight of 168 lbs dated 2/6/26. On 3/11/26 at 10:34 AM, the surveyor conducted an interview with Dietitian #15. During the interview the surveyor asked how providers are notified when a Resident has significant weight loss. Staff #15 stated that she discussed weight loss at the weekly risk meeting and that nurses and the medical director are made aware at that time. On 3/11/26 at 2 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked the DON what the process was for notifying the provider or RP when there is a significant weight loss. The DON stated that a change of condition note should be completed that documents the provider and RP were notified and the actions taken. The surveyor reviewed the concern that there was no documentation in Resident #6's medical record that indicated that the provider or the RP were notified that Resident #6 had a significant weight loss.

Based on interview, observation, and record review, it was determined that the facility failed to provide treatment and services to maintain hearing abilities. This was evident in 1 (Resident #81) out of 8 residents reviewed for vision and hearing during the recertification survey. The findings include:On 03/09/26 at 9:26 AM, the surveyor interviewed Resident #81 during the initial observation. The resident tapped their right ear and mouthed bed bath The resident had a journal on their bedside table and confirmed that they use it to communicate with staff. Resident #81 stated they have never worn hearing aids. Shortly after the interview, the resident's roommate reported that staff typically speak loudly when communicating with Resident #81. On 03/13/26 at 7:45 AM, the surveyor conducted another interview with Resident #81. During this interview, the surveyor typed questions for the resident to answer. The resident stated that the facility assessed their hearing well over a month ago and had not followed up. On 03/13/26 at 8:00AM, the surveyor performed a record review and discovered that the facility was aware of the resident's hearing loss. This was confirmed through various documentation found in the resident's Electronic Health Record (EHR). The onset date for unspecified hearing loss, unspecified ear was noted on 04/01/2025.The Treatment Administration Record (TAR) included a start date of 02/15/2024 for as needed consults with Audiology, Dental, Optometry, Ophthalmology and/or Podiatry. The resident's care plan was initiated on 02/16/2024 and revised on 10/21/2024, indicated that the resident was at risk for a communication problems and had poor hearing in the right ear.The quarterly Minimum Data Set (MDS) dated [DATE] noted that the resident's ability to hear was moderate difficulty. Resident #81 was referred on 01/05/26 by doctor due to a complaint of newly decreased hearing. On 01/08/26, the resident was evaluated by Audiologist. The clinical findings determined that both ears were non-occluded and that there was moderately severe to profound sensorineural hearing loss in both ears. The audiologist recommended hearing aids for both ears, and impressions were taken. A signed and dated note from the audiologist on 01/08/26 stated: Patient is eager for amplification to improve hearing in all situations. Improved hearing will allow patient to enjoy attending activities more frequently. Improved hearing will help the patient to hear and understand nursing staff or interactions. Improved hearing will help the patient become as independent as possible through improved understanding and safety.The audiologist's note included that the resident would need a medical consult to obtain medical clearance for the hearing aids. On 03/13/26 at 9:00 AM, the Unit Manager began addressing the concern.

Based on observation, medical record review and interviews, it was determined the facility staff failed to clarify and document appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (resident #10) of 1 resident reviewed for mobility. The findings include: A contracture is an abnormal shortening of muscle, tendons, skin, or tissues, causing the resistance to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. On 3/13/26 at 7:36 AM, the surveyor observed Resident #10 resting in bed. His/her left hand was noted to be contracted, and no splint was applied or visible in the room. Next the surveyor reviewed Resident #10's orders. The review revealed two orders for a left hand splint. The first order was written on 5/29/26 that stated, nursing to don (apply) left hand splint following morning Activities of Daily Living (ADLs). The patient should be able to remove following about 4 hours and to monitor skin integrity. The next order was written on 9/18/25 and stated, nursing to apply left hand orthotic following ADLs and again to monitor skin integrity. The surveyor reviewed Resident #10's Treatment Administration Record (TAR). The review revealed neither order was placed on the treatment record and no documentation of application and removal was present. On 3/13/26 at 8:30 AM, the surveyor conducted an interview with Unit Manager #14. During the interview the surveyor asked if Resident #10 had a splint. UM #14 stated that he/she did and it was applied for 4 hours a day. The surveyor asked if the application was documented in the medical records. UM stated it was documented in the TAR and would provide a copy. Next the surveyor reviewed the Occupational Therapy (OT) discharge summary note dated 9/19/25. The summary reported the patient's response and stated, Resident #10 reported decreased pain in the left hand/wrist during movement. It continued and stated that the patient demonstrated increased tolerance for left hand orthotic for more than 4 hours with no signs of redness or irritation. On this same day the newest order for the hand splint was ordered without the 4 hour limit. On 3/13/26 at 9:22 AM, the surveyor conducted a follow-up interview with UM #14. During the interview UM#14 stated that the order for the splint never appeared on the TAR and that there was no documentation to demonstrate the splint's application for Resident #10. The surveyor also reviewed the concern that there were two orders written and that there was no clarification as to what order should be followed. UM #14 stated she would clarify the order with therapy and that therapy usually communicates these changes with the Unit Manager at the time of the change.

Based on Resident and staff interviews, observations and surveyor record review it was determined that the facility failed to ensure that a Resident's food preferences, food intolerances and food allergies were followed. This finding was found to be evident in 1 (Resident #41) out of 8 Residents reviewed for food and nutrition services.The findings include:On 3/9/2026 at 11:15 AM Resident #41 stated to the surveyor that he/she had a food intolerance to dairy products, but he/she continues to receive dairy products on the meal trays.The surveyor conducted a record review of Resident #41's medical record on 3/11/2026 at 10:45 AM. Review of the medical record revealed that Resident #41 had an allergy to dairy products as indicated on the physician orders/order summary report. Further review of the Diet History/Food Preferences assessment completed by the Food Services Director (FSD) on 2/11/2026 revealed that Resident #41 had a food allergy/intolerance to dairy products.In an interview with the FSD at 12:15 PM on 3/11/2026 he stated that Resident #41 had a food preference not to receive dairy products and that this was indicated on the Resident's meal tray tickets.At 7:40 AM on 3/13/2026 the surveyor observed Resident #41 in bed eating his/her breakfast tray. Resident #41 had an 8 oz carton of whole milk on the breakfast tray. Resident stated that there was not supposed to be milk on the meal tray and that it was wasteful to have milk on the meal tray because he/she has a dairy intolerance and cannot drink the milk.The surveyor reviewed the meal tray ticket that was on Resident #41's breakfast tray and Milk - 8 oz was indicated on meal tray ticket. Additionally, the meal tray ticket indicated Resident #41's name, breakfast, and date of 3/13/2026.In a follow-up interview with the FSD at 7:45 AM on 3/13/2026 the surveyor conveyed that Resident #41 had a carton of milk on his/her breakfast tray and that the meal ticket on the breakfast tray had Milk - 8 oz indicated on it. The FSD reviewed the breakfast meal ticket and stated that it was incorrect, and that Resident #41 was not supposed to have milk on the meal ticket or on the meal tray.At 9:04 AM on 3/13/2026 the FSD provided the surveyor with a corrected copy of the breakfast meal ticket which did not have milk indicated on the meal ticket.

Based on record review and interviews with staff, it was determined that the primary medical provider failed to review the total program of care for 1 (Resident #11) out of 43 residents reviewed during the survey. The findings include: On 3/9/26 at 8:38 AM, the surveyor interviewed Resident #11. During the interview Resident #11 stated that he/she had recently been admitted to the facility after a hospital stay and alleged that the facility was not following his/her transplant drug regimen correctly. On 3/10/26 at 8:01 AM, the surveyor reviewed Resident #11's medical record. Review of Resident #11's discharge paperwork revealed Resident #11 was discharged to the facility on 2/19/26. The medications were ordered as recommended, however, in the course of stay from the hospital report it was noted that Resident #11's renal function was improving and stable but recommended that Resident #11 needed to have repeat labs such as a Basic Metabolic Panel (BMP) in 1 week. The discharge instructions stated, Labs Needed at Rehab: followed by, please check hematocrit and BMP weekly on Mondays while at rehab. Next the surveyor reviewed the new patient note written by the provider on 2/20/25. The note acknowledged Resident #11's transplant and medications, however, no laboratory monitoring was mentioned or ordered. On 3/11/26 at 9:37 AM, the surveyor requested all laboratory orders for Resident #11 from the Director of Nursing (DON). On 3/11/26 at 2 PM, the surveyor conducted an interview with the DON. During the interview the DON confirmed that the only laboratory order written was for the lab that was to be drawn on 3/10/26. The surveyor reviewed the concern that Resident #11 had been admitted for over two weeks and never had the weekly labs that were recommended to be drawn while in rehab.

Based on observation, interview, and record review, it was determined that the pharmacy failed to deliver the correct medication dosages to the facility. This was evident in 1 (Resident #95) out of 6 residents evaluated for accurate dispensing during the medication administration task. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The findings include: On 03/11/26 at 8:00 AM, the surveyor observed a discrepancy between Resident #95's Diazepam order and the pharmacy script. The resident's active order stated: Diazepam 2mg tablet. Give 1.5 tablets by mouth in the morning for anxiety. Please hold for sedation, while the script stated: Diazepam 2 mg tablet. Give 1 tablet by mouth in the morning for anxiety. The tablets in the bubble packet were only available in one strength and form, consisting of whole 2 mg tablets. On 03/11/26 at 8:03 AM, the surveyor interviewed Staff #19. Staff #19 stated that they administered 1.5 tablets by splitting the available 2mg Diazepam tablets. On 03/11/26 at 12:20 PM, the surveyor interviewed a senior pharmacy technician at Pharmscript. The senior pharmacy technician confirmed that an active script was sent out and received on 03/03/26. Pharmscript reported that they are responsible for providing both partial and whole tablets for specific dosages, such as Resident 95's active order of Diazepam. The technician also reported that the former order was not picked up by the pharmacy and the new Diazepam was not delivered to the facility. The technician added that the delivery was anticipated later in the afternoon or evening. On 03/11/26 at 12:30 PM, the surveyor reviewed the facility's medication administration policy and controlled substances policy. The medication administration policy stated Do not split or alter tablets and Contact pharmacy for correct dosage. The controlled substance policy stated When the prescribed drug is discontinued, or the resident is discharged , the container and control sheet must be removed for drug destruction. Resident #95's 2 mg Diazepam bubble packet containing whole tablets and the corresponding control sheets were still present during medication administration on 03/11/26. On 03/11/26 at 12:45PM, the Unit Manager acknowledged the concerns.

Based on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #9) of 1 resident reviewed for dental services during the survey. The findings include: On 3/9/26 at 8:10 AM, the surveyor interviewed Resident #9. During the interview Resident #9 stated that he/she was still waiting for the facility to follow up on making an appointment for his/her bottom teeth. On 3/11/26 at 7:30 AM, the surveyor reviewed Resident #9's medical record. The review revealed that a dental consult note written on 9/11/25 stated that Resident #9 was seen for a tooth extraction. The note stated that the resident was not able to tolerate the procedure and stated the safest course would be extractions under General anesthesia in the hospital setting. The recommendations were to refer Resident # 9 to Oral and Maxillofacial Surgery OMFS at a local hospital. On further review a dental note was written by a dental provider that sees residents in the facility and was dated 11/3/25. The reason for the visit was the initial exam. The note recommended cleaning every 6 months and stated partial dentures reported missing at the hospital and would recommend Full Mouth Xray (FMX) to further evaluate teeth for extractions and dentures. Resident #9 was seen again on 1/2/26 by the inhouse dental provider for step 1 for dentures. The recommendations were for extractions of retained roots for 9 teeth and again for Full Mouth Xray (FMX) to evaluate teeth further. Resident #9 was seen again on 2/17/26 by the inhouse dental provider due to a request to be seen by the facility for extraction. The note stated that x-rays were not taken and that a successful extraction could not be guaranteed. The note stated the extraction attempts were not successful and after the procedure Resident #9 informed the provider he/she was referred to the hospital for extraction but there had been no follow-up. This provider also documented a referral for an oral surgeon. On 3/11/26 at 8:04 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor relayed the concern that the original recommendation for Resident #9 to be seen in a hospital setting for oral surgery care was not acted upon and after several visits by the in-house dental provider the same recommendation was made 6 months later. The DON stated she would look into the issue. On 3/11/26 at 9:35 AM, the surveyor conducted a follow-up interview with the DON. During the interview the DON stated that after the most recent visit the facility had been pursuing the oral surgery consultation for Resident #9 but agreed that they only started the process after the visit on 2/17/26 and not on the September recommendation which was 6 months prior. Additionally, no documentation was provided to demonstrate the requested x-rays had been completed even with several requests

Based on observation, record review and interview, it was determined that the facility failed to ensure that a controlled medication was labeled and stored properly. This was evident for 1 (Resident #95) out of 6 residents observed during the medication administration task. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The findings include: On 03/11/26 at 8:00 AM, the surveyor observed a discrepancy in Resident #95's medication order. Staff #19 retrieved a bubble packet for Resident #95 labeled, Diazepam 2 mg tab. Give 1 tablet by mouth in the morning for anxiety. When the surveyor checked the order in the Medication Administration Record (MAR), the script on the medication bubble packet did not match the active order. The order on the bubble packet had been discontinued on 03/03/26, and the new order was initiated on 03/04/26. The active order was Diazepam 2mg. Give 1.5 tablets by mouth in the morning for anxiety. Please hold for sedation. The surveyor interviewed Staff #19 to verify the resident's order. Staff #19 confirmed that the order was to give 1.5 tablets of Diazepam and stated they had already administered the dose to Resident #95. On 03/11/26 at 8:03 AM, the surveyor observed half a tablet that had been placed back into Resident #95's previously punctured bubble. Staff #19 confirmed that they returned half a tablet (1mg) of Diazepam to the punctured bubble. Staff #19 stated that Resident #95 did not have an updated order of Diazepam available. On 03/11/26 at 9:30AM, Staff #19 informed the surveyor that they wasted half a tablet of Diazepam that they initially returned to Resident #95's bubble packet. On 03/11/26 at 12:07 PM, the Unit Manager acknowledged the concerns.

Based on observations and staff interviews, it was determined that the facility failed to ensure the call bells were within reach of a resident. This was evident in 1 (Resident #79) of 1 resident reviewed for access to the call system during the recertification survey. The findings include: On 12/2/2024 at 8:33 AM, Resident #79's call bell was observed by surveyors on the floor next to their bed. Further observation on 12/4/2024 at 8:36 AM again revealed Resident #79's call bell on the floor. Geriatric Nursing Assistant (GNA) #11 was interviewed by surveyors on 12/4/2024 at 8:40 AM. GNA #11 confirmed the call bell was on the floor and picked up the call bell and placed it next to the resident. Resident #79's call bell was observed by surveyors on 12/5/2024 at 8:58 AM to be on the floor behind their bed. Licensed Practical Nurse (LPN) #15 was interviewed at 8:59 AM and stated expectations that the call bell is always within reach of the resident. LPN #15 then picked up the call bell and placed it next to the resident. LPN #15 further stated that there was no clip for the call bell and would get one. On 12/5/2024 at 10:56 AM, Registered Nurse Unit Manager (RN) #8 was interviewed about the facility's call bell policy. RN #8 stated it is expected that call bells to always be within reach of residents. Concerns about Resident #79's call bells were addressed by surveyors with the Director of Nursing (DON). The DON acknowledged the concerns and stated that facility's expectations are that call bells should be accessible to residents.

Based on observations and staff interviews, it was determined the facility failed to provide a resident with an environment that promotes a dignified existence. This was evident for 1 (Resident #349) of 8 residents reviewed for dignity. The findings include: On 12/2/24 at 8:25 AM, an observation was made of Resident #349's room. A clear plastic bag was lining the commode. Inside the bag was a yellow-colored liquid with a piece of toilet paper inside. This Surveyor took a picture of the commode. On 12/2/24 at 8:27 AM, an interview was conducted with Registered Nurse (RN) #3. When asked why the resident had a plastic bag over the commode, RN #3 stated they were not sure but stated that the resident does things their way. On 12/3/24 at 10:30 AM, an interview was conducted with RN #7. When asked why there was a bag over the commode, the nurse stated they used bags to dispose of the waste when Resident #349 had a stomach infection recently and kept using a plastic bag to line the commode even after the resident was cleared from the infection.

Based on review of the facility investigation, medical records, interviews with facility staff and other pertinent documentation it was determined that the facility failed to 1) notify the physician when it was discovered on 10/14/19, that the side of the tip of Resident #72's penis was discolored (brownish in color) and had a white milky discharge; 2) to document that an assessment was done during the initial findings, which resulted in a delay in treatment, and 3) provide and implement a revised plan of care to meet the resident needs. This was true of 1 (Resident #72) of 45 residents reviewed as part of the annual survey. Based on the findings, on Thursday, (MONTH) 31st, 2019 at 10:30 AM an Immediate Jeopardy was called related to the quality of care for Resident #72. The facility submitted a revised plan of action at 5:06 PM on 10/31/19 that was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted on, 10/31/19 at 5:25 PM, but the immediate jeopardy was not removed until 11/4/19 at 1:05 PM after the plan of correction was implemented. After removal of the immediate jeopardy, the deficient practice remained for 3 days with the potential for more than minimal harm and a scope and severity of a [NAME] The findings include: According to the medical record Resident #72 was admitted to the facility in (MONTH) (YEAR), with a [DIAGNOSES REDACTED]. Degenerate Joint Disease, Chronic Bilateral Lower Extremity wounds, Obesity, Failure to thrive and Depression. According to the hospital discharge summary dated 12/6/18, the resident was transferred to the facility for management of his/her Chronic Bilateral Lower Extremity wounds and rehabilitation services due to the resident's inability to care for him/herself in the community. Review of the resident medical record on 10/28/19 at 11:30 AM revealed a MOLST (Medical Orders for Life-Sustaining Treatment) dated 12/6/18, which indicated the following: (DNR) DO Not Resituate and (DNI) Do Not Intubate, do not transfer to the hospital, but treat with options available outside of the hospital and Do not perform any medical tests for [DIAGNOSES REDACTED]. On 10/14/19, BLE (Bilateral Lower [MEDICAL CONDITION]), Malnutrition/Kwashiorkor and Hallucinations were added to the resident [DIAGNOSES REDACTED]. Review of Resident #72's medical record on 10/28/19 at 11:30 AM, to investigate complaint MD 497 revealed a concurrent review dated 10/15/19 at 3:03 AM, which noted the following: Geriatric Nursing Assistant (GNA) #8 reported to the 11 PM - 7 AM nurse, Licensed Practical Nurse (LPN) #9, about a condition on Resident's #72's penis. Both employees entered Resident's #72's room and the area was assessed. During the assessment it was noted that the resident had a brownish milky discharge on the shaft of the penis with browning spots on the top of the penis. According to the medical record, LPN #9 cleansed the area with soap and water and attempted to contact the on-call physician at 12 AM but was unsuccessful. Review of the medical record on 10/30/19 at 3:30 pm revealed the labs were drawn on the 7-3 PM shift on 10/15/19. However, the results were not available to the facility until approximately 5:36 PM that night, after the end of LPN #19's shift. At that time LPN #26, who was the 3-11 PM nurse, notified the physician of the following critical lab values: Potassium (2.68) (CL) critical low reference range is 3.5-5.3 mEq/ L, BUN (113) (CL) reference range is 7-25 mg/dl. An order was obtained to send the resident out to the hospital. The resident was transported on 10/15/19 at approximately 6 PM by Emergency Medical Services for abnormal labs. In the emergency room , while a Foley was being placed by the nurse, the resident was noted to have necrosis at the tip of the penis. During the interview with the Director of Nursing (DON) on 10/29/19 at 11:30 AM, s/he revealed the following: at 3:03 AM on 10/15/19, (GNA #8) reported to (LPN #9) about a condition on the resident's penis. Both employees entered the room and (Resident #72's) penis was assessed. During the assessment, it was reported they observed brownish milky discharge on the shaft of the penis. The area was cleansed secondary to a resident having a bowel movement and was further evaluated with browning spots on the top of the penis and whitish discharge on the shaft. The DON continued the interview by stating that LPN #9 reported she initiated a concurrent review for a change in condition on 10/15/19 at approximately 3 AM. LPN #9 had intended to report the change in condition in the morning at 6 am to the doctor. During the report to LPN #19, who was the 7-3 PM nurse, LPN #9 informed LPN #19 of Resident #72's change in condition to the penis, then LPN #19 informed LPN #9 that the resident's primary care physician was scheduled to visit during the 7 am- 3 PM shift on 10/15/19, and she would inform the doctor. The DON stated she had no knowledge of the resident having necrosis or any wounds on the penis. She stated according to the facility policy the nurse is to fill out a concurrent review form and once the concurrent review is locked in the electronic medical record, the form would automatically generate to her as an incident. However, the concurrent review was never locked in the electronic medical record by the nurse, so she had no knowledge of the incident until questioned by the surveyor. During the interview with Resident #72's primary physician, Physician #18, on 10/29/19 at 12:45 PM, she stated, On 10/14/19 I was in to see the resident due to a change in physician care. The resident appeared malnourished and the following labs were ordered: CMP, CBC with diff, [MEDICATION NAME], Vit D, Vit B12, folate, and HgA1C. The labs were ordered to be drawn on 10/15/19. Also, a psych consult was ordered due to hallucinations and depression. I was not informed about the penis that was discovered at the facility. During my assessment on 10/14/19, the resident was noted with 3 plus [MEDICAL CONDITION] from the top of the hip to the lower extremities. I was made aware by the nurse the resident was only consuming soda and sweets. Retracting the foreskin and examining the penis is not a part of my normal assessment unless the resident expresses concerns. During the interview, Resident #72's physician gave the opinion that penile necrosis could develop quickly and worsen in hours depending on the cause of the necrosis. She stated that this resident was also malnourished and had 3+ [MEDICAL CONDITION] which could have also precipitated the necrosis. The physician reported, this was the one and only time she had seen the resident. After a discussion with Physician #18 regarding the condition of the penis, the physician stated, If I had known, I would have sent the resident out to the hospital. During an interview with GNA #8, at 5:40 AM on 10/30/19, he stated, around 7:30 PM to 8:00 PM on 10/14/19 during PM care of (Resident #72), I noticed the resident had a discoloration on the penis after pulling back the foreskin. I notified the 3-11 PM nurse, (LPN #22) about the area on the penis and she replied: 'I am not familiar with the resident and I'll check it out.' I heard no additional information about this resident during the 3-11 PM shift, and nor did I see (LPN #22) do an assessment. I worked a double on 10/14/19 3-11 PM shift on unit 1 and 11-7 AM on unit 2. When the 11-7 AM nurse (LPN #9) came in for the 11-7 AM shift and asked that I help out with another resident, I then made (LPN #9) aware of (Residents #72's) area on the penis and asked if I could show it to her. I went to another nurse because the previous nurse, (LPN #22), had said she wasn't familiar with that resident and I hadn't heard an outcome on the skin issue yet. (LPN #9) and I both went into the resident's room to assess the penis and the resident was soiled. After assisting the resident, I returned to the other unit where I was scheduled and finished my shift. During an interview with LPN #9, on 10/30/19 at 6:05 AM, the following was said: I came in on the 11-7 AM shift on 10/14/19. I was not notified that there was a problem with (Resident #72's) penis at the change of shift from (LPN #22). Immediately, Resident in 106 reported that someone was knocking at his/her window. I called unit 2 to ask for assistance from (GNA #8) (for safety). When he was over with me, he asked me if he could show me something. I was confused because he was not working on Unit 1 at that time. I accompanied him to (Resident #72's room). (GNA # 8) then pulled back the foreskin and showed me the resident's penis. It was horrible. We cleaned the resident up s/he was soiled, and (GNA, #8) went back to the unit. Early in the shift, I attempted to contact the on-call physician who did not respond. This was around 12:00 AM on 10/15/19. Around 2:30 AM, I requested (GNA #8) to accompany me back to the residents' room. We then removed the diaper and I soaked the penis to see if the dark area on the tip of the penis was possibly dried stool. It was noted to have white patches and black skin on the side of the tip. At that time, the resident complained of pain and was medicated with Tylenol. I created a concurrent review of the penis at the time. At 6:00 AM I reported to the oncoming nurse (LPN #19) that I had attempted to notify the physician during the night shift however never received a callback. She stated that the resident physician was due to come in to see the resident and she would notify the physician at that time. I left the concurrent review unlocked so after the physician was notified the time of notification could be entered to that review. When I returned to work on 10/15/19, 11-7 AM shift, I went to see (Resident #72) and noted that s/he was not in the room. I asked the 3-11 PM nurse (LPN# 26) what had happened with the resident, and she stated that his/her labs were critical, and s/he was sent to the hospital. I asked, what about his/her penis? She stated she didn't know anything about it. During an interview with LPN #22 on 10/30/19 at 9 AM, she stated I had a resident that was on hospice that was not doing well on the evening of 10/14/19. I don't remember being told of any issues regarding (Resident #72's) penis by the GN[NAME] When asked by the surveyor, are you saying the GNA did not inform you of an area on the resident penis? The LPN #22 responded, I am not saying I was not told; I am saying I don't remember. During an interview with LPN #19, which took place on 10/30/19 at 2:30 PM, she stated that the 11-7 AM nurse LPN # 9 made her aware of the penis's condition. However, she was so busy trying to get the resident out due to abnormal lab values that she forgot to tell the physician about it. The resident was transferred to the hospital and admitted for critical labs and wound treatment on 10/15/19. The Director of Nursing stated, LPN #22 was terminated due to failure to report a change in condition to the physician when the condition was initially identified on 10/14/19 and due to the omission of documentation in the medical record. Upon further investigation, the decision was made to suspend LPN #19 for failure to report a change in condition to the physician when the condition was reported to her on 10/15/19 and due to the omission of documentation in the medical record. The facility was notified on 10/30/19, by the hospital Social Worker, that the resident would not be returning to the facility. On 10/31/19 the facility submitted an initial plan of action to the surveyors and the Office of Health Care Quality for review at 1:00 PM. This initial plan was not accepted. Revised plans were submitted on 10/31/19 at 2:17 PM, 3:20 PM and 3:30 pm which were not accepted. The facility submitted a revised plan of action at 5:06 PM on 10/31/19 that was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted on, 10/31/19 at 5:25 PM, but the immediate jeopardy was not removed until 11/4/19 at 1:05 PM after the plan of correction was implemented. The Immediate Jeopardy Abatement Plan included: Identification of Others: Unit manager to complete a facility skin sweep of current residents by use of skin check sheet to identify any skin alterations. Skin alterations that are documented on the audit will be addressed to ensure new orders/treatments as appropriate with care plan updates and documentation in the resident's medical record. All current residents' weekly skin evaluations will be audited weekly to ensure completion and ensure that Utilized Date Assessment (UDA) is completed. All Nursing staff to complete competency of questions (separate competency for Licensed Nurses and for Geriatric Nursing Assistants) on how to perform perineal care for residents, notification of a change in condition by 11/4/19. DON/Unit managers/Supervisors will complete a weekly audit of residents for four weeks to ensure that perineal care is completed and documentation if any skin alteration is noted. DON will complete audit of progress notes for the last 30 days to evaluate for residents with a change in condition to validate that notification of change was communicated to the MD, treatment plan was implemented and plan of care is reviewed and/or revised and documented in the resident's medical record. Education: DON /Unit managers/Staff Development coordinator to educate nursing staff on the policy for providing perineal care for residents. Began 10/22/19-11/4/19 DON /Staff Development Coordinator/Unit managers to educate Licensed Nurses on the process for completion of weekly skin evaluation and documentation. Began 10/22/19-11/4/19 DON/Staff Development Coordinator to educate nursing staff on policy for notification of a change in condition for residents to MD and RP, chain of notification to the physician, documentation in the resident medical record and review and revision of the resident plan of care. Began 10/22/19 -11/4/19 DON/Unit manager to educate Geriatric Nursing Assistant on completing a change in condition alert and providing the alerts of concern to DON/ Unit Manager/Executive Director. Began 10/22/19 -11/4/19 Executive Director to educate facility staff on Integrity and use of Action line: 10/30//19-11/4/19. System Change: When a resident is admitted /readmitted to the facility, the Licensed Nurse will be required to complete an evaluation for skin alteration. (For male residents, an evaluation of the penis will be required. The foreskin of the penis for an uncircumcised resident will be retracted to evaluate for any noted skin alteration.) If an alteration is noted, the Licensed Nurse must notify the physician of the change of condition and complete the documentation in the medical record and care plan implementation or updated as needed. Unit managers and/or Nursing supervisors and/or Wound Nurse will complete a second-day skin evaluation of residents that are admitted /readmitted to assess for skin alteration and notify resident physician, implement a treatment plan, complete appropriate documentation in the medical record and review and revise residents' plan of care if applicable. When a change of condition with a resident is observed by the Geriatric Nursing Assistant, he or she will notify the Licensed Charge Nurse and/or Wound Nurse for change in condition related to skin alteration. The Geriatric Nursing Assistant will complete a Stop and Watch Form for the resident observed with a change in condition and submit to the DON. When a change of condition is identified by facility staff, a concurrent review will be completed by the Licensed Charge Nurse. MD and RP will be notified, and the concurrent review will be locked prior to the end of the shift. Licensed Nurses will be required to document the change in condition in the 24-hour report for appropriate follow-up on every shift. The DON will review and follow-up to ensure the care plan is reviewed and revised daily x 4 weeks, then monthly x 3 months and then on an ongoing basis. If a resident refuses assessment, MD (and RP as appropriate) will be notified. Refusal will be carefully planned with the resident's reason for refusal. Every effort will be made to respect resident privacy during assessment. If resident refuses, resident choice care plan will be initiated. Licensed Nurse will make a second attempt to assess within 24 hours. Refusals will be evaluated by DON/Unit Managers daily x 4 weeks, then monthly x 3 months and then on an ongoing basis. Monitoring: Unit Managers/Nursing supervisor will audit daily x 7 days, and then weekly for 4 weeks and then monthly x 3 months all residents to evaluate for any skin alteration (For male residents, an evaluation of the penis will be required. The foreskin of the penis for an uncircumcised resident will be retracted to evaluate for any noted skin alteration). Audits will be reviewed at QAPI monthly x 3 months. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. Quality Assurance Nurse/DON will audit weekly skin evaluations to ensure that they are triggered and completed weekly x 4 weeks and then monthly x 3 months. Audits will be reviewed at QAPI monthly x 3 months. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. QA Nurse/DON will audit progress notes for residents' concerns of skin alterations, notification of change to the physician, documentation in the medical record and care plan reviewed and updated, daily x 7 days, then weekly x 4 weeks, then monthly x 3 months. Audits will be reviewed at QAPI monthly x 3 months. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. If a resident refuses assessment, MD (and RP as appropriate) will be notified. Refusal will be carefully planned with the resident's reason for refusal. Every effort will be made to respect resident privacy during assessment. If resident refuses, resident choice care plan will be initiated. Licensed Nurse will make a second attempt to assess within 24 hours.

Based on medical record review, interview of Resident #1, interviews of facility staff, review of Staff #3's human resources file and review of pertinent policies and procedures it was determined the facility staff failed to ensure a geriatric nursing assistant, Staff #3 had demonstrated competencies and skills sets to operate mechanical lifts (Hoyer and sit to stand) to ensure resident safety resulting in actual harm to Resident #1. This was evident for 1 of 1 staff members selected for review. The findings include: Resident #1's medical record was reviewed on 11/1/18 and 11/14/18. Medical record review revealed Resident #1 had resided at the facility since 2014. The resident has a history of a [MEDICAL CONDITION] with resulting left sided weakness. Review of Resident #1's quarterly Minimum Data Set, an assessment tool, dated 9/24/18 revealed that the resident required the extensive assistance of 2 staff for bed mobility and transfers. On 10/31/18 the Office of Health Care Quality (OHCQ) received a complaint notifying OHCQ that Resident #1 was sent to the hospital emergency department on 10/30/18 due to a fractured left arm. The complaint alleged that Resident #1 stated that the care person woke the resident on 11/1/18 at 6:00 a.m. in the morning trying to get the resident out of bed. The resident stated that he/she used the sit-to-stand mechanical lift and the geriatric nursing assistant (GNA) did not know how to use the sit-to-stand mechanical lift and kept forcing the resident's arms down. The resident further stated that the sit to stand mechanical lift became stuck up in the air and the GNA forced and bent the resident's left arm down and he/she felt his/her bone crack. Medical record review revealed that Resident #1's care plan interventions for transfer were use of the sit-to-stand mechanical lift with the assistance of 2 staff members. Additionally, review of the facility's policy and procedure on 11/1/18 revealed it was the facility's policy that the use of mechanical lifts required a competent and skilled user and required the use of 2 employees to perform the lift safely, for both residents and employees. Medical record review revealed that on 10/30/18 at 6:13 a.m. the Nurse, Staff #5, documented the following entry in the progress notes: At about 6am during care, GNA, caregiver for resident in Room (room number) informed nurse that the mechanical lift she was using to transfer resident into (his/her) w/c (wheelchair) went high up. (He/she) called on another GNA for assistance to bring down the mechanical lift, but first help to hold the arms for safety and was able to transfer the resident into (his/her) w/c. Resident c/o (complained of) pain on (his/her) (left) shoulder. PRN (as needed) Tylenol 325 mg. 2 tabs PO (by mouth) given for pain on scale level 9/10 with good effect for now . Will continue to monitor. Reports given to in-coming nurse for any further necessary f/u (follow up). Medical record review revealed that on 10/30/18 at 14:30 (2:30 p.m.) the Unit Manager, Staff #1, documented the following entry in the medical record: Late Entry: Note Text: Writer had seen pt (patient) earlier this am regarding transfer experience with the aid. (He/She) stated aid had the Hoyer (sit to stand mechanical lift) up and machine was unable to come down but with the help of 2 staff (he/she) was lowered into chair but (his/her) left shoulder still did not feel alright, (he/she) stated (he/she) already got something for pain control. On assessment, skin had a normal temperature, no distention noted from the shoulder blade, writer asked nurse to follow up with MD for X-ray. Review of the x-ray result dated 10/30/18 revealed that the resident had sustained a comminuted proximal humerus fracture. The x-ray result was electronically signed at 7:29 p.m. The Nurse, Staff #3, notified the physician on 10/30/18 at 8:50 p.m. At that time, the physician gave an order to transfer the resident to the hospital emergency department via 911. An x-ray of the resident's left humerus at the hospital revealed an initial closed complete, impacted and well-aligned [MEDICAL CONDITION] left humerus with intact appearing glenohumeral joint. The GNA, Staff #3, was interviewed at the facility on 11/1/18 at 4:55 p.m. The GNA, Staff #3, stated that she had not received training on the sit-to-stand mechanical lift, but had used the lift the night before with no problems. When the GNA, Staff #3, was asked why she did not get a second staff member to assist with the transfer, she stated that the other GNA's use the sit to stand mechanical lift without a second person to assist. Resident #1 was interviewed on 11/14/18 at 5:04 p.m. at the facility where he/she currently resided. The resident stated that she could not walk and staff always helped him/her up out of bed with the sit to stand mechanical lift. The resident stated the GNA, Staff #3, was taking him/her to the bathroom and used the sit to stand lift. The GNA, Staff #3, was the only staff member assisting the resident with the sit to stand lift. The resident stated that the GNA, Staff #3, raised him/her up as high as the lift could go and could not get the resident back down. The GNA, Staff #3 went out in the hall and stated I can't get this machine down. The resident stated that the GNA, Staff #4, that assisted the GNA, Staff #3, grabbed the resident's arm with both hands. The resident stated that she stated to the GNA, Staff #4, please don't pull on my arm. The resident stated that he/she was screaming and as the GNA, Staff #4, grabbed his/her arm and pulled it back, the resident heard the bone crack. The resident stated that he/she screamed and screamed and thought he/she was going to pass out. The resident stated that he/she was in pain all day and the x-ray was not done until approximately 6:00 p.m. in the evening. Interview of the interim Nursing Home Administrator, interim Director of Nursing and the Staff Educator on 11/1/18 revealed that the GNA, Staff #3, that attempted to transfer the resident with the sit-to-stand mechanical lift had been suspended due to an injury to the resident while being transferred with the sit-to-stand mechanical lift, and would not be returning to work until she was retrained on the use of the sit-to-stand lift. Review of the facility's new hire report revealed that the GNA, Staff #3, was hired on 9/24/18. Based on information provided by the interim Nursing Home Administration and interim Director of Nursing on 11/1/18, it was determined the facility utilized a Nurse Aid Orientation/Training Guide which was initialed and dated by a trainer for each skill evaluated which includes demonstration with return demonstration of mechanical lifts (Hoyer and sit-to-stand). Review of Staff #3's human resources file on 11/1/18 revealed no documented evidence that the GNA, Staff #3, had completed a skills evaluation. The surveyor requested documentation of the GNA's, Staff #3's, competency to operate the mechanical lift, but the facility staff was unable to provide documentation that the GNA, Staff #3, had demonstrated competency using a sit-to-stand mechanical lift. Review of the GNA, Staff #3's schedule revealed that the GNA, Staff #3 had worked 16 shifts 9/24/18 through 10/30/18. A statement from the interim nursing home administrator was provided to the surveyor on 11/16/18 by the current Nursing Home Administrator in which she stated that upon further investigation it was determined that the GNA, Staff #3, was performing the transfer of Resident #1 without assistance and then requested assistance after the transfer was initiated. The interim NHA further stated that the facility failed to properly train the GNA, Staff #3, prior to her completing orientation. The GNA was suspended pending an investigation and was trained on the proper lift procedure on 11/1/18. Cross Reference F 689

Based on medical record review, interview of Resident #1, interviews of facility staff and review of pertinent policies and procedures it was determined the facility staff failed to protect Resident #1 while transferring the resident in a sit to stand mechanical lift, failed to promptly notify the physician when the resident complained of pain following transfer with the sit to stand mechanical lift and failed to ensure a geriatric nursing assistant demonstrated competency to operate the sit to stand mechanical lift resulting in actual harm to Resident #1. This was evident for 1 of 1 sampled residents selected for review. The findings include: Resident #1's medical record was reviewed on 11/1/18 and 11/14/18. Medical record review revealed Resident #1 had resided at the facility since 2014. The resident has a history of a [MEDICAL CONDITION] with resulting left sided weakness. Review of Resident #1's quarterly Minimum Data Set, an assessment tool, dated 9/24/18 revealed that the resident required the extensive assistance of 2 staff for bed mobility and transfers. On 10/31/18 the Office of Health Care Quality (OHCQ) received a complaint alleging that Resident #1 was sent to the hospital emergency department on 10/30/18 due to a fractured left arm. The complaint alleged that Resident #1 stated that the care person woke the resident at 6:00 a.m. in the morning trying to get the resident out of bed. The resident stated that he/she uses the sit-to-stand mechanical lift and the geriatric nursing assistant (GNA) did not know how to use the sit-to-stand mechanical lift and kept forcing the resident's arms down. The resident further stated that the sit to stand mechanical lift became stuck up in the air and the GNA forced and bent the resident's left arm down and he/she felt his/her bone crack. Medical record review revealed that Resident #1's care plan interventions for transfer were use of the sit-to-stand mechanical lift with the assistance of 2 staff members. Additionally, review of the facility's policy and procedure on 11/1/18 revealed it was the facility's policy that the use of mechanical lifts required a competent and skilled user and required the use of 2 employees to perform the lift safely, for both residents and employees. Medical record review revealed that on 10/30/18 at 6:13 a.m. the Nurse, Staff #5, documented the following entry in the progress notes: At about 6am during care, GNA, caregiver for resident in Room (room number) informed nurse that the mechanical lift she was using to transfer resident into (his/her) w/c (wheelchair) went high up. (He/she) called on another GNA for assistance to bring down the mechanical lift, but first help to hold the arms for safety and was able to transfer the resident into (his/her) w/c. Resident c/o (complained of) pain on (his/her) (left) shoulder. PRN (as needed) Tylenol 325 mg. 2 tabs PO (by mouth) given for pain on scale level 9/10 with good effect for now . Will continue to monitor. Reports given to in-coming nurse for any further necessary f/u (follow up). Interview of the Nurse, Staff #5, on 11/19/18 at 11:25 a.m. revealed that she was notified by the GNA, Staff #4, that she and another GNA, Staff #3, had finished transferring Resident #1 and the resident complained of pain. The Nurse, Staff #5, stated that the resident told her that the he/she was feeling pain to the left shoulder. The Nurse, Staff #5, stated that she looked at the resident's shoulder and there was no swelling. When asked if the Nurse, Staff #5, notified the physician, the nurse stated that the morning nurse was already in and would follow-up. Medical record review revealed that on 10/30/18 at 14:30 (2:30 p.m.) the Unit Manager, Staff #1, documented the following entry in the medical record: Late Entry: Note Text: Writer had seen pt (patient) earlier this am regarding transfer experience with the aid. (He/She) stated aid had the Hoyer (sit to stand mechanical lift) up and machine was unable to come down but with the help of 2 staff (he/she) was lowered into chair but (his/her) left shoulder still did not feel alright, (he/she) stated (he/she) already got something for pain control. On assessment, skin had a normal temperature, no distention noted from the shoulder blade, writer asked nurse to follow-up with MD for X-ray. Interview of the Unit Manager, Staff #1, revealed that she talked to the resident and the resident stated that his/her arm hurt. The Unit Manager stated she assessed the resident and did not see any deformity of the resident's shoulder. The Unit Manager stated that she was going to have the nurse, Staff #2, talk to the resident's physician and get an x-ray done. The Unit Manager stated that she had done morning rounds and the resident mentioned the incident in passing and that the Nurse, Staff #2, notified the Unit Manager that the resident was complaining of pain that had occurred during a transfer. The Unit Manager stated that she spoke to the resident after the morning meeting, approximately 11:30 a.m., and that the physician was notified and ordered an x-ray at noon, which was close to 6 hours after the resident complained of shoulder pain after the transfer with the sit to stand mechanical lift. Interview of the Nurse, Staff #2, on 11/14/18 at 3:15 p.m. revealed that when the nurse, Staff #2, first assessed the resident on the morning of 10/30/18 there was no pain or swelling to Resident #1's left shoulder. The Nurse, Staff #2, stated that later that day the resident complained of pain (the nurse could not recall the time) and the nurse, Staff #2, noted that the resident's shoulder was swollen and painful to touch. The Nurse, Staff #2, stated that the resident was medicated with Tylenol and the physician was notified. Review of the Medication Administration Record [REDACTED]. The Nurse, Staff #2, stated that not long after, the vendor came to the facility and x-rayed the resident's shoulder. The GNA, Staff #3, was interviewed at the facility on 11/1/18 at 4:55 p.m. The GNA, Staff #3, stated that she had not received training on the sit-to-stand mechanical lift, but had used the lift the night before with no problems. When the GNA, Staff #3, was asked why she did not get a second staff member to assist with the transfer, she stated that the other GNA's use the sit to stand mechanical lift without a second person to assist. Review of the x-ray result dated 10/30/18 revealed that the resident had sustained a comminuted proximal humerus fracture. The x-ray result was electronically signed at 7:29 p.m. The Nurse, Staff #2, notified the physician on 10/30/18 at 8:50 p.m. At that time, the physician gave an order to transfer the resident to the hospital emergency department via 911. An x-ray of the resident's left humerus at the hospital revealed an initial closed complete, impacted and well-aligned [MEDICAL CONDITION] left humerus with intact appearing glenohumeral joint. The hospital medical record was provided to the surveyor on 11/20/18. Review of the hospital history and physical revealed the following assessment: [MEDICAL CONDITION] humerus secondary to forcibly removing (his/her) left arm that was stuck in the 'sit to stand' machine (similar to Hoyer Lift?) on [DATE] AM. (He/She) heard a 'crack' then experienced severe pain on the left shoulder all day long. The patient requested the RN to call the physician to check an (x-ray) but the (x-ray) shoulder was done late in the evening, 6 PM. Resident #1 was interviewed on 11/14/18 at 5:04 p.m. at the facility where he/she currently resided. The resident stated that he/she could not walk and staff at the facility always helped him/her up out of bed with the sit to stand mechanical lift. The resident stated the GNA, Staff #3, was taking him/her to the bathroom and used the sit to stand lift. The GNA, Staff #3, was the only staff member assisting the resident with the sit to stand lift. The resident stated that the GNA, Staff #3, raised him/her up as high as the lift could go and could not get the resident back down. The GNA, Staff #3 went out in the hall and stated I can't get this machine down. The resident stated that the GNA, Staff #4, that assisted the GNA, Staff #3, grabbed the resident's arm with both hands. The resident stated to the GNA, Staff #4, please don't pull on my arm. The resident stated that he/she was screaming and as the GNA, Staff #4, grabbed his/her arm and pulled it back, the resident heard the bone crack. The resident stated that he/she screamed and screamed and thought he/she was going to pass out. The resident stated that he/she was in pain all day and the x-ray was not done until approximately 6:00 p.m. in the evening. Interview of the interim Nursing Home Administrator (NHA), interim Director of Nursing and the Staff Educator on 11/1/18 revealed that the GNA, Staff #3, that attempted to transfer the resident with the sit-to-stand mechanical lift had been suspended due to an injury to the resident while being transferred with the sit-to-stand mechanical lift, and would not be returning to work until she was retrained on the use of the sit-to-stand mechanical lift. The surveyor requested documentation of the GNA's, Staff #3's, competency check off list, but the facility staff was unable to provide documentation that the GNA, Staff #3, had demonstrated competency using a sit-to-stand mechanical lift. A statement from the interim Nursing Home Administrator was provided to the surveyor on 11/16/18 by the current Nursing Home Administrator in which interim NHA stated that upon further investigation it was determined that the GNA, Staff #3, was performing the transfer of Resident #1 without assistance and then requested assistance after the transfer was initiated. The interim NHA further stated that the facility failed to properly train the GNA, Staff #3, prior to her completing orientation. The GNA was suspended pending an investigation and was trained on the proper lift procedure on 11/1/18. Interview of the Maintenance Director revealed that preventive maintenance was done on lifts every month. He was able to produce documentation that preventive maintenance was done on the sit to stand lift utilized by the Resident #1 on 10/30/18, and had, in fact, checked the day before. The facility determined that the lift did not malfunction, however, if the resident's weight was not on the sling, the sling will not lower on the lift. Refer to F 726.

Based on medical record review and interviews, it was determined the physician failed to assess worsening symptoms, consider underlying causes, and implement appropriate interventions for a resident with signs and symptoms of an allergic reaction in one (Resident #24) of 34 residents reviewed in Stage 2. The resident was admitted to the hospital where she was assessed and treated for [REDACTED]. An allergic reaction occurs when your immune system reacts abnormally to a foreign substance such as pollen, foods or medication. Symptoms of an allergic reaction include skin rash, hives, itching, redness, facial swelling, shortness of breath and [MEDICATION NAME], a life-threatening reaction. treatment of [REDACTED]. The findings included: Resident #24 has multiple [DIAGNOSES REDACTED]. Review of the medical record revealed that on 06/17/14 the resident had facial flushing (redness) on her left cheek. The physician was notified at 3:00PM on 06/17/14 and gave the order for the nursing staff to monitor for any changes. Review of the medical record revealed that at 5:00PM on 06/17/14 the resident had "multiple doted (dotted) redness noted to ABD (abdomen), right/upper extremities (arms), face (cheek)..." The physician was notified at 5:00PM and gave the order for the nursing staff to continue to monitor and to call the physician with any changes. The physician did not assess the resident despite worsening signs and symptoms of an allergic reaction (rash on the abdomen, arms and face). Review of the Concurrent Review report dated 06/17/14 revealed a notation by nursing that the resident was receiving an antibiotic, [MEDICATION NAME], for pneumonia. Antibiotics are a common cause of allergic reactions. You can have an allergic reaction to a drug anytime you take it, even if it caused no reaction in the past. Review of the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the medical record revealed that at 5:30PM on 06/18/14 the physician was notified of red and swollen lips. The physician ordered 25mg of [MEDICATION NAME] to be given every eight hours for three days for the swelling of the lips. Again, the physician did not assess the resident to determine the cause of the allergic reaction. Review of the medical record revealed a Concurrent Review report at 3:00PM on 06/19/14 that noted that the resident had a fever (99.1), high blood pressure (284/170), headache and neck pain. The physician was notified and gave the order to send the resident to the emergency room via 911 for further evaluation. The resident was admitted to the hospital. Review of the History and Physical obtained at the hospital revealed the chief complaint to be lip swelling and ulceration. The following was noted by the physician in the emergency room : "Over the last several days, the patient developed a cough which was wet sounding. X-ray showed pneumonia. Four days ago, she was started on [MEDICATION NAME] evening of that day, the patient's daughter noted the patient had swelling of the lower lip and some mild facial flushing. Symptoms worsened over the last several days. The patient noticed itching and was scratching a lot, especially her forehead. Rash intensified over the face, the upper lip also swelled up, the lower lip developed ulceration as of yesterday and started to ooze. The rash was noted yesterday as well as over the body involving the arms and the trunk especially, maybe some on the legs as well. Nothing involving the mucosal membranes of the genital region. The patient complained of pain at the lip as well today, had been eating less than usual and was complaining of a stiff neck yesterday, which is somewhat improved today. The patient's newest medication is [MEDICATION NAME] as noted...In the emergency room , she received Solu-[MEDICATION NAME] 60mg and normal saline 500ml..." Solu-[MEDICATION NAME] is [MEDICATION NAME] that was administered via IV for faster absorption and treatment of [REDACTED]. Solu-[MEDICATION NAME] 40mg was given via IV every 12 hours while in the hospital. Upon readmission to the facility on [DATE] the resident was to receive 10mg of [MEDICATION NAME] orally for three days. Interview with the Director of Nursing at 1:30PM on 09/24/14 revealed that the physician stated that he did not feel the resident was having an allergic reaction despite the worsening signs and symptoms (facial flushing, rash on the arms, legs and abdomen, swelling of the lips). The physician failed to assess the resident resulting in the delay of treatment, identification and removal of the substance causing the allergic reaction.