Every finding on record at Springfield Health & Rehab

Based on interview and record review, the facility failed to report an incident of alleged abuse for 1 of 3 sampled residents. This is a repeat deficiency for this facility, with the violation cited during two previous partial surveys dated 2/17/26 and 12/9/25. Findings include:Per record review, Resident #1 has diagnoses that include vascular dementia, major depressive disorder, and anxiety disorder. Per an MDS (Minimum Data Set, a resident assessment tool) dated 5/20/26, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 1 indicating severely impaired cognition (the ability to perceive, learn, remember, reason, and problem-solve). Per record review of the facility follow-up investigation report dated 5/1/26 of an allegation of abuse, LNA #2 felt uncomfortable assisting LNA #1 with the care of Resident #1 on 4/23/26. Resident #1 was being resistive to care being provided by LNA #1 and LNA #2. She [LNA #2] stated that when [Resident #1] was resistive to care and attempting to bite, that [LNA #1] said 'stop being a retard' to Resident #1. LNA #2 further stated that Resident #1 replied to LNA #1, stating, 'I am not a retard.' The facility investigation states that LNA #1 admitted to saying Don't be a retard and hit and bit me. The facility investigation states that the allegation was verified and that [LNA #1] admitted to using unkind words when caring for [Resident #1]. [LNA #1] was notified that not treating [Resident #1] with dignity and respect, by using the unkind words, goes against resident's rights. LNA #2 did not report to LPN #1 that LNA #1 called Resident #1 a retard until 4/26/26, three days after it occurred. Per review of the facility policy and procedure titled, Abuse Prevention and Prohibition Program, dated 12/2024, section IX, subsection A, Facility Staff are Mandatory Reporters and are obligated by the Elder Justice Act any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. Per interview with the Administrator on 6/8/26 at 12:10 PM, it was confirmed that the incident that occurred on 4/23/26 was not reported to Survey & Certification until three days after the incident, on 4/26/26. An investigation of this incident was not begun until 4/26/26, three days after the incident.

Based on interview and record review, the facility failed to ensure that a resident was treated in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's right to be treated with dignity and respect, and to make choices, for 1 of 3 sampled residents (Resident #1). Findings include: Per record review, Resident #1 has diagnoses that include vascular dementia, major depressive disorder, and anxiety disorder. Per an MDS (Minimum Data Set, a resident assessment tool) dated 5/20/26, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 1 indicating severely impaired cognition (the ability to perceive, learn, remember, reason, and problem-solve). Per record review of the facility follow-up investigation report received by Survey & Certification on 5/1/26, LNA #2 felt uncomfortable assisting LNA #1 with the care of Resident #1 on 4/23/26. Resident #1 was being resistive to care being provided by LNA #1 and LNA #2. She [LNA #2] stated that when [Resident #1] was resistive to care and attempting to bite, that [LNA #1] said 'stop being a retard' to Resident #1. LNA #2 further stated that Resident #1 replied to LNA #1, saying, 'I am not a retard.' The facility investigation states that LNA #1 admitted to saying Don't be a retard and hit and bit me. The facility investigation report states that the allegation was verified and that [LNA #1] admitted to using unkind words when caring for [Resident #1]. [LNA #1] was notified that not treating [Resident #1] with dignity and respect, by using the unkind words, goes against resident's rights. Per review of the facility's Resident Rights - Quality Of Life policy and procedure, dated 12/2024, its purpose is to ensure all residents are treated with a level of dignity they are entitled to while residing at the facility. The policy states, Each resident shall be care for in a manner that promotes and enhances the quality of life, dignity, respect and individuality. Item number VII states, Facility Staff speaks respectfully to residents at all times, including addressing the resident by his or her name of choice. The Administrator confirmed during an interview on 6/8/26 at 12:10 PM, that LNA #1 admitted she called Resident #1 a retard. She realized it was inappropriate.

Based on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for the residents who reside on 2 of 2 units. Findings include:During observations of the 2nd floor unit on 3/29/2026 at approximately 4:50 PM, multiple hallway ceiling lights were noted to have dead bugs in them. Visible from the hallway, there were dusty surfaces in resident rooms # 211 and #214 and the floor in room [ROOM NUMBER] had large pieces of food smeared across it.Per observation on 3/30/2026 at approximately 8:33 AM, the surfaces in the resident rooms #211 and #214 were still dusty, the floor in room [ROOM NUMBER] was also noted to have dust and debris on the floor, room [ROOM NUMBER]'s floor was still dirty with the food from the night before. Cobwebs were noted on the outside of the 2nd floor dining room windows, obscuring the view for residents.Per interview on 3/31/2026 at approximately 2:43 PM, the Unit Manager (UM) confirmed that surfaces in residents' room were dusty.Per interview on 4/1/2026 at approximately 9:33 AM, the Maintenance Director confirmed that there were bugs in the hallway lights on the 2nd floor. He stated that the lights do get cleaned on a schedule but this time of year there tends to be more.On 4/1/2026 at approximately 9:41 AM during an interview in the 2nd floor shower room with a Licensed Nursing Assistant (LNA) s/he stated that the shower room is cold looking making it not as homey for the residents. The LNA was asked about the broken shower chair and s/he stated that it had been like this for a while. The LNA stated that s/he did not know if maintenance was aware of it. The shower room was cluttered with shower chairs, a commode, and mechanical lift, and the floors were observed to have large areas of peeling paint/sealant. The linen closet, located in the shower room, had clean blankets in multiple bags that were being stored on the floor.Per observation on 4/1/2026 at approximately 10:00 AM, the tables in the 1st floor dining room had missing laminate around the sides of the tables and the floors were audibly sticky when walked on. An air conditioner vent with dust in the vents was observed to be blowing right above a dining table where residents eat.Per observation on 4/1/2026 at approximately 10:08 AM, the 1st floor shower room was observed to be cluttered with extra chairs and other durable medical equipment (DME). There were also clean blankets in bags in this linen closet on the floor. The bathtub was noted to have a cracked area in it.Per interview on 4/1/2026 at approximately 10:13 AM, an LNA on the 1st floor reported that the bathroom normally does have all the DME in it when caring for residents making it lack a homelike atmosphere. During an environmental tour on 4/1/2026 at approximately 11:42 AM, with the Maintenance Director, Regional Director of Nursing, Licensed Nursing Home Administrator, and Regional Director of Quality and Compliance, the above environmental concerns were presented and were confirmed.

Based on interview and record review, the facility failed to implement their policy related to Covid 19 vaccination and provide evidence that five out of five sampled staff members were offered a Covid 19 vaccination and consent obtained along with three out of five sampled residents (Resident #9, Resident #43, and Resident #53). Per review of the facility policy titled Coronavirus, Prevention, and Control dated 3/5/26, it states that all residents and staff members will be educated and offered a Covid 19 vaccine unless contraindicated or full immunization has been acquired. That both the staff and resident/resident representative will be educated on the benefits and the risks of the vaccination and that a vaccine will not be administered without written informed consent.Per review of the current CDC guidelines for Covid 19 vaccination (Staying Up to Date with COVID-19 Vaccines | Covid | CDC ) it states that the effectiveness of previous Covid 19 vaccines decrease overtime and identifies getting updated vaccination as being especially important for people aged 65 and up, and those living in a long term care facility.1.Per record review Resident #9's and Resident #53's immunization records reveal that there is no evidence in the medical records that they were offered a Covid 19 vaccination for 2025. There was no evidence that Resident #9 or Resident #53 had consented or refused the vaccine in their medical record.Resident #43 received a Covid 19 vaccination on 7/23/25 and there was no evidence that the resident or resident representative gave informed consent for this vaccination in their record. Per interview on 4/1/26 at approximately 12:25 PM, the Director of Nursing (DON) confirmed that consent forms should be in the medical record for vaccinations, including Covid 19. The DON was unable to provide evidence that Covid 19 consents (forms indicating if they wished to have the vaccine or not) had been obtained for Resident #9, Resident #53, and Resident #43 for 2025.2. Per review of employee files, 5 of 5 sampled employees did not have evidence that they were offered the Covid 19 vaccine for the 2025 season.Per interview on 4/1/26 at 1:40 PM with the Director of Nursing and the Infection Preventionist, they confirmed that they were unable to provide evidence that Covid 19 vaccinations had been offered for the five sampled employees.

Based on record review and staff interview, the facility failed to ensure that a facility investigation of abuse was submitted to the state agency within the required five-day timeframe. Findings include:On 11/5/25 the State Survey Agency received an online self-report regarding allegations of staff to resident neglect/abuse for an incident that occurred on 11/3/25. The State Survey Agency did not receive a report of the facility's investigation results within 5 working days of the alleged incident. Per interview with the Administrator on 2/17/26 at approximately 1:45 PM, s/he stated the facility's investigation summary was sent to the State Survey Agency on 11/10/26 and provided an email receipt of the summary. Upon review of the email receipt, the summary was sent to an incorrect email address. The Administrator confirmed the email address used was not the correct email address to submit a facility's investigation summary.Per facility policy titled Abuse Prevention and Prohibition Program, reviewed/revised 12/2025, The Administrator will provide the state survey agency, law enforcement and the Ombudsman with a copy of the investigative report within 5 days of the incident.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property related to the screening of prospective employees 2 out of 5 sampled staff. Findings include: Per record review, LPN #1 [Licensed Practical Nurse] did not have any adult state background check. LPN#1 has been working at the facility since 9/15/25 without a [NAME] Adult Abuse Registry background check.Per record review LNA#1 [Licensed Nursing Assistant] did not have any [NAME] state adult background check. LNA#1 has been working at the facility since 8/13/25 without a [NAME] Adult Abuse Registry background check.Per the facility's Abuse, Neglect, and Exploitation policy [no revision date] states, A. Screening: 1. A background check will be conducted on all new employees and volunteers to include the following: a. A request for information about all substantiated findings from the Department for Children and Families' Child Abuse Registry b. A request for information about all substantiated findings from the Department of Disabilities, Aging and Independent Living [[NAME]] Adult Abuse Registry c. A request for information on criminal convictions from the [NAME] Crime Information Center d. An online search of the exclusions database of the Department of Health and Human Services office of the Inspector General.4. Information received as a result of background checks will be maintained in the employee's/volunteer's personnel file.Per interview with the Administrator on 10/22/25 at 11:26 AM, the Administrator confirmed they did not have [NAME] adult background checks for either LNA #1 or LPN#1. She stated, They are agency and usually the agency does the background checks. The Administrator was able to give [NAME] adult background checks, but they were dated 10/22/25, the day of the interview. The Administrator conveyed via email on 10/23/25 that Human Resources is responsible for background checks.

Based on interview and record review, the facility failed to investigate two of four sampled allegations of abuse for Resident #3. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 3/27/25. Findings include:Per record review of the facility's Abuse, Neglect, and Exploitation policy [no revision date], it states, E. Investigation 1. Person witnessing the incident or receiving the alleged abuse, neglect or exploitation complaint will immediately make sure the resident is safe and then notify his/her supervisor 2. Supervisor will immediately notify the shift supervisor, who will notify the Administrator. 3. Shift supervisor will meet and discuss the complaint with the alleged victim if he/she is able, witness(s) [sic] if any, and alleged perpetrator to make a written report.1. Explain to all parties involved that an internal investigation will occur and as applicable the incident will be reported to Licensing and Protection/Adult Protective Services and there may be an external investigation by them.Per record review of a grievance filed by Resident #3 dated 8/11/25 states, [Resident #3] told me that during the overnight shift on 8/10 that [s/he] requested to see the nurse on duty for [his/her] throat and that [s/he] was told no by the LNA [Licensed Nursing Assistant] times 3 the last time [s/he] asked the LNA told her to stop [expletive] playing games walked out and slammed [his/her] door shut behind her.Per record review of a grievance filed 10/13/25, stated, [Resident #3] Stated nurse told [him/her] to shut up and go to sleep it was midnight and [s/he] was asking for a popsicle [s/he] doesn't want [licensed nurse] to be [his/her] nurse if she's going to be mean to [him/her].There was no evidence or record that shows that these allegations were investigated by the facility.Per interview with the Administrator on 10/21/25 at 3:04 PM, the administrator confirmed the facility did not do an internal investigation into any of the three mentioned grievances alleging abuse.

Based on interview and record review, the facility failed to report three allegations of abuse to the state for one of two sampled residents (Resident #3). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 3/3/25. Findings include:Per record review of the facility's Abuse, Neglect, and Exploitation policy p[no revision date] states, Mental and verbal abuse: Is the use of verbal and nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.G. Reporting/Response Abuse Neglect and Exploitation Procedure Form-CLR 1. For any actual or suspicious act of or sign of abuse, neglect or exploitation it is the responsibility of every employee and volunteer to make sure the resident is safe first. 2. Every employee and volunteer of CLR are mandated reporters and must cause a report to be made to APS [Adult Protective Services] by reporting any actual or suspected abuse, neglect or exploitation immediately to their supervisor.Per record review, a grievance filed by Resident #3 dated 8/11/25 states, [Resident #3] Told me that during the overnight shift on 8/10 that [s/he] requested to see the nurse on duty for [his/her] throat and that she was told no by the LNA [Licensed Nursing Assistant] times 3 the last time [s/he] asked the LNA told her to stop [expletive] playing games walked out and slammed [his/her] door shut behind her. Per record review, a grievance filed 10/13/25, stated, [Resident #3] Stated nurse told [him/her] to shut up and go to sleep it was midnight and [s/he] was asking for a popsicle [s/he] doesn't want [licensed nurse] to be [his/her] nurse if she's going to be mean to [him/her]. There was no evidence or records that the above situations were reported to the state agency.Per interview with the Administrator on 10/21/25 at 3:04 PM, the Administrator confirmed these events were not reported to the state agencies.

Based on observation and interview, the facility failed to store medications appropriately on one randomly observed medication cart, potentially impacting residents on 1 of 2 units. Findings include: Per observation on 10/22/25 at 8:53 AM, an unopened Lidocaine 5% patch was found to be on top of the medication cart on the second floor. There was one resident sitting in the hallway, one resident self-propelling, and 8 residents in the dining room.Per record review of the facility's Storage of Medications policy [last revised 1/2025] states, 3. During a medication pass medications must be under the direct observation of the person administering medications or locked in the Med storage area/cart.An interview was conducted with Licensed Nurse #1 on 10/22/25 at 8:58 AM. She confirmed she left the lidocaine patch on the top of the medication cart unsupervised stating, I was just coming out of a patient's room. The resident didn't want the patch, so I left it at the cart.

Based on observation, record review, and staff interview, the facility failed to honor residents' choices as outlined in their care plan for 1 of 3 sampled residents (Resident #3). Findings include: Per record review, Resident #3 has diagnoses including major depressive disorder, post-traumatic stress disorder, schizoaffective disorder, and borderline personality disorder. Per record review, a facility grievance dated 10/13/25 denotes that Resident #3 did not wish to have LPN #2 care for them. A progress note from 10/15/25 written by the Director of Nursing (DON) states they Spoke with resident regarding grievance against nurse. [She/he] has stated that she/he feels that a certain nurse isn't as attentive as [she/he] should be and refused to give [her/him] a popsicle that [she/he] paid for. [She/he] would prefer this nurse not care for [her/him] anymore.Facility policy titled Care Plans, Comprehensive, Person-Centered, reviewed/revised 2/2025 states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #3's care plan reads, [Resident #3] has potential to exhibit behaviors that are a result of past trauma(s), which may impact my moods or behaviors as evidenced by Anxiety/ GAD [Generalized Anxiety Disorder, a mental health condition characterized by persistent and excessive worry about various everyday things], Schizophrenia / Schizo-effective disorder. That section of the care plan contains an intervention [Resident #3] has requested that [LPN#2] not care for [her/him]. [She/he] understands that if [LPN#2] is working that it may take a bit longer to get a nurse from a different wing to attend to [her/his] needs. Date Initiated: 10/15/2025.Per record review, LPN #2 administered morning and evening medications and provided multiple treatments to Resident #3 on 10/21/25. LPN #2 also assessed the resident's pain level and oxygen saturation. When interviewed on 10/22/25 at 9:03 AM, Resident #3 confirmed she/he had submitted this grievance. Resident #3 stated she/he did not want care from LPN #2 and did not like it. Per staff interview on 10/22/25 at 9:58 AM, the Administrator confirmed that the care plan stated that LPN #2 is not to care for Resident #3. She/he confirmed that LPN #2 had provided care to Resident #3 on 10/21/25. She/he stated that LPN #2 had been off from work and she/he had not gotten word to her/him in time of this change, before she/he provided care to Resident #3.

Based on interview and record review, the facility failed to accurately reconcile physician orders needed to provide necessary care and services on admission, once the facility identified an issue with the admission orders, they failed to review the rest of the discharge summary for other potential missed orders for 1 of 3 residents in the sample (Resident #1). All residents admitting or readmitting to the facility are at risk for serious injury or death as a result of noncompliance. This deficient practice rose to the immediate jeopardy level due to the facility's failure to provide accurate admission orders, which resulted in Resident #1 experiencing antipsychotic withdrawal and worsening psychiatric symptoms including refusal of medications and care, unmonitored and untreated blood sugars, increased risk for developing a urinary tract infection, falls resulting in a subdural hematoma that worsened over time resulting in death. This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25. Findings include:Per record review Resident #1 was admitted to the facility for short term rehab after a fall at their home resulting in a distal radius fracture and multiple fractured ribs. Additional diagnoses included left third finger fracture, urinary tract infection (UTI), osteoporosis, frequent falls, schizophrenia, narcolepsy with cataplexy (sudden weakness or limping of the muscles), recurrent UTIs, and hypertension.Review of the hospital discharge orders dated 8/15/2025 revealed physicians' orders for Keflex 500 mg every 12 hours for 4 days, then resume nitrofurantoin (Macrobid) 100mg daily. Guaifenesin 600mg twice daily, sliding scale insulin lispro with blood sugars 4 times daily, lidocaine patch 2 patches daily, and Quetiapine (Seroquel) 600mg at bedtime. None of these orders were implemented on admission to the facility. The Food and Drug Administration's (FDA's) Boxed Warning states that some commonly reported Seroquel withdrawal symptoms can occur include nausea, vomiting, anxiety, irritability, agitation or restlessness, panic-like symptoms, and rebound mood swings. Rebound symptoms include mania or hypomania, depression, Psychotic symptoms, and severe insomnia. When it is stopped abruptly -especially at higher doses such as 300-800 mg the sudden loss of receptor blockade can cause the body to rebound and over-respond until it readjusts. Acute withdrawal symptoms such as insomnia, nausea, and vomiting have been reported following abrupt cessation of quetiapine (Seroquel). It is recommended that, where possible, the dose be tapered gradually. On 8/18/2025 three days after admission and three days of the missing Seroquel administration, Resident #1 began experiencing hallucinations and then began exhibiting anxious, angry, and combative behaviors which were not her/his baseline. A Skilled Note dated 8/18/2025 states Hallucinations (perceptual experiences in the absence of real external sensory stimuli). Comments: resident observed talking to internal stimuli at times while at nursing station. A Psychiatry Note dated 8/19/2025 states Resident is pleasant, with occasional non distressful hallucinations with talking to others not there. An Administration Note dated 8/22/2025 states Resident refused to take [her/his] meds, stating that [s/he] does not take meds. Various approaches were used without success. Provider on call [name omitted] was informed who also tried without success. Resident refused dinner, drink and [vital signs]. [S/he] was hallucinating. An Administration Note dated 8/23/2025 states refused care and [vital signs].A Progress note date 9/9/2025 reveals that Resident #1 was anxious, hallucinating, and wandering. The progress note also states Safety concerns: resident often observed self-transferring without calling for assistance from staff. A Progress Note dated 9/10/2025 states resident observed multiple times by staff throughout [evening] wandering and responding to internal stimuli. resident observed stating dad she wont let me do it, and bill is not going to let me sleep. resident easily redirected by staff. resident assisted with toileting and clothing.A Skilled Note dated 9/10/2025 states Mental Status: Anxious, Pleasant, Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Wandering. Comments: [s/he] has auditory hallucinations that [s/he] is talking to '[her/his] father', he tells [her/him] what to do and what not to do . Concerns: gets mad at staff, swings [her/his] cast trying to hit us . Per Progress Note dated 9/11/2025 Resident #1 was found at 12:45 AM lying in bed with a cut and swelling on the left side of their forehead. The Resident stated that s/he got up, froze, and fell flat, then got up and layed on her/his bed. The incident report identifies predisposing factors as ambulation without assist, wanderer, and history of falls. A progress note dated 9/11/2025 reflects that at 12:30 PM the Resident was sent to the hospital emergency department for evaluation of the head wound and complaints of left foot pain. The Resident returned to the facility on 9/12/2025 with diagnoses of subdural hematoma and fracture of the foot with a walking boot in place. A Progress Note dated 9/12/2025 states resident's [guardian and spouse] called facility asking for an update on residents' condition since returning from hospital today. informed [guardian] that resident refused all [evening] medications at the present time and continues to be confused and agitated when approached by staff. resident also refused dinner during shift and [Nurse Practitioner (NP)] was notified as well. [Guardian and Spouse] expressed concerns about resident's state of mind when [s/he] is not medicated and has questions for the primary doctor in regard to [her/him] current medication regime. informed [Guardian and Spouse] to call on Monday and speak with unit manager about any medication concerns so they can be relayed to in house provider. also informed them that nursing would continue to monitor resident for any changes in [her/his] LOC or worsening in [her/his] condition and report to the on-call NP throughout weekend. [Guardian and Spouse] acknowledged understanding and asked if they could attempt to talk with resident to encourage [her/him] to take [their] medications tonight. [Guardian] attempted to talk with resident over the phone and resident stated to [Guardian] no I will not take that and its between me and god. informed [Guardian] that staff would continue to encourage resident and notify them with any changes. On 9/13/2025 a physician's order for Seroquel 600 mg was initiated. According to the FDA's prescribing recommendation for starting Seroquel (Resident #1 had not received Seroquel for 30 days, since 8/15/25), Day 1: 25mg twice daily. Day 2-3: Increase increments of 25 - 50 mg divided doses (two or three times per day), to reach a total of 300 - 400 mg/day by day 4. Further adjustments should be in increments of 25 - 50 mg twice daily, with intervals of not less than 2 days between dose changes. Risks of starting Seroquel at 600 mg without gradual dose increase include: Orthostatic blood pressure (drop in blood pressure when standing up) dizziness, sedation, impaired motor coordination, blood sugar alterations. A Provider Progress Note dated 9/16/2025 states [S/he] was restarted on [her/his] Seroquel 600mg at bedtime and has had a marked improvement in [her/his] mood. [S/he] is more appropriate and able to make [her/ his] needs known. [S/he] offers no complaints. A Provider Note dated 9/18/25 states Per nursing, [Resident's] family strongly requested that [Resident] be restarted on Seroquel 600 mg daily, which [s/he] apparently had been on in the past. This medication was restarted on 9/13/2025. Per nursing, [s/he's] been sleeping more, but no other adverse effects have been noted. [S/he] has a significant history of falls at baseline, with and without the Seroquel.Per Nursing Progress Note dated 9/17/2025 the Resident was found on the floor after an unwitnessed fall at the nurse's station. A Nursing Progress Note states [S/he] was drowsy. [S/he] was uncooperative with [the Nurse]. [S/he] was assisted onto [her/his] wheelchair and wheeled into [her/his] room and transferred onto [her/his] bed. On assessment, there was a bump on top of [her/his] head (parietal lobe), the size of a coin-10 cents. The Resident was transferred to the hospital for evaluation. Further review of the hospital discharge orders revealed a sliding scale insulin (a specific dose to be administered according to the results of blood sugar) Lispro with blood sugars 4 times daily. The discharge paperwork stated that the sliding scale had been implemented due to elevated blood sugar readings. Review of Resident #1s physicians orders after admission to the facility revealed that an order for finger sticks (a method used to obtain blood sugars) once in the AM was entered on 8/17/2025. Review of Resident #1's daily blood sugars revealed that between 8/17/25- 10/9/25 the blood sugars were obtained during the evening or night shift as opposed to morning on 8 occasions, and the resident experienced 10 documented episodes of hyperglycemia (blood glucose above which would have required the administration of the sliding scale insulin. There is no way to determine if the Resident was experiencing hyper or hypoglycemia (high or low blood sugars) or would have required sliding scale coverage the other three times per day because the blood sugars were not ordered or obtained. Further review of the hospital discharge orders for admission dated 8/15/2025 revealed an antibiotic order for Keflex 500 mg every 12 hours for 4 days to treat the UTI, then resume nitrofurantoin (Macrobid) 100 mg daily for prophylaxis, Additional orders were 2 lidocaine patches daily for pain. Review of admission orders revealed that neither of these orders were implemented on admission to the facility. A Nurse Practitioner Progress Note dated 10/8/2025 reveals Resident . is seen today for UTI. Resident had a urine done and is positive for Hemolytic Strep Group B. [S/he] remains unresponsive. [S/he] was recently in the ER and given IV fluids and has since returned. Potential for discharge tomorrow to sister facility for ongoing care - confirmation is pending.On 10/3/2025 Resident #1 returned to the hospital and was diagnosed with a worsening hematoma including an Uncal hernia according to the National Library of Medicine Uncal herniation occurs when rising intracranial pressure causes portions of the brain to flow from one intracranial compartment to another; this is a life-threatening neurological emergency .Resident #1 was transferred to another facility on 10/9/2025 where s/he would be closer to family and died on [DATE]. Per review of Resident #1's death certificate s/he died on [DATE]. The manner of death was listed as Accident. The date and time of the accident states September 11, 2025 / ~8:00 PM. How injury occurred is listed as Fall(s) from Standing Height and the cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PM.Per phone interview with Resident #1's guardian and their spouse on 11/4/2025 at 2:00 PM Resident #1 has a long history of mental illness including schizophrenia, depression, and narcolepsy with cataplexy and it took doctors several years to find the best combination of medications which included Abilify, Protriptyline, and Seroquel. They became very concerned when nursing staff notified them on 9/12/2025, a Friday that the Resident had been refusing medications and care. According to the Guardian this is a behavior that occurs when the Resident is not taking her/his medications correctly. The Guardian stated that they asked if s/he had been taking her/his Protriptyline and Seroquel and the nurse informed them that s/he did not have an order for Seroquel. The Guardian then requested a meeting with the physician to discuss the medications and the nurse with whom they were speaking with informed them that they could contact the unit manager on Monday and discuss it then the unit manager would talk with the provider. When they asked to speak with the physician the Nurse informed them that the physicians only communicate with the facility staff not the families. Review of the facility policy titled admission Process states The facility will obtain the appropriate physician orders from the discharging facility, if applicable. The RN/LPN [Registered Nurse/Licensed Practical Nurse] will verify the admission orders with the attending physician. The RN/LPN will reconcile medication orders with the physician based on the discharge instructions from the transferring facility.Per interview with the facility Administrator on 11/4/2025 at 3:19 PM when the family was notified on 9/12/2025 of the increased behaviors the Resident had been experiencing such as refusals of medications and hallucinations, they questioned whether or not s/he had been getting the right medications. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled and only every other page had been available at the time.Per interview with the Regional Assistant Director of Nursing ([NAME]) on 11/6/2025 at approximately 4:30 PM it is the expectation that nursing staff reconcile medications using the discharge medication list. Staff are not expected to review the entire discharge summary or other information that comes from the hospital. The [NAME] confirmed that the missed medications on Resident #1's hospital discharge summary should have been ordered on admission and were not. Per interview with the facility Administrator on 11/12/2025 at 11:30 AM she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review the rest of the summary to ensure that there were not additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors. Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the facility staff and herself had only reviewed every other page of the hospital discharge summary on the Resident's admission and that an order for Seroquel had been omitted as a result. However, she had not been aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, but that had not been addressed because it had been missed. The Physician confirmed that the expectation is that the Unit Manager and/or admissions person review the discharge summary in its entirety. Per interview with the facility Medical Director on 11/18/2025 at 10:10 AM confirmed that when a Resident is admitted from the hospital, it is important and their expectation that nursing staff review the discharge packet that comes with the resident. The Medical Director stated you need to know as much as possible about your patient. We should have a good idea of the patient, and the medication lists don't tell you the whole picture. You can build off the medication list but you should not rely solely on it.

The facility failed to develop a care plan or implement interventions specific to the safety risks associated with narcolepsy with cataplexy (sudden weakness or limping of the muscles), risk factors for the use of antipsychotic medications, implement care plan interventions to monitor blood glucose 4 times daily and administer insulin on a sliding scale for a diabetic who was admitted with physician orders to do so, identify safety/fall risk related to complications of the diagnosis of a subdural hematoma for 1 of 3 residents in the sample (Resident #1). This deficient practice rose to the immediate jeopardy level due to the facility's failure to ensure care plans are developed and implemented, which resulted in Resident #1 experiencing a fall that resulted in a head injury with a subdural hematoma that worsened over time and resulted in death. This is a repeat deficiency for this facility, with the violation cited during a partial survey dated 3/3/25. Findings include:Per record review Resident #1 was admitted to the facility for short term rehab after a fall at their home resulting in a distal radius fracture and multiple fractured ribs. Additional diagnoses included left third finger fracture, urinary tract infection (UTI), osteoporosis, frequent falls, schizophrenia, narcolepsy with cataplexy (sudden weakness or limping of the muscles), recurrent UTIs, and hypertension. Review of the hospital Discharge summary dated [DATE] revealed physicians' orders for Keflex 500 mg every 12 hours for 4 days, then resume nitrofurantoin (Macrobid) 100mg daily. Guaifenesin 600mg twice daily, sliding scale insulin lispro with blood sugars 4 times daily implemented due to elevated blood sugar readings, lidocaine patch 2 patches daily, and Quetiapine (Seroquel, an antipsychotic) 600mg at bedtime. Review of the facility admission provider orders and the August 2025 medication administration record revealed that these orders were not implemented on admission to the facility. Review of Resident #1's care plan revealed a focus initiated on 8/16/2025 of at risk for MDRO [Multi Drug Resistant Organism] colonization/infection due to history of MRSA and at risk for infection/sepsis, Limited mobility, HX of UTI's, history of MRSA initiated on 8/16/2025. The care plan does not reflect the actual urinary tract infection that the resident was admitted with, or interventions related to the treatment of an actual UTI.Review of Resident #1s physicians orders after admission to the facility revealed that an order for finger sticks (a method used to obtain blood sugars) once in the AM was entered on 8/17/2025. The Resident's plan of care does not address the use of sliding scale insulin or finger sticks 4 times per day. Review of Resident #1's daily blood sugars revealed that between 8/17/25- 10/9/25 the resident experienced 13 documented episodes of hyperglycemia (blood glucose above which would have required the administration of the sliding scale insulin). There is no way to determine if the Resident was experiencing hyper or hypoglycemia (high or low blood sugars) or would have required sliding scale coverage the other three times per day because the blood sugars were not ordered or obtained. Further review of hospital discharge orders included Quetiapine (Seroquel, an antipsychotic) 600mg at bedtime for schizophrenia. According to the hospital records Resident #1 has been on Seroquel 600 mg since 9/1/2023. Review of the facility documentation including physician's orders and the August medication administration record (MAR) revealed that the Seroquel 600 mg was not ordered on admission. Review of the Resident's care plan reveals that the plan of care did not identified risks associated with or management of withdrawal symptoms caused by abrupt cessation of Seroquel. The Food and Drug Administration's (FDA's) Boxed Warning states that some commonly reported Seroquel withdrawal symptoms can occur include nausea, vomiting, anxiety, irritability, agitation or restlessness, panic-like symptoms, and rebound mood swings. Rebound symptoms include mania or hypomania, depression, Psychotic symptoms, and severe insomnia. When it is stopped abruptly -especially at higher doses such as 300-800 mg the sudden loss of receptor blockade can cause the body to rebound and over-respond until it readjusts. Acute withdrawal symptoms such as insomnia, nausea, and vomiting have been reported following abrupt cessation of quetiapine (Seroquel). It is recommended that, where possible, the dose be tapered gradually. An admission Fall Risk Assessment completed on 8/15/2025 was noted to have several inaccuracies and reflected that Resident #1 had a diminished safety awareness, impaired mobility with continence, required the use of an assistive device, 1-2 falls in the past 3 months, takes 1-2 high risk medications, no change in medication and/or change in dosage in the past five days 1-2 predisposing diseases/conditions. The Fall Risk care planning section of the assessment was not completed. The Resident was actually prescribed 4 of the high-risk medications which included antihypertensives, antiseizure, hypoglycemics, and psychotropics. Although unbeknownst to the facility, the Resident did have a change in medications as they were not receiving their long-term dose of Seroquel 600 mg (antipsychotic), sliding scale insulin, and the antibiotic that was prescribed during their hospital stay. The Resident also had 4 predisposing diseases/condition rather than 1-2 which included hypertension, osteoporosis, fractures, and dementia. Review of Resident #1's care plan reflects a care plan focus of risk for falls due to cognitive loss, lack of safety awareness, history of falls. The care plan interventions implemented on the baseline care plan included provide Resident with opportunities for choice, assist to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement, engage in simple, structured activities of their preference: that avoid overly demanding tasks. The care plan focus and/or interventions did not address the increased fall and safety risks due to diagnoses such as narcolepsy with cataplexy, osteoporosis, and fractures or the use of high-risk medications including antihypertensives, antiseizure, hypoglycemics, and psychotropics. During an interview on 11/6/2025 at 1:17 PM the Regional Assistant Director of Nursing confirmed that Resident #1's care plan did not address safety or fall risk concerns related to narcolepsy with cataplexy. When asked if narcolepsy with cataplexy should be on the care plan for safety risks, she stated that the care plan addresses falls and that not every diagnosis would be in the care plan.A care plan focus initiated on 8/16/2025 of at risk for decreased ability to perform ADLs (activities of daily living) related to dementia. Interventions included X1 assist for transfers that was implemented on 8/16/2025. This intervention was then revised on 8/16/2025 when ambulation status was replaced with X1 assist for transfers. There was no longer an indication for ambulation status on the care plan. On 8/18/2025 three days after admission and three days of the missing Seroquel administration, s/he began experiencing hallucinations and then began exhibiting anxious, angry, and combative behaviors which were not her/his baseline. These behaviors continued to occur. Review of Provider's Progress Notes, the provider was notified on 8/22, 8/25, and 9/12 of medication refusals. The care plan was not updated regarding safety risks or interventions to prevent accidents and hazards related to the change in condition. A Progress note date 9/9/2025 reveals that Resident #1 had weakness of their right and left lower extremities and left upper extremity, their balance was unsteady, and they were anxious, hallucinating, and wandering. The progress note also states Safety concerns: resident often observed self-transferring without calling for assistance from staff. A Progress Note dated 9/10/2025 states resident observed multiple times by staff throughout [evening] wandering and responding to internal stimuli. resident observed stating dad she wont let me do it, and bill is not going to let me sleep. resident easily redirected by staff. resident assisted with toileting and clothing. There is no documented evidence that any additional care plan interventions related to falls or safety precautions including increased supervision were implemented. A Skilled Note dated 9/10/2025 states Mental Status: Anxious, Pleasant, Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Wandering. Comments: [s/he] has auditory hallucinations that [s/he] is talking to '[her/his] father', he tells [her/him] what to do and what not to do . Concerns: gets mad at staff, swings [her/his] cast trying to hit us . Review of Resident #1's care plan revealed that it did not address hallucinations first documented on 8/18/2025 and there were no safety interventions put in place related combative behaviors until 9/18/2025. Per Progress Note dated 9/11/2025 Resident #1 was found at 12:45 AM lying in bed with a cut and swelling on the left side of their forehead. The Resident stated that s/he got up, froze, and fell flat, then got up and layed on her/his bed. The incident report identifies predisposing factors as ambulation without assist, wanderer, and history of falls. A progress note dated 9/11/2025 reflects that at 12:30 PM the Resident was sent to the hospital emergency department for evaluation of the head wound and complaints of left foot pain. The Resident returned to the facility on 9/12/2025 with diagnoses of subdural hematoma and fracture of the foot with a walking boot in place. On 9/11/2025 a care plan intervention of Hung a call, don't fall sign in [Resident's] room to remind [Resident] to call for assistance with transfers was added to the fall risk care plan. There were no revisions to the care plan to address the increased fall risks and interventions associated with the subdural hematoma and fractured foot with a walking boot or wandering. On 9/13/2025 a physician's order for Seroquel 600 mg was initiated. According to the FDA's prescribing recommendation for starting Seroquel (Resident #1 had not received Seroquel for 30 days, since 8/15/25), Day 1: 25mg twice daily. Day 2-3: Increase increments of 25 - 50 mg divided doses (two or three times per day), to reach a total of 300 - 400 mg/day by day 4. Further adjustments should be in increments of 25 - 50 mg twice daily, with intervals of not less than 2 days between dose changes. Risks of starting Seroquel at 600 mg without gradual dose increase include: Orthostatic blood pressure (drop in blood pressure when standing up) dizziness, sedation, impaired motor coordination, blood sugar alterations. All listed risks increase the risks for falls and safety risks. Further review of Resident #1's care plan reveals a focus dated 8/16/2025 of risk for complications related to the use of psychotropic drugs however, it did not address fall or safety risks associated with the use of psychotropic medications or specific interventions to manage fall and safety risks. it was also not updated after the 9/13/2025 addition of Seroquel. A Nursing Progress Note dated 9/14/2025 read Resident was rude to staff. [S/he] walked to the bathroom by [her/himself] and the nurse took the wheelchair to [her/him]. [S/he] refused to eat [their] food. [S/he] only ate 1 cup of ice cream with [her/his] meds and put [her/himself] to bed. The Resident continued to self-ambulate with no additional interventions to prevent or protect them from falls and injury, Per Nursing Progress Note dated 9/17/2025 the Resident was found on the floor at the nurse's station. A Nursing Progress Note states [S/he] was drowsy. [S/he] was uncooperative with [the Nurse]. [S/he] was assisted onto [her/his] wheelchair and wheeled into [her/his] room and transferred onto [her/his] bed. On assessment, there was a bump on top of [her/his] head (parietal lobe), the size of a coin-10 cents. The Resident was transferred to the hospital for evaluation. The Resident's fall risk care plan was updated on 9/18/25 to include an intervention of Med review by MD this intervention was later revised on 9/23/2025 to When rounding offer and assist with alternative sitting options such as sitting up in W/C [wheelchair], Laying in bed as [s/he] will allow and tolerate. A Post Event Note dated 9/22/2025 reveals that the Resident is supposed to be non-weight bearing on left foot until cleared, but they were often found walking with their walker down the hall. The need for increased supervision related to the Resident's self-ambulating and self-toileting and other risks was not addressed in the care plan. Nursing Progress notes reveal that on 10/2/2025 Resident #1 was found in bed choking on vomit. S/he was sent to the hospital for evaluation and returned. On 10/3/2025 Resident #1 returned to the hospital and was diagnosed with a worsening hematoma including an Uncal hernia according to the National Library of Medicine Uncal herniation occurs when rising intracranial pressure causes portions of the brain to flow from one intracranial compartment to another; this is a life-threatening neurological emergency . Upon return to the facility the care plan was not updated to reflect the Resident's care needs related to the diagnosis of the worsening subdural hemorrhage and uncal herniation. The Resident was transferred back to the facility on [DATE] on comfort measures and on 10/16/2025 was transferred to a skilled nursing facility closer to the family and died. Resident #1 was transferred to another facility on 10/9/2025 where s/he would be closer to family and died on [DATE]. Per review of Resident #1's death certificate s/he died on [DATE]. The manner of death was listed as Accident. The date and time of the accident states September 11, 2025 / ~8:00 PM. How injury occurred is listed as Fall(s) from Standing Height and the cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PM.Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified, but she was not aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, however she did not address that because she had missed it. The Physician confirmed that the discharge summary that was used to admit Resident #1 only included every other page of information, and that the expectation is that the Unit Manager and/or admissions person review all of the discharge summary. Ref. F635

Based on interview and record review the facility failed to effectively assess a resident's risks, implement, monitor, and modify interventions when necessary to prevent falls with major injury resulting in death. The facility also failed to provide necessary treatment of clinical conditions which put the resident at an increased risk of safety and accidents. The facility also failed identify and address potential accident hazards related to the resident's clinical condition. As a result, the resident experienced a recuring UTI, a decline in behavioral health, hyperglycemic episodes, medication withdrawal, and increased fall risk for 1 of 3 Residents in the sample (Resident #1). This deficient practice rose to the immediate jeopardy level due to the facility's failure to prevent falls, which resulted in Resident #1 sustaining two falls resulting in a subdural hematoma that worsened over time resulting in death. This is a repeat deficiency for this facility, with the violation cited during partial surveys, dated 6/12/24, 10/18/24, 3/3/25 (at immediate jeopardy), and 5/28/25. Findings include: Per record review Resident #1 was admitted to the facility for short term rehab after a fall at their home resulting in a distal radius fracture and multiple fractured ribs. Additional diagnoses included left third finger fracture, urinary tract infection (UTI), osteoporosis, frequent falls, schizophrenia, major depressive disorder, narcolepsy with cataplexy (sudden weakness or limping of the muscles) recurrent UTIs, and hypertension. Review of the hospital discharge orders dated 8/15/2025 revealed physicians' orders for Keflex 500 mg every 12 hours for 4 days, then resume nitrofurantoin (Macrobid) 100mg daily. Guaifenesin 600mg twice daily, sliding scale insulin lispro with blood sugars 4 times daily, lidocaine patch 2 patches daily, and Quetiapine (Seroquel) 600mg at bedtime. None of these orders were implemented on admission to the facility. Review of physician's orders revealed that on 8/17/25 a Registered Nurse entered an order for fingerstick (a method for testing blood sugars) once daily. Review of Resident #1's blood sugars between 8/17- 10/9 revealed that the resident experienced 10 episodes of hyperglycemia (High blood sugar) which would have required the administration of the sliding scale insulin. There is no way to determine if the Resident had other episodes of hyperglycemia because the blood sugars were not completed as directed in the discharge orders. Per the National Library of Medicine Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence.Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified, but she was not aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, however she did not address that because she had missed it. The Physician confirmed that the discharge summary that was used to admit Resident #1 only included every other page of information, and that the expectation is that the Unit Manager and/or admissions person review all of the discharge summary. During an interview on 11/6/2025 at 1:17 PM the Regional Assistant Director of Nursing when asked if the diagnosis or narcolepsy with cataplexy should be identified on the care plan as a safety or fall concern, she stated that the Resident had an at risk for falls care plan that addressed fall risks, and not all diagnoses are on the care plan. The [NAME] confirmed that the care plan did not address fall or safety concern related to the diagnosis of narcolepsy with cataplexy. An admission Fall Risk Assessment completed on 8/15/2025 was noted to have several inaccuracies and reflected that Resident #1 had a diminished safety awareness, impaired mobility with continence, required the use of an assistive device, 1-2 falls in the past 3 months, takes 1-2 high risk medications, no change in medication and/or change in dosage in the past five days 1-2 predisposing diseases/conditions. The Fall Risk care planning section of the assessment was not completed. The Resident was actually prescribed 4 of the high-risk medications which included antihypertensives, antiseizure, hypoglycemics, and psychotropics. Although unbeknownst to the facility, the Resident did have a change in medications as they were not receiving their long-term dose of Seroquel 600 mg (antipsychotic), sliding scale insulin, and the antibiotic that was prescribed during their hospital stay. The Resident also had 4 predisposing diseases/condition rather than 1-2 which included hypertension, osteoporosis, fractures, and dementia. Review of Resident #1's care plan reflects a care plan focus of risk for falls due to cognitive loss, lack of safety awareness, history of falls. The care plan interventions implemented on the baseline care plan included provide Resident with opportunities for choice, assist to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement, engage in simple, structured activities of their preference: that avoid overly demanding tasks. The care plan focus and/or interventions did not address the increased fall and safety risks due to diagnoses such as narcolepsy with cataplexy, osteoporosis, and fractures or the use of high-risk medications including antihypertensives, antiseizure, hypoglycemics, and psychotropics. During an interview on 11/6/2025 at 1:17 PM the Regional Assistant Director of Nursing confirmed that Resident #1's care plan did not address safety or fall risk concerns related to narcolepsy with cataplexy. When asked if narcolepsy with cataplexy should be on the care plan for safety risks, she stated that the care plan addresses falls and that not every diagnosis would be in the care plan.A care plan focus initiated on 8/16/2025 of at risk for decreased ability to perform ADLs (activities of daily living) related to dementia. Interventions included X1 assist for transfers that was implemented on 8/16/2025. This intervention was then revised on 8/16/2025 when ambulation status was replaced with X1 assist for transfers. There was no longer an indication for ambulation status on the care plan. On 8/18/2025 three days after admission and three days of the missing Seroquel administration, s/he began experiencing hallucinations and then began exhibiting anxious, angry, and combative behaviors which were not her/his baseline. These behaviors continued to occur. Review of Provider's Progress Notes, the provider was notified on 8/22, 8/25, and 9/12 of medication refusals. The care plan was not updated regarding safety risks or interventions to prevent accidents and hazards related to the change in condition. A Progress note date 9/9/2025 reveals that Resident #1 had weakness of their right and left lower extremities and left upper extremity, their balance was unsteady, and they were anxious, hallucinating, and wandering. The progress note also states Safety concerns: resident often observed self-transferring without calling for assistance from staff. A Progress Note dated 9/10/2025 states resident observed multiple times by staff throughout [evening] wandering and responding to internal stimuli. resident observed stating dad she wont let me do it, and bill is not going to let me sleep. resident easily redirected by staff. resident assisted with toileting and clothing. There is no documented evidence that any additional care plan interventions related to falls or safety precautions including increased supervision were implemented. A Skilled Note dated 9/10/2025 states Mental Status: Anxious, Pleasant, Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Wandering. Comments: [s/he] has auditory hallucinations that [s/he] is talking to '[her/his] father', he tells [her/him] what to do and what not to do . Concerns: gets mad at staff, swings [her/his] cast trying to hit us . Review of Resident #1's care plan revealed that it did not address hallucinations first documented on 8/18/2025 and there were no safety interventions put in place related combative behaviors until 9/18/2025. Per Progress Note dated 9/11/2025 Resident #1 was found at 12:45 AM lying in bed with a cut and swelling on the left side of their forehead. The Resident stated that s/he got up, froze, and fell flat, then got up and layed on her/his bed. The incident report identifies predisposing factors as ambulation without assist, wanderer, and history of falls. A progress note dated 9/11/2025 reflects that at 12:30 PM the Resident was sent to the hospital emergency department for evaluation of the head wound and complaints of left foot pain. The Resident returned to the facility on 9/12/2025 with diagnoses of subdural hematoma and fracture of the foot with a walking boot in place. On 9/11/2025 a care plan intervention of Hung a call, don't fall sign in [Resident's] room to remind [Resident] to call for assistance with transfers was added to the fall risk care plan. There were no revisions to the care plan to address the increased fall risks and interventions associated with the subdural hematoma and fractured foot with a walking boot or wandering. On 9/13/2025 a physician's order for Seroquel 600 mg was initiated. According to the FDA's prescribing recommendation for starting Seroquel (Resident #1 had not received Seroquel for 30 days, since 8/15/25), Day 1: 25mg twice daily. Day 2-3: Increase increments of 25 - 50 mg divided doses (two or three times per day), to reach a total of 300 - 400 mg/day by day 4. Further adjustments should be in increments of 25 - 50 mg twice daily, with intervals of not less than 2 days between dose changes. Risks of starting Seroquel at 600 mg without gradual dose increase include: Orthostatic blood pressure (drop in blood pressure when standing up) dizziness, sedation, impaired motor coordination, blood sugar alterations. All listed risks increase the risks for falls and safety risks. Further review of Resident #1's care plan reveals a focus dated 8/16/2025 of risk for complications related to the use of psychotropic drugs however, it did not address fall or safety risks associated with the use of psychotropic medications or specific interventions to manage fall and safety risks. it was also not updated after the 9/13/2025 addition of Seroquel. A Nursing Progress Note dated 9/14/2025 read Resident was rude to staff. [S/he] walked to the bathroom by [her/himself] and the nurse took the wheelchair to [her/him]. [S/he] refused to eat [their] food. [S/he] only ate 1 cup of ice cream with [her/his] meds and put [her/himself] to bed. The Resident continued to self-ambulate with no additional interventions to prevent or protect them from falls and injury, Per Nursing Progress Note dated 9/17/2025 the Resident was found on the floor at the nurse's station. A Nursing Progress Note states [S/he] was drowsy. [S/he] was uncooperative with [the Nurse]. [S/he] was assisted onto [her/his] wheelchair and wheeled into [her/his] room and transferred onto [her/his] bed. On assessment, there was a bump on top of [her/his] head (parietal lobe), the size of a coin-10 cents. The Resident was transferred to the hospital for evaluation. The Resident's fall risk care plan was updated on 9/18/25 to include an intervention of Med review by MD this intervention was later revised on 9/23/2025 to When rounding offer and assist with alternative sitting options such as sitting up in W/C [wheelchair], Laying in bed as [s/he] will allow and tolerate. A Post Event Note dated 9/22/2025 reveals that the Resident is supposed to be non-weight bearing on left foot until cleared, but they were often found walking with their walker down the hall. The need for increased supervision related to the Resident's self-ambulating and self-toileting and other risks was not addressed in the care plan. Nursing Progress notes reveal that on 10/2/2025 Resident #1 was found in bed choking on vomit. S/he was sent to the hospital for evaluation and returned. On 10/3/2025 Resident #1 returned to the hospital and was diagnosed with a worsening hematoma including an Uncal hernia according to the National Library of Medicine Uncal herniation occurs when rising intracranial pressure causes portions of the brain to flow from one intracranial compartment to another; this is a life-threatening neurological emergency . Resident #1 was transferred to another facility on 10/9/2025 where s/he would be closer to family and died on [DATE]. Per review of Resident #1's death certificate s/he died on [DATE]. The manner of death was listed as Accident. The date and time of the accident states September 11, 2025 / ~8:00 PM. How injury occurred is listed as Fall(s) from Standing Height and the cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PM.During an interview on 11/4/2025 at 3:19 PM when the facility Administrator confirmed that family was notified on 9/12/2025 of the increased behaviors the Resident had been experiencing such as refusals of medications and hallucinations, they questioned whether or not s/he had been getting the right medications. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled and only every other page had been available at the time. The Administrator confirmed that the missed Seroquel was a medication error however, the facility did not implement an incident report per policy. Per interview with the facility Administrator on 11/12/2025 at 11:30 AM she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review it to ensure there were not additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors. Ref. F635

Based on interview and record review, the facility failed protect a resident's right to be free from neglect by failing to provide services to the resident that are necessary to avoid physical harm, pain, mental anguish and emotional distress for 1 of 5 residents in the applicable sample (Resident #1).This deficient practice rose to the immediate jeopardy level due to the facility's failure to provide necessary services, which resulted in antipsychotic medication withdrawal, repeated falls with major head injury, and death. This is a repeat deficiency for this facility, with the violation cited at immediate jeopardy during a partial survey dated 3/3/25. Findings include:Per record review Resident #1 was admitted to the facility for short term rehab after a fall at their home resulting in a distal radius fracture and multiple fractured ribs. Additional diagnoses included left third finger fracture, urinary tract infection (UTI), osteoporosis, frequent falls, schizophrenia, major depressive disorder, narcolepsy with cataplexy (sudden weakness or limping of the muscles) recurrent UTIs, and hypertension.Review of the hospital discharge orders dated 8/15/2025 revealed physicians' orders for Keflex 500 mg every 12 hours for 4 days, then resume nitrofurantoin (Macrobid) 100mg daily. Guaifenesin 600mg twice daily, sliding scale insulin lispro with blood sugars 4 times daily, lidocaine patch 2 patches daily, and Quetiapine (Seroquel) 600mg at bedtime. None of these orders were implemented on admission to the facility. Not identifying and ordering the medications listed resulted in Resident #1 not receiving antibiotic therapy needed to prevent infection, not being monitored for effective diabetic management, and not receiving an antipsychotic necessary to treat schizophrenia causing exacerbation of symptoms increasing the risks of falls and other safety risks.Per interview on 11/4/2025 at 3:19 PM with the facility Administrator after the facility became aware that Resident #1 did not have their long-term order of Seroquel 600 mg daily on 9/12/2025, the facility had identified that the information that had arrived at the facility with the Resident had been scanned into the electronic health record excluding every other page. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled. The Administrator confirmed that the missed order Seroquel was a medication error however, the facility did not review the entire discharge summary to ensure there were no other orders that should have been implement that were not.Per interview with a Licensed Practical Nurse on 11/13/2025 at 5:10 PM she is typically the nurse who does the second check on admission orders and finishes the admission process because she works evenings. When asked about the process of obtaining and reconciling admission orders she stated that she compares the medication list to what has been entered in the electronic health record by another nurse. When asked if she reviews the rest of the information that comes from the hospital, she stated that she does try to read through it but does not always get to it.Per interview with the facility Administrator on 11/12/2025 at 11:30 AM she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital and there was a medication error as a result, they did not further review it to ensure there were no additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics for treatment of UTI and prophylaxis, and the lidocaine patches were not identified until the surveyor identified the errors.Per interview on 11/13/2025 at 5:30 PM the Regional Assistant Director of Nursing ([NAME]) stated that the process for admission medication reconciliation involves review of the medication list that comes from the hospital. The [NAME] confirmed that it is not practice to review all of the information that comes from the hospital stating, sometimes we get a packet this thick holding up fingers about an inch apart we can't possibly read all of that. The [NAME] stated again we just review the medication list.Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified on 9/13/2025, but she was not aware that the other medications had been missed in the admission process. The Physician confirmed that the discharge summary that was used to admit Resident #1 only included every other page of information, and that the expectation is that the Unit Manager and/or admissions person review the complete discharge summary.The Food and Drug Administration's (FDA's) Boxed Warning states that some commonly reported Seroquel withdrawal symptoms can occur include nausea, vomiting, anxiety, irritability, agitation or restlessness, panic-like symptoms, and rebound mood swings. Rebound symptoms include mania or hypomania, depression, Psychotic symptoms, and severe insomnia. When it is stopped abruptly -especially at higher doses such as 300-800 mg the sudden loss of receptor blockade can cause the body to rebound and over-respond until it readjusts. Acute withdrawal symptoms such as insomnia, nausea, and vomiting have been reported following abrupt cessation of quetiapine (Seroquel). It is recommended that, where possible, the dose be tapered gradually.Review of physician's orders revealed that on 8/17/25 a Registered Nurse entered an order for fingerstick (a method for testing blood sugars) once daily. Review of Resident #1's blood sugars between 8/17- 10/9 revealed that the resident experienced 10 episodes of hyperglycemia (High blood sugar) which would have required the administration of the sliding scale insulin had it been ordered per the hospital discharge orders. There is no way to determine if the Resident had other hyper/hypoglycemia episodes because the blood sugars were not completed as directed in the discharge orders. Per the National Library of Medicine Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence.Further review of the hospital discharge orders for admission dated 8/15/2025 revealed an antibiotic order for Keflex 500 mg every 12 hours for 4 days to treat the UTI, then resume nitrofurantoin (Macrobid) 100 mg daily for prophylaxis, Additional orders were 2 lidocaine patches daily for pain. Review of admission orders revealed that neither of these orders were implemented on admission to the facility. A Nurse Practitioner Progress Note dated 10/8/2025 reveals Resident . is seen today for UTI. Resident had a urine done and is positive for Hemolytic Strep Group B. [S/he] remains unresponsive. [S/he] was recently in the ER and given IV fluids and has since returned. Potential for discharge tomorrow to sister facility for ongoing care - confirmation is pending. An order was written on 10/8/2025 for Rocephin Inject 1 gram intramuscularly one time a day for UTI for 5 Days mix with lidocaine. The Resident received one dose on 10/8/2025 and was transferred to another nursing facility on 10/9/2025.An admission Fall Risk Assessment completed on 8/15/2025 was noted to have several inaccuracies and reflected that Resident #1 had a diminished safety awareness, impaired mobility with continence, required the use of an assistive device, 1-2 falls in the past 3 months, takes 1-2 high risk medications, no change in medication and/or change in dosage in the past five days 1-2 predisposing diseases/conditions. However, the Resident was actually prescribed 4 of the high-risk medications which included antihypertensives, antiseizure, hypoglycemics, and psychotropics. Although unbeknownst to the facility, the Resident did have a change in medications as they were not receiving their long-term dose of Seroquel 600 mg (antipsychotic), sliding scale insulin, and the antibiotic that was prescribed during their hospital stay. The Resident also had 4 predisposing diseases/conditions rather than 1-2 which included hypertension, osteoporosis, fractures, and dementia. The Fall Risk care planning section of the assessment was not completed.Review of Resident #1's care plan reflects a care plan focus of risk for falls due to cognitive loss, lack of safety awareness, history of falls. The care plan interventions implemented on the baseline care plan included providing Resident with opportunities for choice, assist to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement, engage in simple, structured activities of their preference: that avoid overly demanding tasks. The care plan focus and/or interventions did not address the increased fall and safety risks due to diagnoses such as narcolepsy with cataplexy, osteoporosis, and fractures and did not include the use of high-risk medications including antihypertensives, antiseizure, hypoglycemics, and psychotropics.During an interview on 11/6/2025 at 1:17 PM the Regional Assistant Director of Nursing confirmed that Resident #1's care plan did not address safety or fall risk concerns related to narcolepsy with cataplexy. When asked if narcolepsy with cataplexy should be on the care plan for safety risks, she stated that the care plan addresses falls and that not every diagnosis would be in the care plan.A care plan focus initiated on 8/16/2025 of at risk for decreased ability to perform ADLs (activities of daily living) related to dementia. Interventions included X1 assist for transfers that was implemented on 8/16/2025. This intervention was then revised on 8/16/2025 when ambulation status was replaced with X1 assist for transfers. There was no longer an indication for ambulation status on the care plan.On 8/18/2025 three days after admission and three days of the missing Seroquel administration, s/he began experiencing hallucinations and then began exhibiting anxious, angry, resistive and combative behaviors which were not her/his baseline. These behaviors continued to occur. Review of Provider's Progress Notes, the provider was notified on 8/22, 8/25, and 9/12 of medication refusals. The care plan was not updated regarding safety risks or interventions to prevent accidents and hazards related to the change in condition. A Progress note dated 9/9/2025 reveals that Resident #1 had weakness of their right and left lower extremities and left upper extremity, their balance was unsteady, and they were anxious, hallucinating, and wandering. The progress note also states Safety concerns: resident often observed self-transferring without calling for assistance from staff. A Progress Note dated 9/10/2025 states resident observed multiple times by staff throughout [evening] wandering and responding to internal stimuli. resident observed stating dad she wont let me do it, and bill is not going to let me sleep. resident easily redirected by staff. resident assisted with toileting and clothing. There is no documented evidence that any additional care plan interventions related to self-ambulation with unsteady balance, wandering, hallucinations, and falls or safety precautions including increased supervision were implemented.A Skilled Note dated 9/10/2025 states Mental Status: Anxious, Pleasant, Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Wandering. Comments: [s/he] has auditory hallucinations that [s/he] is talking to '[her/his] father', he tells [her/him] what to do and what not to do . Concerns: gets mad at staff, swings [her/his] cast trying to hit us . Review of Resident #1's care plan revealed that it did not address hallucinations first documented on 8/18/2025 and there were no safety interventions put in place related to resistive, combative behaviors until 9/18/2025.Per Progress Note dated 9/11/2025 Resident #1 was found at 12:45 AM lying in bed with a cut and swelling on the left side of their forehead. The Resident stated that s/he got up, froze, and fell flat, then got up and layed on her/his bed. The incident report identifies predisposing factors as ambulation without assist, wanderer, and history of falls. A progress note dated 9/11/2025 reflects that at 12:30 PM the Resident was sent to the hospital emergency department for evaluation of the head wound and complaints of left foot pain. The Resident returned to the facility on 9/12/2025 with diagnoses of right and left subdural hematomas, a minimal intraventricular hemorrhage, and fracture of the foot with a walking boot in place.On 9/11/2025 a care plan intervention of Hung a call, don't fall sign in [Resident's] room to remind [Resident] to call for assistance with transfers was added to the fall risk care plan. There were no revisions to the care plan to address the increased fall risks, increased supervision, or interventions associated with the subdural hematoma and fractured foot with a walking boot or wandering.On 9/13/2025 a physician's order for Seroquel 600 mg was initiated. According to the FDA's prescribing recommendation for starting Seroquel (Resident #1 had not received Seroquel for 30 days, since 8/15/25), Day 1: 25mg twice daily. Day 2-3: Increase increments of 25 - 50 mg divided doses (two or three times per day), to reach a total of 300 - 400 mg/day by day 4. Further adjustments should be in increments of 25 - 50 mg twice daily, with intervals of not less than 2 days between dose changes. Risks of starting Seroquel at 600 mg without gradual dose increase include: Orthostatic blood pressure (drop in blood pressure when standing up) dizziness, sedation, impaired motor coordination, blood sugar alterations. All listed risks increase the risks for falls and safety risks. Further review of Resident #1's care plan reveals a focus dated 8/16/2025 of risk for complications related to the use of psychotropic drugs however, it did not address fall or safety risks associated with the use of psychotropic medications or specific interventions to manage fall and safety risks. it was also not updated after the 9/13/2025 addition of Seroquel.A Nursing Progress Note dated 9/14/2025 read Resident was rude to staff. [S/he] walked to the bathroom by [her/himself] and the nurse took the wheelchair to [her/him]. [S/he] refused to eat [their] food. [S/he] only ate 1 cup of ice cream with [her/his] meds and put [her/himself] to bed. The Resident continued to self-ambulate with no additional interventions implemented to prevent or protect them from falls and injury.A Nurse Practitioner's Progress Note dated 9/17/2025 states Psychiatric: Appropriate mood and affect, does not appear to be reacting to any internal psychotic stimuli. Assessment & Plan: SCHIZOPHRENIA, UNSPECIFIED Mood is stable/improved. Continue with Seroquel 600mg at bedtime, Aripiprazole 15mg daily and Protriptyline 10mg BID.Per Nursing Progress Note dated 9/17/2025 the Resident was found on the floor after an unwitnessed fall at the nurse's station. A Nursing Progress Note states [S/he] was drowsy. [S/he] was uncooperative with [the Nurse]. [S/he] was assisted onto [her/his] wheelchair and wheeled into [her/his] room and transferred onto [her/his] bed. On assessment, there was a bump on top of [her/his] head (parietal lobe), the size of a coin-10 cents. A progress note written by a Nurse Practitioner stated, When the staff spoke with the family they requested the patient be sent to the ER because the patient had brain bleed last week after a fall per nursing. Okay to send to ER. The Resident was transferred to the hospital for evaluation. Review of a CAT scan (computed tomography scan, which uses x-rays and computer processing to create detailed cross-sectional images of the body) dated 9/17/2025 reveals that the Resident's intercranial hemorrhage was stable with no significant change. The Resident's fall risk care plan was updated on 9/18/25 to include an intervention of Med review by MD this intervention was later revised on 9/23/2025 to When rounding offer and assist with alternative sitting options such as sitting up in W/C [wheelchair], Laying in bed as [s/he] will allow and tolerate. A Post Event Note dated 9/22/2025 reveals that the Resident is supposed to be non-weight bearing on left foot until cleared, but they were often found walking with their walker down the hall. The care plan was also updated on 9/18/2025 to reflect a focus of [Resident] is resistive to care related to: Cognitive Loss/Dementia. However, the need for increased supervision related to the Resident's self-ambulating and self-toileting, a fractured foot with a non-weight bearing status, and other risks was not addressed in the care plan.A facility incident report dated completed on10/2/2025 states Heard choking coming from [resident's] room. I went in to evaluate. [Resident] was lying on [her/his] back vomiting pale green and choking. [Her/his] eyes were watering face was red and [s/he] was not speaking. The documented description states I sat [Resident] up to 90 degrees assisted with clearing vomit from [her/his] mouth did some deep breathing with [her/him] [s/he] was able to regulate breathing wipe tears and relax. Per review of a Nurse Practitioner's progress not dated 10/2/2025 states History of present illness: Resident is seen and examined today via telehealth.Resident is an [AGE] year-old [female/male] with a pmhx [past medical history] of dementia and shizophrenia who is seen today for vomiting since last night, increased weakness, and lethargy. [S/he] does have a known brain bleed.Review of a Nursing Progress note dated 10/2/2025 reads 10/2/2025 19:42 resident returned to facility via medical transport. resident transferred via stretcher to bed. resident drowsy upon arrival. resident skin color normal and no new skin alterations observed to body at this time. band aid to left AC observed from s/p IV meds received in ER. resident speaking low but able to understand and be understood. resident denies any pain or discomfort at the present time. Upon checking discharge summary from hospital, observed a diagnosis of aspiration pneumonia due to findings of possible left lateral infiltrate. to Xray. resident also is to continue on Zosyn and albuterol, but no complete orders stated in summary. call placed to [NAME] ER for clarification of orders and scripts to be faxed over. unable to speak with nurse at the present time, was told to call back since nurse is unavailable at this present time. Unit manager notified.Another progress note written by the Nurse Practitioner on 10/2/2025 at 10:14:00 PM states Patient returned from ER diagnosed with possible aspiration PNA- given Zosyn, albuterol Nebulizer and Zofran and discharged back to facility. On nurse review of ER notes it states to continue Zosyn, but no orders were sent with patient on discharge. Nurse calling back to ER to get clarification and then will call provider back.Another Nursing Progress Note date 10/3/2025 at 2:00 AM states no fax received, call placed to [NAME] ER. [name omitted] RN states Someone would have to come and pick up the orders because our provider cannot send it in on our end. there is an order here for Zosyn 3.375gm 50ml/hr q6hrs x4 doses. there is no order for albuterol at this time, your in house provider will have to order it. call placed to on-call [name omitted] and notified her of ER recommendations. new order given.A Nurse Practitioner (NP) note dated 10/3/25 at 2:00 AM reveals orders to Give dose of Zofran 4mg now- continue PRN [as needed] as ordered DuoNeb Q [every] 4hours PRN for SOB [shortness of breath] /wheezing Place on 2L O2 [oxygen]continuous until reevaluated by primary provider Place peripheral IV [intravenous line], if unable then okay to place midline. Monitor vital signs every shift x 3 days. Continue to monitor and notify on call provider of any changes or concerns. [follow-up] primary provider.Nursing Progress Note 10/3/2025 at 7:15 AM unit manager notified in house [NP] about residents status and issues during shift. order given to send resident back to ER for iv doses of zosyn and evaluation of change in condition. 911 called. report called into [name omitted] RN. notified POA [power of attorney] of residents change in condition and order to be transferred back to ER. POA acknowledged understanding. Review of physicians orders reveals an order written on 10/3/2025 that reads Place Peripheral IV, if unable then okay to place midline for IV ATB [antibiotic therapy.On 10/3/25 a Progress Note written by the Nurse Practitioner reads Resident is an [AGE] year old [female/male] with a pmhx of dementia and shizophrenia who is seen today for vomiting since last night, increased weakness, and lethargy. She does have a known brain bleed which was not evaluated in the ER yesterday. Today she continues to decline with vomiting, lethargy, and weakness with worsening confusion.Another Nurse Practitioner Progress Note dated 10/3/2025 Concern for progressive bleeding based on symptoms. Instructed nursing to send resident back to the ER as [s/he] is a full code and continued decline.Per interview with the facility Administrator on 11/4/2025 at 10:30 AM the facility does not provide IV therapy and is not able to administer IV antibiotics. The Administrator confirmed that after the Resident returned to the facility orders for IV Zosyn were given and the next morning the Resident was sent back to the hospital to receive the Zosyn because they were unable to administer it there.Review of Resident #1's care plan revealed an updated intervention added 10/2 and revised on 10/3/25 of Aspiration 10/2- Send out for evaluation on decline and possible aspiration pneumonia. This was not updated with appropriate interventions when the Resident returned from the hospital.A care plan focus initiated on 10/4/2025 of [Resident's] care decision maker has expressed desire for palliative/comfort care measures only related to (does not address) with a goal of [Resident] will have the highest possible level of comfort x90 days. However, there were no interventions put in place until 10/7/2025 which included Encourage and allow time for verbalization of feelings of fear, anxiety, or depression and provide support, Provide medication as ordered and monitor effectiveness and monitor for side effects and report to physician/advanced practice practitioner as indicated, and Provide preventative skin care per skin plan of care.On 10/7/2025 Resident #1 returned to the hospital and was diagnosed with a worsening hematoma including an Uncal hernia according to the National Library of Medicine Uncal herniation occurs when rising intracranial pressure causes portions of the brain to flow from one intracranial compartment to another; this is a life-threatening neurological emergency .Resident #1 was transferred to another facility on 10/9/2025 where s/he would be closer to family and died on [DATE]. Per review of Resident #1's death certificate s/he died on [DATE]. The manner of death was listed as Accident. The date and time of the accident states September 11, 2025 / ~8:00 PM. How injury occurred is listed as Fall(s) from Standing Height and the cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PM.During an interview on 11/4/2025 at 3:19 PM the facility Administrator confirmed that when family was notified on 9/12/2025 of the increased behaviors the Resident had been experiencing such as refusals of medications, combativeness with care, and hallucinations, they questioned whether or not s/he had been getting the right medications specifically the Seroquel. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled and only every other page had been available at the time. The Administrator confirmed that the missed Seroquel was a medication error however, the facility did not implement an incident report per policy.Per interview with the facility Administrator on 11/12/2025 at 11:30 AM she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review it to ensure there were not additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors.Per phone interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified, but she was not aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, however she did not address that because she had missed it. The Physician confirmed that the discharge summary that was used to admit Resident #1 only included every other page of information, and that the expectation is that the Unit Manager and/or admissions person review all of the discharge summary. When asked if she knew that the Resident had returned to the facility with orders for IV therapy and the facility could not provide IV therapy, she stated that she did not. The Primary Physician also stated that she felt the family did not understand how serious the critical diagnoses related to the subdural hematoma versus an uncal herniation that was identified on the third CAT scan were. When asked if she had communicated with the guardian about the Resident's condition, she stated no, I did not. An email written by the Primary Physician dated 11/14/2025 4:51 PM responding to a question posed during the 11/14/25 interview regarding accepting the Resident back to the facility with orders for IV antibiotic therapy that they could not provide she responded I know you were concerned that the resident was knowingly taken back to the facility with an IV antibiotic the facility could not provide, but the nurse was given notification of the need for IV Zosyn after the resident was already transported back to the facility. However, once the Resident returned to the facility the Nurse obtained orders from the NP for the IV Zosyn. Ref. F635, F656, F689, F760

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (Resident #1). This deficient practice resulted in harm; Resident #1 had antipsychotic medication withdrawal, increased behavior health distress exhibited by hallucinations, resistive and combativeness with care, and medication refusals; unmonitored and untreated blood sugars; increased risk of urinary tract infection resulting in a hemolytic Strep Group B urinary tract infection, and increased risk for and repeated falls with major head injury, and death. This is a repeat deficiency for this facility, with the violation cited during two recent partial surveys dated 3/3/25 and 5/28/25. Findings include:Per record review Resident #1 was admitted to the facility on [DATE] for short term rehab after a fall at their home resulting in a distal radius fracture and multiple fractured ribs. Hospital diagnoses included a urinary tract infection (UTI). Per review of hospital documentation, while in the hospital s/he had a change in mental status that was attributed to acute metabolic encephalopathy likely caused by the UTI and was started on an antibiotic to be continue for 4 days after discharge and then another antibiotic prophylactically thereafter. Prior diagnoses include osteoporosis, frequent falls, schizophrenia, narcolepsy with cataplexy (a chronic neurological disorder characterized by excessive daytime sleepiness and sudden, involuntary muscle weakness), and recurrent UTIs. Hospital discharge orders included Quetiapine (Seroquel, an antipsychotic) 600mg at bedtime for schizophrenia. According to the hospital records Resident #1 has been on Seroquel 600 mg since 9/1/2023. Review of the facility documentation including physician's orders and the August Medication Administration Record (MAR) revealed that the Seroquel 600 mg was not ordered on admission. The Food and Drug Administration's (FDA's) Boxed Warning states that some commonly reported Seroquel withdrawal symptoms can occur include nausea, vomiting, anxiety, irritability, agitation or restlessness, panic-like symptoms, and rebound mood swings. Rebound symptoms include mania or hypomania, depression, Psychotic symptoms, and severe insomnia. When it is stopped abruptly -especially at higher doses such as 300-800 mg the sudden loss of receptor blockade can cause the body to rebound and over-respond until it readjusts. Acute withdrawal symptoms such as insomnia, nausea, and vomiting have been reported following abrupt cessation of quetiapine (Seroquel). It is recommended that, where possible, the dose be tapered gradually. Review of progress notes written since admission reveal that on 8/18/2025 Resident #1 began experiencing hallucinations which increased over time and also began exhibiting behaviors. A Skilled Note dated 8/18/2025 states Hallucinations (perceptual experiences in the absence of real external sensory stimuli). Comments: resident observed talking to internal stimuli at times while at nursing station. A Psychiatry Note dated 8/19/2025 states Resident is pleasant, with occasional non distressful hallucinations with talking to others not there. An Administration Note dated 8/22/2025 states Resident refused to take [her/his] meds, stating that [s/he] does not take meds. Various approaches were used without success. Provider on call [name omitted] was informed who also tried without success. Resident refused dinner, drink and [vital signs]. [S/he] was hallucinating. An Administration Note dated 8/23/2025 states refused care and [vital signs].A Skilled Note dated 9/8/2025 states Disorganized Thinking, Oriented to: Person .Mental Status: Anxious, Depressed, Angry, Hallucinations (perceptual experiences in the absence of real external sensory stimuli). Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Physical Behaviors (Hitting, Kicking, ect.) Verbal Behaviors (Screaming, Cursing, etc.) Wandering. Resident/ Care Giver Education: a cast should not be used to hit people Comments: when [s/he] is hallucinating or attempting to hit, stay away from [her/him] until [s/he] calms down .A Skilled Note dated 9/10/2025 states Mental Status: Anxious, Pleasant, Delusions (misconceptions or beliefs that are firmly held, contrary to reality) Wandering. Comments: [s/he] has auditory hallucinations that [s/he] is talking to '[her/his] father', he tells [her/him] what to do and what not to do. today [s/he] took [her/his] pills without difficulty. pleasant and cooperative. Therapy: Physical Therapy, while outside of physical therapy functionality has improved. Safety Concerns: gets mad at staff, swings [her/his] cast trying to hit us Comments: no [complaint of] pain or discomfort.An Administration Note dated 9/10/2025 states resident observed multiple times by staff throughout [hour of sleep] wandering and responding to internal stimuli. resident observed stating dad she wont let me do it, and bill is not going to let me sleep. resident easily redirected by staff. resident assisted with toileting and clothing. A Nursing Progress Note dated 9/12/2025 states resident refused all medications at the present time. On-call NP notified. no new orders from NP at this time. resident allowed blood glucose to be checked, and insulin was administered per order. residents awake, alert and oriented x1 at the present time. resident continues to respond to internal stimuli stating, dad no, I won't take that medicine. resident unable to be redirected at the present time. call light within reach. safety rounds in progress.A Nursing Progress Note dated 9/12/2025 states resident's [guardian and spouse] called facility asking for an update on residents' condition since returning from hospital today. informed [guardian] that resident refused all [hour of sleep] medications at the present time and continues to be confused and agitated when approached by staff. resident also refused dinner during shift and [Nurse Practitioner, (NP) ] was notified as well. [Guardian and spouse] expressed concerns about resident's state of mind when [s/he] is not medicated and has questions for the primary doctor in regard to [her/his] current medication regime. informed [Guardian and spouse] to call on Monday and speak with unit manager about any medication concerns so they can be relayed to in house provider. also informed them that nursing would continue to monitor resident for any changes in [her/his] [level of conciseness] or worsening in [her/his] condition and report to the on-call NP throughout weekend. [Guardian and spouse] acknowledged understanding and asked if they could attempt to talk with resident to encourage [her/him] to take her medications tonight. [Guardian] attempted to talk with resident over the phone and resident stated to [Guardian no I will not take that and its between me and god. informed [Guardian] that staff would continue to encourage resident and notify them with any changes .A nurse Progress Note dated 9/13/2025 states that Resident #1 has been vomiting, babbling, and has removed [her/his] catheter. [S/he] is not at baseline and I am unable to fully evaluate [her/his] situation Returned from [NAME] ED [Emergency Department] on 09/12/2025 with [diagnoses] of stable brain bleed, broken foot and urinary retention. The Nurse spoke with the Nurse Practitioner and sent the Resident back to the ED. A Nursing Progress Note dated 9/14/2025 states Resident was rude to staff. [S/he] walked to the bathroom by [her/himself] and the nurse took the wheelchair to [her/him]. [S/he] refused to eat [her/his] food. [S/he] only ate 1 cup of ice cream with [her/his] meds and put [her/himself] to bed.An Administration Note dated 9/14/2025 Swinging and hitting staff with [her/his] cast when care is being attempted.A Regulatory Note written by a NP dated 9/17/2025 states Resident was recently readmitted back to the facility. [S/he] was restarted on [her/his] Seroquel 600mg for[her/his] mood disorder and has since had a marked improvement in [her/his] overall mood. [S/he] is feeling well. More conversant and appropriate.A Physician's Progress Note dated 9/18/2025 states Per nursing, [the Resident's] family strongly requested that [s/he] be restarted on Seroquel 600 mg daily, which [s/he] apparently had been on in the past. This medication was restarted on 9/13/2025. Per nursing, she's been sleeping more, but no other adverse effects have been noted. [S/he] has a significant history of falls at baseline, with and without the Seroquel . Schizophrenia: Continue protriptyline 10 mg twice daily and aripiprazole 15 mg daily. Seroquel restarted for delusions at family's strong request.According to the FDA's prescribing recommendation for starting Seroquel Day 1: 25mg twice daily. Day 2-3: Increase increments of 25 - 50 mg divided doses (two or three times per day), to reach a total of 300 - 400 mg/day by day 4. Further adjustments should be in increments of 25 - 50 mg twice daily, with intervals of not less than 2 days between dose changes. Risks of starting Seroquel at 600 mg without gradual dose increase include: Orthostatic blood pressure (drop in blood pressure when standing up) dizziness, sedation, impaired motor coordination, blood sugar alterations.Further review of the hospital discharge orders date 8/15/2025 revealed a sliding scale insulin (a specific dose to be administered according to the results of blood sugar) Lispro with blood sugars 4 times daily. The discharge paperwork stated that the sliding scale had been implemented due to elevated blood sugar readings. Review of Resident #1s physicians orders after admission to the facility revealed that an order for finger sticks (a method used to obtain blood sugars) once in the AM was entered on 8/17/2025. Review of Resident #1's daily blood sugars revealed that between 8/17/25- 10/9/25 the blood sugars were obtained during the evening or night shift as opposed to morning on 8 occasions, and the resident experienced 10 documented episodes of hyperglycemia (blood glucose above which would have required the administration of the sliding scale insulin. There is no way to determine if the Resident was experiencing hyper or hypoglycemia (high or low blood sugars) or would have required sliding scale coverage the other three times per day because the blood sugars were not ordered or obtained. Further review of the hospital discharge orders dated 8/15/2025 revealed an antibiotic order for Keflex 500 mg every 12 hours for 4 days to treat the UTI, then resume nitrofurantoin (Macrobid) 100 mg daily for prophylaxis, Additional orders were 2 lidocaine patches daily for pain. Review of admission orders revealed that neither of these orders were implemented on admission to the facility. On 10/8/2025 a Nurse Practitioner wrote a progress note stating Resident is an [AGE] year old [female/male] seen today for UTI. Resident had a urine done and is positive for Hemolytic Strep Group B. [S/he] remains unresponsive. [S/he] was recently in the ER and given IV fluids and has since returned . An order was written on 10/8/2025 for Rocephin Inject 1 gram intramuscularly one time a day for UTI for 5 Days mix with lidocaine. The Resident received one dose on 10/8/2025 and was transferred to another nursing facility on 10/9/2025.Per review of Resident #1's death certificate s/he died on [DATE] at another facility. The manner of death was listed as Accident. The date and time of the accident states September 11, 2025 / ~8:00 PM. how injury occurred is listed as Fall(s) from Standing Height and the Cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PMReview of the facility policy titled Medication Errors last revised 1/2024 reveals a Policy Statement that states In the event of a medication error, the facility will act promptly to assess for adverse consequences, notify the physician, carry out follow-up orders as directed by the physician, and address the root cause error. The policy also states 4. The attending physician is notified promptly of any significant error or adverse consequence. a. The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. 5. The following information is documented in an incident report: a. Factual description of the error or adverse consequence. b. Name of Physician and time notified. c. Physician's subsequent orders.Per interview with the facility Administrator on 11/4/2025 at 3:19 PM when the family was notified on 9/12/2025 of the increased behaviors the Resident had been experiencing such as refusals of medications and hallucinations, they questioned whether or not s/he had been getting the right medications. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled and only every other page had been available at the time. The Administrator confirmed that the missed Seroquel was a medication error however, the facility did not implement an incident report per policy. Per interview with the facility Administrator on 11/12/2025 at 11:30 AM, she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review it to ensure there were not additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors. Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM, she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified, but she was not aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, however she did not address that because she had missed it. The Physician confirmed that the expectation is that the Unit Manager and/or admissions person review all of the discharge summary to ensure that all orders are noted.

Based on interview and record review the facility failed to ensure that one of five nurses, an agency nurse in the applicable sample had received training and competencies needed to provide care for the residents who reside in the facility. This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25. Findings include: Per review of 5 nurse's education and training files to determine if they had the training and skill set to perform an admission the facility was unable to locate the employee training and competency files of an agency staff nurse. Per interview with the facility Administrator on 11/4/2025 at approximately 4:00 PM the agency nurse no longer works there, and they had a recent change in the education department. The Administrator confirmed that they were not able to find the agency nurses file that consists of training and competencies required to provide care to the residents who live there.

Based on interview and record review the facility failed to notify the resident representative of a change in condition related to laboratory results and treatment options for one of three residents in the sample (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a partial survey dated 3/3/25. Findings include:Based on record review Resident #1 had a court appointed guardian with the guardian's spouse listed as emergency contact #2 on their information sheet. A progress note dated 10/8/2025 states The nurse received a fax from the [NAME] lab of a urine culture. The nurse sent the culture results to the [Nurse Practitioner]. The Resident was evaluated by OT [occupational therapy] and determined the resident is not safe to take anything orally other than a [tablespoon] of water every so often for comfort. Based on OTs evaluation the nurse attempted to call the [guardian] to talk about the results of the culture and talk about options regarding [antibiotic] treatment. The nurse left a voicemail for the [guardian] to call the nurse back. Another progress note dated 10/8/1025 states The nurse tried calling the [guardian's] phone but was not home just [spouse]. [Spouse] had questions regarding the resident being sent out to a different [facility] or hospital. The nurse did not talk with the [spouse] about the urine as [they] are not the resident's legal guardian. Per phone interview with Resident #1's guardian and their spouse on 11/4/2025 at 2:00 PM communication with the facility was not good and they did not return her/his calls even after s/he was told that someone will call back. The facility did not consistently share information regarding the Resident's condition. S/he stated that one nurse had hung up on her/him when s/he had called to ask questions about the Resident's condition. Review of the facility policy titled Notification of change in condition or status states 1. The nurse will notify the resident's attending Physician or physician on call when there has been a (an) . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; Per interview on 11/4/2015 at 3:15 PM the facility Administrator confirmed that Resident #1's guardian's spouse was emergency contact #2 and should have been updated regarding the positive results and treatment. The Administrator also confirmed that the nursing progress note reflected that the Nurse had not notified the Guardian's spouse of the results of the Resident's urine as she should have.

Based on interview and record review the facility failed to inform in advance of the risks and benefits of the proposed care, the treatment alternatives or other options for 1 of 5 sampled residents (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25. Findings include:Per record review Resident #1 was admitted with physician's orders for an antidepressant, Protriptyline (Vivactil) 10 mg twice daily, and an antipsychotic medication, Aripiprazole (Abilify) 15 mg daily. A consent form for antipsychotic medications was completed on and signed by the Resident's Guardian on 8/15/2025 listing the Aripiprazole as a prescribed medication. Further record review revealed a Consent for Antidepressant Medication form which was blank, it did not list the Protriptyline, and it was not signed by the Guardian. There was no documented evidence that the facility obtained informed consent for the Protriptyline. A physician's order dated 9/13/2025 for Quetiapine (Seroquel, an antipsychotic) 600 mg daily was initiated. A Psychotropic Medication Administration Disclosure form that includes the Abilify, Seroquel, and Protriptyline was completed by the Unit Manager on and states that the guardian gave verbal consent for the psychotropic medications on 9/16/2025 however, this was one month after the Protriptyline was initiated and three days after the Seroquel was initiated. Review of Resident #1's care plan revealed a focus initiated on 8/16/2025 of [Resident] is at risk for complications related to the use of psychotropic drugs with an intervention of Provide informed consent to resident or healthcare decision maker Date Initiated: 08/16/2025.Per interview with the facility Administrator on 11/6/2025 at 3:30 PM the consent for antipsychotic form in the Resident's chart dated 8/15/2025 did not reflect the Protriptyline. The Administrator also confirmed that the Psychotropic Medication Administration Disclosure form had not been completed until 9/16/2025, after the initiation of the Protriptyline and Seroquel.

Based on observation, interview, and record review of facility policy, the facility failed to establish a grievance policy that contains the correct information to support the residents' rights to file a grievance for seven of the seven residents in the sample (Resident #62, #15, #51, #19, #30, #46, and #35). This has the potential to affect all residents in the facility. Findings include: A review of the Grievance /Concerns Policy & Procedure, posted in the lobby of the facility, contained information pertaining to the previous owners and named the current Administrator as the Grievance Officer, providing the wrong email address for the Administrator. A review of document Patient Concern/Grievance Policy, revised on 1/2024, reads: 1) The grievance officer is the Director of Social Services, and her name, extension, and location are posted throughout the facility. 2) If a resident/family member has a concern, they can approach /contact any facility staff member, or a resident concern form can be filled out . 6) There will be a follow-up with the residents and/or family member regarding the concern, which will be noted on the concern form and concern log. 7) Concern forms are available at the reception desk upon request. Once completed, all forms should be brought to the receptionist, who will deliver them to the Director of Social Services. Forms can also be placed in a secure box at the reception desk. A third document titled Resident Grievance/Complaint Procedures, reviewed/revised 12/2024 reads A resident representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other resident or staff members, theft of property, etc., with fear of threat or reprisal in any form. Complaints may be filed anonymously. You are requested to follow the procedures outlined below when filing a written grievance or complaint. 1) Obtain a Resident Grievance/Complaint Form from the green nurse's station or from the Business Office 2) Answer all questions on the form as applicable. Be sure that all information is accurate. 3) Sign and date the form. 4) Give the completed form to the Administrator. If the Administrator is not available, you may leave the form with the supervisor on duty. 5) After you have filed the grievance, you will receive a written summary of the results of the investigation within a reasonable timeframe. 6) Should you disagree with the findings, recommendations, or actions taken, you may meet with the Administrator or file a complaint with any of the advocacy agencies listed on the Resident Resources List on the consumer bulletin board. The documents contain discrepancies regarding the identity of the Grievance Officer and the process for filing a grievance. The policy lacks information about the grievance officer's responsibilities, name, contact information, or a process to remain anonymous. Per observation, a facility tour on 3/26/25 at 2:00 PM did not disclose easily obtainable forms or signage indicating a process for filing a grievance or maintaining anonymity for the residents. A Resident Council meeting with the survey team occurred on 3/26/2025 at 2:00 PM, with seven attendees (Residents #62, #15, #51, #19, #30, #46, and #35). A collaborative conversation with all seven residents revealed they did not know how to file a grievance or where to find the information. Per interview with the Administrator on 3/28/24 at approximately 1:30 PM, she confirmed that the posted grievance document in the lobby contained incorrect information. She stated that the Social Service Director was now the Grievance Officer, and the policy did not include the required information per Federal Regulation. She agreed that the policy and procedures do not support the resident's rights to file grievances and that the supplied information is inconsistent. Per interview with Resident Council on 3/25/25 at 2:00 PM, Resident #51 stated they did not know how to file a grievance. Resident #51 discussed that s/he did not feel the facility responded to grievances promptly, and stated s/he was still waiting for a response for a grievance s/he had filed. Several residents also stated that they were fearful of retaliation if they voiced concerns.

Based on the interview and staff education record review, the facility failed to ensure that 2 of 3 sampled licensed nursing assistants (LNAs) were assessed for the competency and skill sets needed to provide care and respond to each resident's individualized needs. This is a repeat deficiency for this facility, with violations cited during a previous complaint survey, dated 4/16/24, and has the potential to affect all residents. Findings include: Per review of 3 LNA education records, 2 of the 3 sampled LNAs currently working at the facility did not have documentation of the competency evaluation required to demonstrate that they had the necessary skills to provide the care needed. Per interview on 3/26/24 at approximately 3:30 PM, the Director of Nursing (DON) indicated that she is responsible for assessing competencies. She is currently developing a system that has not been implemented yet. Per interview with the Regional Director of Nursing on 3/26/2024 at approximately 4:59 PM, she indicated the facility does not have hard copies of employee files that were also employees of the preceding owners. The current company has a system that accesses employee files online through the Human Resource System. The facility could not produce evidence of competencies for 2of 3 of the files sampled

3. Per record review Resident #9 has a urinary catheter and open pressure ulcers that require dressing changes. A care plan focus initiated on [DATE] reflects that the Resident requires the use of enhanced barrier precautions (EBP) related to indwelling device: Foley Catheter. Interventions initiated on [DATE] state use of face mask or eye protection if there is a risk of splash or spray and use of gloves and gown for high-contact care activities. A facility policy titled Enhanced Barrier Precautions states the Enhanced barrier Precautions require staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading an MDRO [Multi-drug resistance organism]. 1. Enhanced barrier precautions will be applied to: . b. Residents with an indwelling medical device including central venous catheter, urinary catheter, feeding tube .regardless of their MDRO status. c. Residents with a chronic wound, regardless of their MDRO status. Chronic wounds include pressure ulcers, diabetic foot ulcers . High-contact resident care activities include: . g. Caring for or using an indwelling medical device (for example, central venous catheter, urinary catheter .) h. performing wound care (for example any skin opening requiring a dressing) Per observations on [DATE] at 2:55 PM a Licensed Practical Nurse (LPN) and Director of Nursing (DON) were observed entering Resident # 9's room with supplies to flush his/her foley catheter, which carries a moderate risk of splashing. They were both observed in the room over the bed without face mask and eye protection. When the LPN and DON exited the room they both went to the treatment cart and retrieved the supplies needed for Resident #9's treatments. Both the LPN and DON reentered the Resident's room and were observed performing wound care without wearing the proper personal protective equipment. Immediately after the wound care was performed this surveyor asked the DON why Resident #9 was on EBP and he stated that s/he would be on EBP due to his/her foley and open wounds. The DON confirmed that he and the LPN should have worn PPE during the catheter flush and the wound care per care plan and facility protocol. On [DATE] at 1:45 PM the LPN was again observed in Resident #9's room performing wound care without the indicated PPE. After exiting the room, the LPN was interviewed and stated that she should have donned PPE and she did not. Based on observations, interviews, and record review, the facility failed to implement an infection prevention and control program that follows the accepted national standards regarding preventing, identifying and controlling communicable diseases. Specifically, the facility failed to follow the CDC (Centers of Disease Control) and state health department recommendations for outbreak management, related to testing and other mitigation strategies including containment and personal protective equipment (PPE) use. The deficient practices associated with the lack of infection control measures led to the determination that the residents in the facility were in immediate jeopardy of serious harm and/or death. At the time that the facility was notified of the immediate jeopardy on [DATE] at 12:00 PM, 11 residents and 15 staff members had tested positive for COVID-19 since the beginning of the facility outbreak that began on [DATE]. 5 residents (Residents #1, # 3, #13, and #12 and #14) were positive for COVID-19 at the time of survey entrance. Of the 11 residents that tested positive for COVID-19 during this outbreak, 2 residents (Resident #7 and #8) were sent to the hospital with respiratory distress. Resident #7 died shortly after being transferred to the hospital on [DATE]. According to Resident's #7 Death Certificate dated [DATE], his/her cause of death included cardiopulmonary arrest due to COVID. Findings include: 1). The facility failed to follow facility policy and state health department recommendations for outbreak management related to contact tracing and testing strategies. Facility policy titled Coronavirus, Prevention and Control, dated 1/2024, reads, The Infection Preventionist maintains close communication and collaboration with local and state health authorities. Per policy, in the event of an outbreak, testing guidance reads, the facility will initiate contact tracing to identify residents or staff who may have had close contact . When close contacts can be identified, all HCP with higher risk exposure to the positive individual and all residents who had close contact with the positive individual will be tested on Day 1 following the exposure, and again on Day 3, and Day 5 following exposure .When close contacts cannot be identified, broad based (unit- based or facility - wide) will be conducted for staff and residents. Testing will be conducted for all residents and staff on the affected unit(s), who have not previously been positive in the past 30 days, immediately, and if negative again 48 hours later, and if negative 48 hours later (Day 1, 3 and 5). If additional cases are identified, testing should continue every 3-7 days until there are no new cases for 14 days. Policy also states that The facility will maintain records of all testing performed for surveillance, symptoms, or outbreak purposes. Records will include the names of the individuals tested, dates of testing, and results. Resident testing information will be recorded in the individual resident's electronic health record. Per an email dated [DATE], the [NAME] Department of Health (VDH) Epidemiologist revealed that the facility originally reported 1 positive on [DATE]. They did not report additional positives to VDH until [DATE] and did not indicate the number of positive cases, whether they were staff or residents, or include a line list. Guidance that was provided to the facility on [DATE] included A person's infectious period begins 2 days before symptom onset date or positive test date, whichever comes first. If a staff person worked during their infectious period and close contacts are identified, we recommend the close contacts are tested on Days 1, 3, and 5 post exposure. If a resident ends up testing positive, we recommend they isolate for 10 days (and come out of isolation on Day 11). Per the VDH Epidemiologist the last day they were contacted by the facility was on [DATE] when they sent an updated line list and they answered the following question. How are you currently managing masking, testing, isolation of residents, exclusion of staff? And they responded ., We are managing ok with testing and masking. The facility was unable to provide any contact tracing logs, or testing logs for residents or staff since the outbreak began. There was no one at the facility that was aware of the outbreak management plan, or the status of the COVID outbreak. Per an interview with the Director of Nursing (DON) on [DATE] at approximately 11:00 AM, he revealed that the facility did not have an Infection Control Nurse (ICN) since [DATE]. See F882 for more information. The DON was unable to provide evidence that the facility followed their policy or recommendation by VDH related to contact tracing, testing, or use of PPE . Per further interview he had not been in contact with VDH for any further guidance related to the outbreak and that they were not familiar with the current CDC or VDH guidance related to COVID-19. DON confirmed he was not aware of how many residents at the facility are positive for COVID and has no documented evidence of current outbreak status. During an interview on [DATE] at approximately 2:55 PM with the new Infection Control Nurse (ICN) she stated she had just been designated to the ICN role and had not been trained, did not possess the qualifications, and had not been provided with information related to the facility's current outbreak status or mitigation strategies. Per [NAME] Department of Health (VDH) on [DATE] via email stated the facility did not report the death of Resident #7 or seek additional guidance related to the COVID outbreak. Per VDH during emails the line list submitted by the facility was incomplete or not attached and did not always identify resident or staff member. 2. The facility was not observed implementing mitigation strategies, including proper PPE use while working with COVID-19 positive residents, and isolation. Staff were unaware of mitigation strategies and timelines for COVID-19 positive residents. Per observation on [DATE] at 11:00 AM on the second-floor unit, Residents #3, #12, #14, and #1 all have a personal protective equipment caddy outside the room and precaution signs posted on each door stating, stop isolation in addition to standard precautions staff and provider must: clean hands when entering and exiting, gown to be changed between residents, N95 respirator (facemask acceptable if N95 not available), eye protection (goggles or face shields) and gloves (changed between each resident). Facility policy titled Coronavirus, Prevention and Control, dated 1/2024, reads, COVID-19 transmission based precautions include: For staff entering the resident's room/provide care: use of N95 mask or equivalent, eye protection, gown and gloves. Per record review, Resident #15 tested positive for COVID-19 on [DATE], Resident #3 on [DATE], Resident #12 on [DATE], Resident #14 on [DATE] and Resident #1 on [DATE]. Based on the guidance provided to the facility by VDH, Resident #15 would bi in isolation, requiring transmission based precautions, through [DATE], Resident #3 through [DATE], Resident #12 through [DATE], and Resident #1 through [DATE]. Per observation on the unit on [DATE] at 11:20 AM, 1:20 PM, 2:00 PM and at 5:15 PM three different staff members were observed entering in and out of the precaution rooms wearing only a mask, without eye protection, gown, or gloves. The staff were not observed completing hand hygiene when entering or exiting the rooms. Per observation on the second-floor unit on [DATE] at 11:20 LNA #1 entered room of Resident #12 wearing only a mask, without eye protection, gown, or gloves. Resident # 12 tested positive for COVID on [DATE]. Per interview of LNA #1 who was observed entering Resident room [ROOM NUMBER] [DATE] at 2:00 PM room with only a mask and without gown and gloves (and without eye protection stated, at 2:05 PM I thought the residents were not on precautions anymore, and that the signs may be old. Per interview on [DATE] at 3:30 PM, the License Practical Nurse #2 (LPN) caring for Residents #14, #12, and #1 on the second floor stated that she was unsure if the precautions were still active and stated, the residents were positive a few weeks ago, I am pretty sure it's all cleared up. Per observation on [DATE] at approximately 1:00 PM, Resident #3 who tested positive for COVID on [DATE], was sitting in the activity dining area on the second-floor unit with another resident. Per interview on [DATE] at 5:10 PM, the LPN #2 caring for COVID positive residents on the (second floor unit stated that s/he was unaware if the residents should still be on precautions, then stated that s/he thinks the precautions signs are old and just have not been taking down. Per interview on [DATE] at 1:15 PM, the License Practical Nurse #3 caring for residents on the second-floor unit stated that she was not aware of the facility policy related to COVID-19 or the guidelines given by VDH. She confirmed that the residents did not maintain precautions and that they do not make residents stay in their room when COVID-19 positive. She stated that since the infection preventionist left on [DATE] there has not been guidance or education related to the current outbreak. Per interview on [DATE] at 4:15 PM, the Medical Director, who is also the attending physician at the facility, confirmed that she was not aware of the facility's COVID-19 policies or COVID-19 guidance from [NAME] Department of Health (VDH), including when to discontinue mitigation strategies. Per further interview she stated she was not made aware of all COVID positive residents and that she was not notified of Resident #7 lethargy.

Based on observation, interview, and record review, the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to multiple deficiencies that resulted in harm and immediate jeopardy by failing to ensure that the physician was notified of changes, residents were free from abuse, care plans were implemented, pressure ulcer care and prevention was provided, adequate supervision of residents, residents' care is supervised by a physician, the responsibilities of the Medical Director were met, implement an effective infection prevention program, and have a qualified infection preventionist. Findings include: During an investigation of 3 facility reported incidents and 3 complaints, the facility was found to have deficient practices that resulted in 5 citations at Immediate Jeopardy level, 5 harm level citations, and 7 potential for more than minimal harm citations. On [DATE], the survey team identified and notified the facility of deficiencies at the immediate jeopardy (IJ) level for F689 related to violations around accidents, hazards, and supervision. This IJ determination also results in substandard quality of care. On [DATE], during an onsite extended survey, the survey team identified and notified the facility of deficiencies at the immediate jeopardy (IJ) level for violations around F-580 related to physician notification, and F-880 infection control. During off-site review on [DATE] additional immediate jeopardy was identified at F710 and F835. The identified failures by the lack of administrative oversight put all residents at risk for serious harm, injury, or death. 1. Per interview with the Medical Director (MD) on [DATE] at 1:42 PM the facility has had a lot of changes. The MD stated we lost the Director of Nursing (DNS) and critical access nurses. It had been a bad transition between owners. There are a lot of new people and travelers right now. Per interview on [DATE] at 3:20 PM, a resident's responsible party stated the lack of consistent administration has caused issues with resident care and follow through of issues and concerns. Per review of the facility's license to operate issued by the Division of Licensing and Protection since [DATE] reveals the following changes to administration: -There was a change in the Administrator twice within the past year; on [DATE] and [DATE]. -There was a change in the Medical Director three times within the past year; on [DATE], [DATE], and [DATE]. -There was a change in the Director of Nursing six times within the past year; on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 2. As a result of the facility failing to ensure notification and consultation with the attending physician, a resident was physically assaulted by another resident and was not evaluated for potential significant injury that may have been caused by the assault, a resident did not receive treatment orders for a developed pressure ulcer, and residents did not receive treatment related to COVID, including a resident who suffered a COVID related death. This citation is at the immediate jeopardy level due to the lack of notification and consultation with the physician during a COVID-19 outbreak and with significant changes in resident statuses, putting all residents at risk for serious injury and/or death because of the noncompliance. See F580 for more information. 3. As a result of the facility's failure to provide adequate supervision, a resident gained access to an alarmed stairwell and fell down a flight of 8 stairs and sustained a head injury, a resident sustained a head injury when s/he was assaulted by another resident, and a security system to prevent wandering was observed to be ineffective. This citation is at the immediate jeopardy level due to the lack of adequate supervision to prevent mobile residents from entering secured, dangerous areas within the facility, prevent residents from leaving the unit or building, and prevent resident assault, putting all residents at risk for serious injury and/or death because of the noncompliance. This is a repeat deficiency for this facility, with violations cited during two partial surveys, dated [DATE] and [DATE]. See F689 for additional information. 4. As a result of the facility's failure to ensure that the medical care of each resident is supervised by a physician, a resident who was positive for COVID did not receive antiviral's and died of COVID, and a resident's violent behaviors caused a resident to suffer injury that was not assessed or treated by the physician and continued to put other residents at risk. This citation is at the immediate jeopardy level due to medical care not being supervised by the physician resulting in residents not being treated for COVID, aggressive behaviors, and failure to assess resident with suspected injury to his/her head. See F710 for additional information. 5. As a result of the facility's failure to implement an infection prevention and control program that follows the accepted national standards regarding preventing, identifying, and controlling communicable diseases and failing to follow the CDC (Centers of Disease Control) and state health department recommendations for outbreak management, related to testing and other mitigation strategies including containment and personal protective equipment (PPE) use, a resident died of COVID and the residents in the facility were in immediate jeopardy of serious harm and/or death. See F880 for additional information. 6. As a result of the facility failing to protect the resident's right to be free from physical abuse, a resident suffered injury and remained in persistent fear that s/he would be physically assaulted again. This deficient practice resulted in harm. See F600 for more information. 7. As a result of the facility's failure to implement care plan interventions related to skin and wound assessments, a resident's pressure ulcers worsened. This deficient practice resulted in harm. See F656 for more information. 8. As a result of the facility's failure to ensure that a resident received necessary treatment and services for pressure ulcers consistent with professional standards of practice to promote healing, by not obtaining physician's orders for treatment, not following care plan interventions, and not performing accurate skin and wound assessments, the resident's wounds deteriorated and caused him/her to develop additional pressure ulcers. This deficient practice resulted in harm. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated [DATE]. See F686 for additional information. 9. As a result of the facility's failure to ensure that a staff member with specialized Infection Prevention and Control training beyond initial professional training was designated as the facility's Infection Preventions (IP), the facility failed to prevent spread of COVID-19 through mitigation strategies that would be directed by an infection preventionist, and 1 resident died from COVID-19. The failure to designate a qualified infection preventionist caused harm and has the potential to impact all residents who reside in the facility. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated [DATE] and [DATE]. See F882 for additional information.

Based on observation, interview, and record review the facility failed to ensure consultation with the attending physician during a COVID-19 outbreak, and failed to notify the physician of positive COVID-19 results for 3 of 11 residents who tested positive for COVID-19 (Residents #6, #7, and #12). The facility also failed to notify the physician after a resident physically assaulted another resident causing injury (Resident #1 and #4), and at the time of significant changes in condition regarding development of pressure ulcers (Resident #9). This citation is at the immediate jeopardy level due to the lack of notification and consultation with the physician during a COVID-19 outbreak and with significant changes in resident statuses puts all residents at risk for serious injury or death because of the noncompliance. Findings include: 1. Per record review, Resident #7 was admitted to the facility with the primary diagnosis of a non-ST segment elevation myocardial infarction (NSTEMI, a type of heart attack), and was no longer able to care for her/himself at home due to advancing dementia. A COLST (Clinicians orders for life sustaining treatment) dated [DATE] reflects that Resident #7 was a full code in the event of cardiac arrest. Per review of the facility documented COVID-19 line list, Resident #7 tested positive for COVID-19 on [DATE] and was experiencing symptoms of lethargy (a general state of fatigue that involves a lack of energy and motivation for physical and mental tasks). See F880 for more information. Per record review there is no documented evidence in the Resident's record or facility reports that the Physician was notified on [DATE] that Resident #7 had tested positive for COVID-19 or that s/he was experiencing lethargy. There is also no documented evidence that the Physician was consulted regarding the treatment and care needs of Resident #7 related to COVID-19, and no documented evidence that the Resident was closely monitored after [DATE] or received any treatment specifically related to the COVID-19 infection. From 1/7-[DATE] the resident was being monitored for a previous dental infection, using a standardized sepsis questionnaire but the last vital signs were taken on [DATE]. See F710 for more information. The facility policy titled Change in Resident Condition or Status states: 1. Purpose of Policy Our facility shall promptly notify the resident, his or her attending physician, and responsible party of changes in the residents' condition and/or status. IV. Policy Statement A. The Nurse Supervisor, Manager, or Charge Nurse will notify the resident's attending physician when 1. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 2. There is a significant change in the resident's physical, mental, or psychological status. 3. There is a need to alter the resident's treatment significantly . Per record review, a Progress Note written by a Licensed Practical Nurse (LPN) on [DATE] reveals that the Resident was found in bed unresponsive and gurgling the physician was notified, s/he was sent to the hospital, and subsequently died. Per review of the Resident's Death Certificate the cause of death was cardiopulmonary arrest due to COVID, hypertension (high blood pressure), diabetes, coronary artery disease (disease in the heart's major blood vessels). During an interview on [DATE] at 4:15 PM the Medical Director, who is also the attending physician, stated that she was not sure if she had been notified of Resident #7's COVID-19 positive results. The Medical Director confirmed that she was not notified that the Resident was experiencing lethargy, and that the nurse should have notified her. The Medical Director also stated the nurse should have completed a change of condition notification. 2. Further review of the facility documented COVID-19 outbreak line list revealed that in addition to Resident #7, 10 other Residents and 15 staff members tested positive for COVID-19 between [DATE] and [DATE]. Per review of resident and facility records, 2 of the other Residents who tested positive (Residents #6, #12) had no documented evidence of physician notification in their medical records. During an interview on [DATE] at 4:15 PM the Medical Director, who is also the attending physician, stated that she was not sure if she had been notified of each resident who tested positive during the outbreak. The Medical Director confirmed that she had not been consulted with regarding the facility policies, mitigation plan, or COVID-19 guidance from [NAME] Department of Health (VDH). 3. Per record review Resident #1 was admitted to the facility with diagnoses that include cognitive communication deficit, and dementia with mood and behavioral disturbance. A Nurse Progress Note dated [DATE] revealed that Resident #1 entered Resident #4's room while s/he was in bed. Resident #1 knocked over the bedside table and threw a can or cans of soda at Resident #4's face resulting in bruising to his/her forehead, left eye, and a skin tear to the left forearm. There is no documented evidence in the record that Resident #4 received any additional monitoring related to being struck in the head immediately following the incident. During an interview on [DATE] at 3:06 PM Resident #4 stated that [s/he] is afraid to fall asleep because [Resident #1] will come in the room again. During an interview on [DATE] at approximately 2:00 PM a Licensed Practical Nurse (LPN) confirmed that Resident #1 had hit Resident #2 in the head with a 12 pack of soda on [DATE]. Review of the facility incident report dated [DATE] reveals that the nurse had documented that the Medical Director had been notified of the incident. However, during an interview with the Medical Director on [DATE] at 5:14 PM they stated that they had not been notified of the incident that occurred on [DATE]. The Medical Director stated that they would have had Resident #1 sent out to the hospital for evaluation due to aggression and Resident #4 would be sent out for evaluation for the need for an x-ray or scans had they been notified. The Medical Director also said that s/he would expect to be notified of incidents such as this. 4. Per record review a Skin Wound Evaluation dated [DATE] reveals that Resident #9 had a newly developed an in house acquired moisture associated skin damage (MASD) related to incontinence associated dermatitis (IAD) on their sacrum that measured 0.9 cm in length and 0.5 cm in width. The notification section of the form is blank indicating that there were no required notifications made. Assessments dated [DATE] documented the skin was intact. Per record review an Integrated Wound Care (IWC) Progress Note dated [DATE] states that Resident #9 is being seen for the evaluation and treatment of deep tissue injury (DTI), [a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. (NPAUP, 2005)] to the right trochanter (near the hip). Further record review revealed that there was no documented evidence that the physician was notified of the development of the DTI. An IWC Progress Note dated [DATE] reveals that the DTI had progressed to a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister). There is no evidence in the Resident's record that the physician was notified that the DTI had progressed to a stage 2 pressure ulcer. Per interview on [DATE] at 2:23 PM the Director of Nursing and the Regional Director of Nursing confirmed that there was no documented evidence that the physician was notified of Resident #9's recently developed pressure ulcers. During a dressing change observation on [DATE] at 3:10 PM the Licensed Practical Nurse (LPN) was observed changing dressings on Resident #9's sacrum, hip, and right outer ankle. There was a large dry wound noted on the outer aspect of the Resident's left foot. This surveyor asked the LPN and the Director of Nursing (DON) who was assisting with the treatment, if there was a treatment ordered for that area. Both the LPN and DON were not aware of the wound. The DON recommended that the LPN leave the wound open to air. There was no previous documentation of the wound on the outer aspect of the left foot and no documented physician notification. Review of the Resident's Treatment Administration Record revealed that there was no physician's order for treatment of the wound until [DATE]. Per interview on [DATE] at 5:14 PM the Medical Director stated that she had not been informed that Resident #9 had developed the pressure ulcers on his/her trochanter (hip), right ankle, and out aspect of the left foot. The physician confirmed that she should have been notified of the new pressure ulcers. Reference: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent 1 of 3 sampled residents (Resident #6) from gaining access to an alarmed stairwell and falling down a flight of 8 stairs, sustaining a head injury. The facility failed to ensure resident safety by not responding timely to a door alarm that is used to alert staff of potential resident elopement. The facility also failed to provide adequate supervision of 2 residents in the applicable sample (Resident #1 and Resident #4) to prevent a resident-to-resident assault that resulted in fear and injury to Resident #4. This citation is at the immediate jeopardy level due to the lack of adequate supervision to prevent mobile residents from entering secured, dangerous areas within the facility, prevent residents from leaving the unit or building, and prevent resident assault, putting all residents at risk for serious injury or death because of the noncompliance. This is a repeat deficiency for this facility, with violations cited during two partial surveys, dated 10/18/24 and 6/12/24. Findings include: 1. Per record review, Resident #6 has medical diagnoses that include dementia, Alzheimer's Disease, history of falling, and cognitive communication deficit. A care plan focus initiated on 6/16/23 indicates that s/he is at risk for elopement related to exit seeking behavior. Interventions implemented on 6/16/23 include door alarms on at all times, answer alarms promptly, redirect if near exits or doorways, and utilization of a Wander Guard device. A Nursing Progress Note dated 10/23/24 revealed that on 10/22/24 at approximately 7:00 PM Nurse #1 was giving medications out. There were TV's blaring, bathroom bells ringing on both sides of the hall, certain resident's screaming instead of using their call bell, and [residents] at the nurses station needing attention. This [ Nurse #1] r ealized a door alarm was going off and went to answer the alarm. The Resident was already on the other side of the East Stairway exit door when this nurse opened the door to the sounding alarm. This nurse observed [the resident] at the top of the stairs at which point the resident was in [her/his] wheelchair rolling forward and heard the resident scream and start to fall down the stairs, tumbling in somersaults-head over heels down the stairs with [her/his] wheelchair. The ground floor stopped [Resident #6's] fall and [her/his] head was resting on the floor while [her/his] body was still on the stairs with [her/his] wheelchair on top of [her/him]. This nurse lifted the wheelchair off the resident, checked for breathing, resident was unconscious, I ran up the stairs, screamed for 911 and help, and ran back down to the resident and held [the Resident's] neck in position until [s/he] regained consciousness again and was moving [her/his] head on [her/his] own, arm and legs, but c/o hip pain. [On call physician] assessed the patient and agreed [s/he] needed to be sent to the [emergency room] ER. Paramedics arrived and transported resident to [NAME] ER. A provider Encounter Note written on 10/22/23 states that Resident #6 was observed by nurse falling down one flight of stairs. Nurse states prior to the fall, multiple bathroom alarms were ringing and [s/he] could not differentiate those alarms from the stairway alarm. [S/he] reports going down the hall with [his/her] med cart and finally recognizing that the stairway alarm was alerting [her/him] and the door to the stairway was unlocked. When [s/he] checked the door, [s/he] saw [patient] standing at the top of the stairway starting to fall . States the patient has two lacerations to bilateral temporal areas of scalp and a possible left hip fracture. Review of the facility Incident Report dated 10/22/2024 states The resident went to the door was able to read the egress sign and pushed on the door until it released (as it is intended to do). According to the Incident Report, predisposing factors were noise and alarm on and sounding, and predisposing situation factors include active exit seeker, wanderer, and history of falls. Review of the facility incident folder revealed staff statements describing what they were doing at the time of Resident #6's fall and the nursing schedule for 10/22/24 reveals that there was one Licensed Practical Nurse (LPN, Nurse #2), who was off the floor at the time of the incident, and two Licensed Nursing Assistants (LNAs #1 and #2) one of which was on break (LNA #2), and one who was at the nurse's station documenting care (LNA #1), assigned to the east hall. The west hall had one LPN (Nurse #1) who was at the nurse's station administering medications, and three LNAs ( #3, #4, and #5), one who was off the unit (LNA #3) and two who were in Resident rooms providing care (LNA #4,and LNA #5). Leaving two staff members on the floor to respond to the alarm (Nurse #1 and LNA #1). Nurse #1 was the first to respond to the alarm finding Resident #6 in the stairwell. Per observation on 1/22/25 at 2:10 PM, the east stairway exit door was noted to have a cloth stop sign door banner across the doorway at approximately waist height. This banner was connected to a magnetic fixture that was connected to an alarm on the door by a string that was attached through a hole in the banner. This surveyor was able to disconnect the string easily without sounding the alarm. Per interview with the Administrator on 1/24/25 at 10:45 AM the incident occurred prior to her employment. She only had access to what information is in the Incident Report and incident file. When asked if there was access to the video from the hall surveillance camera film she stated that it does not save for that long of a period of time. 2. On entrance to the facility on 1/22/25 at 9:05 AM, the Wander Guard System had been activated and the alarm at the front door was sounding. There were no staff present, and the front lobby was empty. One staff member was observed getting into the elevator without concern for the alarm. Another staff member approached the elevator and asked the team if they had been helped. This surveyor asked them if the administrator was available. She went down the hall to get the Administrator, leaving the alarm on. When the Administrator approached s/he introduced herself and was informed why the team was there. While standing there, the alarm continued to sound. At this time she confirmed that it was the Wander Guard and stated it was alarming because at mealtimes, when residents get too close to the windows in the dining room upstairs, they set off the alarm. Approximately 10 minutes had elapsed between arrival and when the alarm was turned off. There was no investigation to determine if a resident had left the building. A list of 15 residents who have been identified as at risk for elopement was provided by the facility Administration. Per observations made on the second floor on 1/23/25 at approximately 1:15 PM, the Wander Guard alarm was sounding. There were two LNAs and one nurse in the nursing station area, none of whom responded to the alarm to ensure that a resident had not left the building. During an interview with the facility Administrator on 2/3/25 at 10:15 AM, she stated that the Wander Guard System had been repaired to make the distance between the Wander Guards and the alarm further apart. Although staff had received training regarding elopement and the Wander Guard alarm, they did not follow the facility policy/procedure. The Administrator confirmed that staff had been desensitized due to the frequency of it being set off . 3. A facility investigation report of an allegation of physical abuse in a resident-to-resident altercation submitted to the State Agency on 1/9/25 stated that on 1/8/25 Resident #1 entered the room of Resident #4 and threw a can of soda at his/her arm causing a skin tear to the left forearm and a bruise to the forehead. This was Resident #1's third resident-to-resident altercation investigated by the facility since 12/23/24. The facility did not revise Resident #1's care plan to include effective interventions for supervision to keep other residents safe. Per review of facility risk management report (RMS) documented on 1/8/25 by nursing staff [Resident #4] c/o (complained of) [Resident #1] coming into [his/her] room, [s/he] pushed the bedside table over, picked up a can of ginger ale, and [hit him/her] in the left arm with it causing a skin tear 1 cm x 1 cm. [S/he] received a bruise to [his/her] forehead. See F600 and F689 for more information. Per interview on 1/22/25 at approximately 10:00 AM, Resident #4 stated that Resident #1 came into his/her room while s/he was asleep and threw a 12 pack of soda at his/her face. Per observation Resident #4 had evidence of bruising around his/her left eye, mid forehead and left side of forehead. There was a dressing on his/her left forearm dated 1/17/25. Per further interview the s/he stated that s/he is afraid to sleep because [s/he] is worried that [Resident #1] will come back in [his/her] room. Per interview with an LNA #1 on 1/22/25 at 2:00 PM, he stated that there has been no education provided to staff related to how to manage Resident #1 behavior. He stated that when Resident #1 is agitated it is difficult to redirect him/her. He stated that when he cares for other residents, Resident #1 goes into other resident rooms and is hard to get him/her out. During an interview on 1/23/25 at approximately 2:00 PM, a Licensed Practical Nurse (LPN #1) confirmed that Resident #1 had hit Resident #4 in the head with a 12 pack of soda on 1/8/25 and that staff were not aware that Resident #1 was in the room until the event occurred. Per interview of a LPN #3 on 1/23/25 at approximately 10:50 AM, she stated she was concerned that all residents would be at risk from Resident #1, on the second floor unit because she feels there are not enough staff to keep Resident #1 from going into to other resident rooms. Per interview with LPN #2 on 1/23/25 at 10:55 AM, She stated that she is concerned that all residents on the second floor are at risk from Resident #1 because once s/he is in wheelchair, s/he is independent with mobility. The LPN stated Resident #1 has been found in multiple resident's rooms and is difficult to redirect due to his/her aggression. Per a nursing note dated 1/15/25 [Resident #1] entered [Resident #5's and Resident #14] room [Resident #1] had the following behavior note dated 1/15/25 Resident was found in another resident's room [Resident #5 and #14] . [the] resident was screaming and yelling at [him/her] to get out of [his/her] room, but the resident refused to leave. [Resident #1] threw motor to low loss air mattress on the floor. [S/he] started swinging at staff and grabbing other resident's bed and wall so [s/he] wouldn't leave. Resident finally returned to [his/her] room and laid down in bed. Per interview with the Medical Director on 1/23/2025 at 5:14 PM stated she was unaware that Resident #1 had been violent toward the other residents. She stated that she had not been notified of the incident that occurred on 1/8/2025. The Medical Director stated that she would have had Resident #1 sent out to the hospital for evaluation due to aggression and Resident #4 would have been sent out for evaluation for the need for an x-ray or scans had s/he been notified. See F580 and F710 for further information. The Medical Director also said that she would expect to be notified of incidents such as this. Per record review of Resident #4's medical chart there is no documented evidence that the facility assessed resident neurological status or reported to the provider that Resident #4 had an apparent head injury. The facility is unable to provide any documented evidence of how the bruise occurred to Resident #4's forehead, left eye and left side of face or that the bruising had been investigated. Per facility reported incidents Resident #1 had two other incidents in the last 30 days with other residents. Including an altercation on resident-to-resident altercation on 12/23/25, when Resident #1 pushed and punched Resident #3. Per facility investigation staff reported hearing Resident #1 threatening to kill Resident #3. Another facility incident was submitted on 12/29/24 stated that an unsolicited event occurred between Resident #1 and Resident #2 on 12/29/24 in which an Activity Aide .Witnessed [Resident #1] go down the hallway, go past [Resident #2], turn around, get behind [him/her] and hit [her/him] on the left side of back of head. Per a nursing behavior note dated 12/29/24 [Resident #1] had an incident with another resident today. [Resident #1] slapped [Resident #2] behind the head. This incident was witnessed and reported to this nurse. Per review of Resident #1's care plan dated 1/19/24 [Resident #1] exhibits or has the potential to exhibit physical and verbal behaviors. [Interventions include] listen to [Resident #1] and help [him/her] calm down .[12/20/24] remove [Resident #1] from public area when behavior is disruptive/unacceptable, offer [Resident #1] to lay down, and assist to room. Per further review of Resident #1's care plan dated 12/10/24 s/he is identified as risk for wandering and has an intervention include offer resident schedule time for appropriate walks/appropriate activity. Residents #1's care plan fails to address behaviors of entering into other residents rooms, or supervision after multiple resident to resident incidents. Per interview with the Director of Nursing on 1/23/25 at approximately 11:00 AM stated that he was aware of Resident #1's behaviors toward other residents on the unit and had discussed with the staff redirecting the resident. He stated the facility had not discussed a referral for a psychiatric evaluation or placement related after recent escalation in behaviors. he stated that he was unaware of the bruising to Resident #4 forehead and did not know if Resident #4 had been hit with a can or a 12 pack of soda. The DON confirmed that Resident #4 did have a small red area on his/her forehead after the incident. Per interview with the Regional Director of Nursing on 1/23/25 at approximately 6:00 PM stated that per Resident #1's task list s/he should have been on 15-minute checks starting 12/21/24 prior to the above incidents occurred. However, according to clinical lead there is no documented evidence that staff completed 15-minute checks or documented in the medical record. She also confirmed that this was not added to his/her care plan. Per interview of nursing staff on the second-floor unit on 1/23/25 at 6:30 PM they stated they were unaware of any residents on the unit who were receiving 15 minutes checks.

Based on observation, interview, and record review, the facility failed to ensure that the medical care of each resident is supervised by a physician for 3 of 15 sampled residents (Resident #7, #1, #4). As a result Resident #7 who was positive for COVID, did not receive specific monitoring or treatment for the COVID infection, and died of COVID, Resident #1's violent behaviors continued to put other residents at risk, and Resident #4 suffered injury that was not immediately assessed or treated. This citation is at the immediate jeopardy level due to medical care not being supervised by the physician resulting in residents not being treated for COVID, aggressive behaviors, and failure to assess resident with suspected injury to his/her head. Findings include: 1. Per review of the facility documented COVID-19 line list, Resident #7 tested positive for COVID-19 on [DATE] and was experiencing symptoms of lethargy (a general state of fatigue that involves a lack of energy and motivation for physical and mental tasks). Per record review there is no documented evidence in the Resident's record or facility reports that the Physician was notified on [DATE] that Resident #7 had tested positive for COVID-19 or that s/he was experiencing lethargy. There is also no documented evidence that the Physician was consulted regarding the treatment and care needs of Resident #7 related to COVID-19, and no documented evidence that the Resident was closely monitored after [DATE] or received any treatment specifically related to the COVID-19 infection. From 1/7-[DATE] the resident was being monitored for a previous dental infection, using a standardized sepsis questionnaire but the last vital signs were taken on [DATE]. Per record review, a Progress Note written by a Licensed Practical Nurse on [DATE] reveals that the Resident #7 was found in bed unresponsive and gurgling the physician was notified, s/he was sent to the hospital, and subsequently died. Per review of the Resident's Death Certificate the cause of death was cardiopulmonary arrest due to COVID, hypertension (high blood pressure), diabetes, coronary artery disease (disease in the heart's major blood vessels). Per further record review of the record there were no notes from a physician that they had supervised the change in condition for Resident #7 or that she was assessed or treated for COVID. Per CDC recommendations for high risk individuals Per the Centers for Disease Control individuals at high risk related to COVID include those with cardiovascular disease and diabetes. This includes heart failure, coronary artery disease, cardiomyopathies, and possibly high blood pressure (hypertension). People with diabetes are more likely to have serious complications from COVID-19. [The CDC recommends] Anyone that is [AGE] years of age, especially 65 and older, OR have certain underlying medical conditions, such as a weakened immune system, heart disease, obesity, diabetes, or chronic lung disease, regardless of age be treated with antivirals. During an interview on [DATE] at 4:15 PM the Medical Director, who is also the attending physician, stated that they were not sure if they had been notified of Resident #7's COVID-19 positive results. The Medical Director confirmed that she was not notified that Resident #7 was experiencing lethargy, and that the nurse should have notified her. See F710 for more information. 2. Per record review, a Nurse Progress note dated [DATE] revealed that Resident #1 entered into Resident #4's room while s/he was in bed. Resident #1 knocked over the bedside table and threw a can or cans of soda at Resident #4's in a skin tear to the left forearm and bruise on his/her forehead. There is no documented evidence in the record that Resident #4 received any additional monitoring related to being struck in the head. See F600 and F689 for more information. Per observation on [DATE] at approximately 10:00 AM, Resident #4 had evidence of bruising around his/her left eye, mid forehead and left side of forehead. There was a dressing on his/her left forearm dated [DATE]. During an interview on [DATE] at approximately 2:00 PM a Licensed Practical Nurse (LPN) confirmed that Resident #1 had hit Resident #4 in the head with a 12 pack of soda on [DATE]. Per record review, Resident #1 did not receive care from a physician related to his/her aggressive behavior or the event that occurred on [DATE] and Resident #4 did not receive immediate care after a head injury, including an assessment, from a physician related to injuries to their head and face. Review of the facility risk management report dated [DATE] reveals that the nurse had documented that the Physician had been notified of the incident. However, during an interview with the Physician, who is also the Medical Director, on [DATE] at 5:14 PM she stated that she had not been notified of the incident that occurred on [DATE]. The Physician stated that if she had been notified Resident #1 would have been sent out for evaluation for aggressive behavior and Resident #4 would have been sent to the emergency department for evaluation and a possible x-ray or scans. The Physician, also said that s/he would expect to be notified of incidents such as this. Per further interview with the Medical Director on [DATE] she stated she was unaware that Resident #1 had been violent toward the other residents. S/he stated that s/he had not been notified of the incident that occurred on [DATE].

Based on observations, interviews, and record review, the facility failed to ensure that 1 of 3 residents in the applicable sample (Resident #9) received necessary treatment and services consistent with professional standards of practice to promote healing by not obtaining physician's orders for treatment, not following care plan interventions, and not performing accurate skin and wound assessments. This deficient practice caused Resident #9's wounds to deteriorate, and caused him/her to develop additional pressure ulcers. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/10/25. Findings include: Per observation on 1/22/2025 at 3:10 PM a Licensed Practical Nurse (LPN) and Director of Nursing (DON) were observed performing wound care to Resident #9's pressure ulcers. The Resident was noted to have an excoriated sacrum with two open areas that were cleansed and a new dressing was applied. The pressure ulcer on his/her right hip was also cleansed and a new dressing was applied. The pressure ulcer on his/her right malleolus (ankle) was noted to be open with slough around the edges of the wound. This area was also cleansed and a new dressing was applied. There were 2 open area on the Resident's left distal foot that were cleansed and a new dressing applied. This surveyor noted a large dry wound on Resident #9's left lateral foot and asked the LPN and DON if there was a treatment ordered for that area. Both the LPN and DON were not aware of the wound. The DON recommended that the LPN leave the wound open to air. Per record review there was no previous documentation of the wound on the left lateral foot, no documented physician notification, and there was no treatment ordered for the wound until 1/30/2025. An Integrated Wound Care (IWC) Progress Note dated 1/7/2025 states that Resident #9 is being seen for the evaluation and treatment of deep tissue injury to the right trochanter (near the hip) measuring 4 cm length x 2.1 cm width. The wound notes state Non-blanching discoloration, no open areas and no bogginess. Keep clean and dry, apply skin prep and protective DPD (dry protective dressing) daily and PRN (as needed). There is no documented evidence that this treatment recommendation was initiated. Review of Resident #9's January 2025 Treatment Administration Record (TAR) reveals a wound treatment initiated on 1/11/2025 that states cleanse right hip with wound cleanser or normal saline. Pat dry. Apply sureprep (used to create a barrier film on peri-wound skin). Cover with optifoam (a foam wound dressing) dressing daily. There is no documented evidence that the newly developed pressure ulcer was treated when it was identified on 1/7/2025 until 1/11/2025, four days after it was identified. During an interview on 1/22/2025 at 2:23 PM the Director of Nursing (DON) and the Regional DON confirmed that although the pressure ulcer was identified and assessed by the IWC Consultant on 1/7/2025, there was no documented evidence that the IWC Consultant's recommendations for treatment were implemented, and no treatment orders were in place for the DTI until 1/10/2025. An IWC Progress Note dated 1/14/2025 reveals that the DTI had progressed to a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also be presented as an intact or open/ruptured blister) measuring 4 cm length, 2 cm width, and 0.18 cm depth. Resident #9 has a Care Plan focus that indicates s/he is at risk for skin breakdown related to: foley catheter use and fragile skin. On 1/10/2025 the focus was revised to include MASD (moisture associated skin damage) to the sacrum and a deep tissue injury (DTI; a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a stage [three and stage four] pressure ulcer even with optimal treatment. [NPAUP, 2005] ) on his/her right hip. Interventions include weekly skin checks by licensed nurse (initiated on 11/7/22), and weekly wound assessment to include measurements and description of the wound (initiated on 5/12/2023). The Care Plan was not updated to reflect the unstageable pressure ulcer to the left distal foot, stage 2 pressure ulcer to the left lateral proximal foot, and the unstageable pressure ulcer to the right medial malleolus until 1/29/2025. Review of the weekly checks titled Skin Observation/Check reveals that skin checks were documented on 12/31/2024 with no wound measurements or description, 1/12/2025 with no wound measurements or description, 1/20/2025 no wound measurements or description, and on 1/31/2025 no wound measurements or description and only indicates that there is a coccyx wound, there is no documentation regarding the four additional pressure ulcers that included an unstageable pressure ulcer to the right trochanter, an unstageable pressure ulcer on the right medial malleolus (ankle), a stage 2 pressure ulcer of the left proximal foot, a stage 2 pressure ulcer on the left distal foot. Further record review reveals that there is no documented evidence that Resident #9's wounds were assessed or measured weekly between 1/15/25 - 1/27/25. An IWC Follow-up Progress Note dated 1/28/2025 reveals that Resident #9 was seen for follow-up for the pressure ulcer to the right trochanter that was now unstageable (Pressure ulcers that are known but not stageable due to coverage of the wound bed by slough [dead tissue within a wound], and/or eschar [dry dead tissue] ) with 10% slough and 90% eschar and measures 3.5 cm length, 1.5 cm width, and 0.1 cm depth. The wound on Resident #9 sacrum was also documented as unstageable with 30% slough and 70% eschar measuring 10 cm length, 11 cm width, and 0.1 cm depth. A note states that there are 3 areas separated by skin bridge with periwounds intact and blanching. The IWC Follow-up Progress Note dated 1/28/2025 also reflects three additional pressure ulcers had developed since the last consultation on 1/14/2025. An unstageable pressure ulcer on the right medial malleolus (ankle) was noted as 10% granulation (tissue is new connective tissue and blood vessels that form on wound surfaces during healing), 70% eschar, and 20% slough and measure 9.5 cm length x 2.5 cm width x 0.1 depth. A stage 2 pressure ulcer of the left proximal foot that measures 2.5 cm length, 0.3 cm width, and 0.1 cm depth. A stage 2 pressure ulcer developed on the left distal foot that measured 1.5 cm length, 1.5 cm width, and 0.1 cm depth. Per interview with the Director of Nursing (DON) and the Regional DON on 1/22/25 at 2:23 PM, Resident #9 was being followed by the IWC Consultant in the past for a DTI on her/his right trochanter that had resolved. On 1/7/2025 when the Resident returned from an appointment it was brought to the DON's attention by the Resident's family member that a new wound had developed on the Resident's hip. The DON confirmed that there was no documentation regarding the development of the DTI and no new orders for wound care were received until 1/10/2025. The DON also stated that a Skin Observation/Check was completed on 1/12/2025 however, there is no description or measurements of the wound, and he did not know why it fell through the cracks. The Regional DON also confirmed that the Skin Observation/Check completed on 1/12/2025 was the first documentation of the DTI . Per interview with the facility Administrator on 1/23/25 at 5:48 PM the IWC Consultant had been asked to reschedule the 1/22/25 visit. On 2/5/2025 at 12:30 PM the Administrator confirmed that the Wound Care Consultant had not provided consultation during the week of 1/20/25- 1/24/2025. Reference: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Based on observation, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 residents in the sample (Resident #4). As a result, Resident #4 suffered injury and persistent fear that s/he would be physically assaulted again. Findings include: A review of a facility reported incident submitted to the State Agency on 1/9/25 of an allegation of physical abuse related to a resident-to-resident altercation that occurred on 1/8/25 at approximately 5:12 PM, revealed that Resident #1 entered the room of Resident #4 and threw a can of soda at Resident #4's arm causing a skin tear to the left forearm. Resident #4 also suffered a bruise to his/her forehead. A review of the nursing documentation and risk management notes reveals no evidence of how the bruise occurred to Resident #4's forehead. See F689 for more information. Per interview on 1/22/25 at approximately 10:00 AM, Resident #4 stated that Resident #1 came into his/her room while s/he was asleep and threw a 12 pack of soda at his/her face. Per observation, Resident #4 had evidence of bruising around his/her left eye, mid forehead and left side of forehead. There was a dressing on his/her left forearm dated 1/17/25. Per further interview s/he stated that s/he is afraid to sleep because [s/he] is worried that [Resident #1] will come back in [his/her] room. Per review of Resident #4's care plan dated 2/6/24 [S/he] requires assistance/dependent for movement related to weakness and due to bilateral ankle fractures s/he is unable to stand on her own, s/he requires a mechanical lift. The care plan also reveals that [Resident #4] is blind in the left eye . has a history of adjustment disorder and depression. [Interventions include] provide a calm environment, and assess for fear, and anxiety. Per the facility investigation, staff interviews dated 1/8/25, revealed staff were passing dinner trays, when one staff member noticed Resident #1 was exiting Resident #4's room. When the Licensed Nursing Assistant (LNA) serving drinks entered Resident #4s room she noted the nightstand was knocked over and Resident #4 reported being assaulted by Resident #1. During an interview on 1/23/25 at approximately 2:00 PM, a Licensed Practical Nurse (LPN #1) confirmed that Resident #1 had hit Resident #4 in the head with a 12 pack of soda on 1/8/25 and that staff were not aware that Resident #1 was in the room until the event occurred . Per review of Resident #1's care plan dated 1/19/24 [Resident #1] exhibits or has the potential to exhibit physical and verbal behaviors. [Interventions include] listen to [Resident #1] and help [him/her] calm down .[12/20/24] remove [Resident #1] from public area when behavior is disruptive/unacceptable, offer [Resident #1] to lay down, and assist to room. Per further review of Resident #1's care plan dated 12/10/24 s/he is identified as risk for wandering and has an intervention to offer resident schedule time for appropriate walks/appropriate activity. Residents #1's care plan fails to address behaviors of entering other residents' rooms, or the need for supervision after multiple resident to resident incidents. Per interview with an LNA #1 on 1/22/25 at 2:00 PM, he stated that there has been no education provided to staff related to how to manage Resident #1 behavior. He states that when Resident #1 is agitated it is difficult to redirect him/her. He stated that when he cares for other residents, Resident #1 goes into other resident rooms and is hard to get him/her out. Per interview of a LPN #3 on 1/23/25 at approximately 10:50 AM, she stated she was concerned that all residents would be at risk from Resident #1, on the second floor unit because she feels there are not enough staff to keep Resident #1 from going into other resident rooms. Per interview with LPN #2 on 1/23/25 at 10:55 AM, She stated that she is concerned that all residents on the second floor are at risk from Resident #1 because once s/he is in wheelchair, s/he is independent with mobility. The LPN stated Resident #1 has been found in multiple resident's rooms and is difficult to redirect due to his/her aggression. Per facility investigation reports, Resident #1 had a recent history of aggressive physical behaviors toward other residents, including an altercation on 12/23/25, when Resident #1 was witnessed pushing and punching Resident #3, and threatening to kill him/her. Then again on 12/29/24 when staff witnessed Resident #1 go down the hallway, go past Resident #2, turn around, get behind him/her and hit him/her in the back of the head. Per interview with Regional Director of Nursing on 1/23/25 at approximately 6:00 PM, she stated that per Resident #1's task list s/he should have been on 15-minute checks starting 12/21/24 prior to the above incidents occurring on 12/23/24, 12/29/24 and on 1/8/25. However, according to her, there is no documented evidence that staff completed 15-minute checks at any point since initiated on 12/21/24. She stated there was no evidence on Resident #1's care plan of the intervention and there should have been. She also stated there was no documented evidence of 15 minute checks in the record, which would have been done on paper then scanned into medical record. Review of Resident #1's medical record did not contain any evidence that 15 minute checks were performed. Per interview with an LPN on the second-floor unit on 1/23/25 at 6:30 PM, she stated she was unaware of any residents on the unit who were receiving 15 minutes checks including Resident #1.

Based on interview and record review, the facility failed to ensure the staff member designated as the facility's Infection Preventions (IP) had obtained specialized Infection Prevention and Control training beyond initial professional training. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated [DATE] and [DATE]. As a result the facility failed to prevent spread of COVID-19 through mitigation strategies that would be directed by an infection preventionist, and 1 resident died from COVID-19 (Resident #7). The failure to designate a qualified infection preventionist has the potential to impact all residents who reside in the facility. Findings include: Record review reveals that 11 residents and 15 staff members had tested positive for COVID-19 during a facility outbreak that began on [DATE]. 5 residents (Residents #1, #3, #13, and #12 and #14) were positive for COVID-19 at the time of survey entrance on [DATE]. Of the 11 residents that tested positive for COVID-19 during this outbreak, 2 residents (Resident #7 and #8) were sent to the hospital with respiratory distress. Resident #7 died shortly after being transferred to the hospital on [DATE]. According to Resident's #7 Death Certificate dated [DATE], his/her cause of death included cardiopulmonary arrest due to COVID. See F880 for more information. During an interview with the Director of Nursing (DON) on [DATE] at approximately 11:00 AM, he stated that the facility did not have a qualified designated infection prevent (IP) since [DATE]. The DON also confirmed that the current designated staff member did not have the required specialized training to act as the Infection Preventionist. Per interview on [DATE] at 2:55 PM the staff member who was designated as the facility's Infection Preventionist did not have the required specialized training as of [DATE]. She stated that she had no specialized training in infection prevention and control. Per interview with the Administrator and Director of Nursing (DON) on [DATE] at approximately 10:00 AM the facility did not have a qualified designated infection preventionist from [DATE] until the new DON completed a CDC (Center for Disease Control and Prevention) Nursing Home Infection Preventionist Training Course on [DATE]. The facility went 14 days without a qualified IP during a COVID-19 outbreak.

Based on interview and record review the facility failed to ensure that the medical director fulfilled her responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility regarding the surveillance of, and development of policies that reflect current professional standards of practice to prevent the spread of potential COVID-19 infection, and coordinate care of residents. This deficient practice resulted in ineffective COVID-19 mitigation, death of a resident from COVID-19, and resident abuse with injury. 1. Per review of the facility documented COVID-19 outbreak line list revealed that 11 Residents and 15 staff members tested positive for COVID-19 between [DATE] and [DATE]. Resident #7 tested positive for COVID-19 on [DATE] and was experiencing symptoms of lethargy (a general state of fatigue that involves a lack of energy and motivation for physical and mental tasks). Per record review, a Progress Note written by a Licensed Practical Nurse on [DATE], 6 days after being diagnosed with COVID-19, reveals that the Resident was found in bed unresponsive and gurgling the physician was notified, s/he was sent to the hospital, and subsequently died. Per review of the Resident's Death Certificate the cause of death was cardiopulmonary arrest due to COVID, hypertension (high blood pressure), diabetes, coronary artery disease (disease in the heart's major blood vessels). Per record review there is no documented evidence in Resident #7's record or facility reports that the Medical Director was notified that Resident #7 had tested positive for COVID-19 or that s/he was experiencing lethargy. There is also no documented evidence that the Physician was consulted regarding the treatment and care needs of Resident #7 related to COVID-19, and no documented evidence that the Resident was monitored or received any treatment related to the COVID-19 infection. During an interview on [DATE] at 4:30 PM the Medical Director stated that she had only been acting as the facility's medical Director since December and had not had a chance to review facility policies and procedures. She also had not reviewed the infection control policies related specifically to the COVID-19 outbreak. The Medical Director confirmed that she had no knowledge of what the facility was doing regarding surveillance and prevention of COVID-19 cases during the outbreak. The Medical Director stated the COVID-19 cases at the facility to her knowledge had been mild and that she had no formal conversations with the facility about mitigation strategies. Further review of the facility documented COVID-19 outbreak line list revealed that in addition to Resident #7, 10 other Residents and 15 staff members tested positive for COVID-19 between [DATE] and [DATE]. Per review of resident and facility records, 4 other Residents who tested positive (Residents #6, #12, #13, and #14) had no documented evidence of physician notification or consultation in their medical records. During an interview on [DATE] at 4:15 PM the Medical Director stated that she was not sure if she had been notified of each resident who tested positive during the outbreak. The Medical Director confirmed that they had not been consulted with regarding the facility policies, mitigation plan, or COVID-19 guidance from [NAME] Department of Health (VDH). 2. Per record review Resident #1 has a history of aggressive behavior towards others. There is no documented evidence in Resident #1's medical record that the Medical Director was aware of or consulted with regarding a violent incident toward another Resident. Per review of facility risk management report (RMS) documented on [DATE], [Resident #4] c/o (complained of) [Resident #1] coming into [his/her] room, [s/he] pushed the bedside table over, picked up a can of ginger ale, and [hit him/her] in the left arm with it causing a skin tear 1 cm x 1 cm. [S/he] received a bruise to [his/her] forehead. Per interview on [DATE] at approximately 10:00 AM, Resident #4 stated that Resident #1 came into his/her room while s/he was asleep and threw a 12 pack of soda at his/her face. Per observation Resident #4 had evidence of bruising around his/her left eye, mid forehead and left side of forehead. There was a dressing on his/her left forearm dated [DATE]. Per further interview the s/he stated that s/he is afraid to sleep because [s/he] is worried that [Resident #1] will come back in [his/her] room. Per interview with the Medical Director on [DATE] at 5:14 PM stated she was unaware that Resident #1 had been violent toward the other residents. She stated that she had not been notified of the incident that occurred on [DATE]. The Medical Director stated that if she had been consulted she would have had Resident #1 sent out to the hospital for evaluation due to aggression and Resident #4 would be sent out for evaluation for the need for an x-ray or scans had s/he been notified. The Medical Director also said that she would expect to be notified of incidents such as this. Per record review of Resident #4's medical chart there is no documented evidence that the facility assessed resident neurological status or reported to the provider that Resident #4 had an apparent head injury.

Based on interview and record review the facility failed to implement care plan interventions related to skin and wound assessments for 1 of 15 residents in the sample (Resident #9). As a result of the failure to follow care plan interventions Resident #9's pressure ulcers worsened. Findings include. 1. Per observation on 1/22/2025 at 3:10 PM a Licensed Practical Nurse (LPN) and Director of Nursing (DON) were observed performing wound care to Resident #9's pressure ulcers. The Resident was noted to have an excoriated sacrum with two open areas that were cleansed and a new dressing was applied. The pressure ulcer on his/her right hip was also cleansed and a new dressing was applied. The pressure ulcer on his/her right malleolus (ankle) was noted to be open with slough around the edges of the wound. This area was also cleansed and a new dressing was applied. There were 2 open area on the Resident's left distal foot that were cleansed and a new dressing applied. This surveyor noted a large dry wound on Resident #9's left lateral foot and asked the LPN and DON if there was a treatment ordered for that area. Both the LPN and DON were not aware of the wound. The DON recommended that the LPN leave the wound open to air. Per record review there was no documentation of the wound on the left lateral foot, no documented physician notification, and there was no treatment ordered for the wound until 1/30/2025, 8 days after it was identified. Review of Resident #9's Care Plan focus dated 3/8/2024 for at risk for skin breakdown reveals that it was not updated to include the stage 2 pressure ulcer on his/her left lateral foot until 1/29/2025. Per record review Resident #9 has a Care Plan focus dated 3/8/2024 that indicates s/he is at risk for skin breakdown related to: foley catheter use and fragile skin. On 1/10/2025 the Care Plan focus was revised to include MASD (moisture associated skin damage) to the sacrum and a deep tissue injury (DTI), (a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage [three and stage four] pressure ulcer even with optimal treatment. [NPAUP, 2005]) on his/her right hip. Interventions include weekly skin checks by licensed nurse (initiated on 11/7/22), and weekly wound assessment to include measurements and description of the wound (initiated on 5/12/2023). Review of the weekly checks titled Skin Observation/Check reveals that skin checks were documented on 12/31/2024 identifying moisture associated skin damage (MASD) related to incontinence associated dermatitis (denuded, excoriation), there are no documented wound measurements or description, 1/12/2025 identifying a right trochanter (hip) open area-tx in place, and sacrum, scattered open areas to bilateral buttocks-tx in place, there are no wound measurements or description, 1/20/2025 identified a coccyx ulcer and was updated on 1/29/25 to include right trochanter (hip), right ankle (outer), and left ankle (outer) no wound measurements or description, and on 1/31/2025 no wound measurements or description and only mentions that there is a coccyx wound, not documenting the presence of the four additional pressure ulcers that included an unstageable pressure ulcer to the right trochanter, an unstageable pressure ulcer on the right medial malleolus (ankle), a stage 2 pressure ulcer of the left proximal foot, a stage 2 pressure ulcer on the left distal foot. Per record review an Integrated Wound Care (IWC) Progress Note dated 1/7/2025 states that Resident #9 is being seen for the evaluation and treatment of deep tissue injury to the right trochanter (near the hip) measuring 4 cm length x 2. 1 cm width. The wound notes state Non-blanching discoloration, no open areas and no bogginess. An IWC Progress Note dated 1/14/2025 reveals that the DTI had progressed to a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister) measuring 4 cm length, 2 cm width, and 0.18 cm depth. There is no evidence in the Resident's record that the physician was notified that the DTI had progressed to a stage 2 pressure ulcer. Further record review reveals that Resident #9's wounds were not assessed or measured weekly between 1/14/25 - 1/28/25. An IWC Follow-up Progress Note dated 1/28/2025 reveals that Resident #9 was seen for follow-up for the pressure ulcer to the right trochanter that was now unstageable (Pressure ulcers that are known but not stageable due to coverage of the wound bed by slough [dead tissue within a wound], and/or eschar [dead tissue] )with 10% slough and 90% eschar and measures 3.5 cm length, 1.5 cm width, and 0.1 cm depth. The wound on Resident #9 sacrum is also documented as unstageable with 30% slough and 70% eschar measuring 10 cm length, 11 cm width, and 0.1 cm depth. A note states that there are 3 areas separated by skin bridge with periwounds intact and blanching. Three additional pressure ulcers had developed since the last consultation . An unstageable pressure ulcer on the right medial malleolus (ankle) was noted as 10% granulation (tissue is new connective tissue and blood vessels that form on wound surfaces during healing), 70% eschar, and 20% slough and measure 9.5 cm length x 2.5 cm width x 0.1 depth. A stage 2 pressure ulcer of the left proximal foot that measures 2.5 cm length, 0.3 cm width, and 0.1 cm depth. A stage 2 pressure ulcer developed on the left distal foot that measured 1.5 cm length, 1.5 cm width, and 0.1 cm depth. Per interview with the facility Administrator on 1/22/25 at 9:45 AM the IWC Consultant had been asked to reschedule the 1/22/25 visit. 2. Further record review reveals that Resident #9 has a care plan focus initiated on 4/25/2024 that states requires the use of enhanced barrier precautions (EBP) related to Indwelling device: Foley Catheter. An intervention initiated on 4/25/24 states Use of face mask or eye protection if there is a risk of splash or spray and Use of gloves and gown for high-contact care activities (personal protective equipment, PPE). Per observations on 1/22/2025 at 2:55 PM a Licensed Practical Nurse (LPN) and Director of Nursing (DON) were observed entering Resident # 9's room with supplies to flush his/her foley catheter. There was a sign on the Resident's door that indicated that EBP should be used. Both the LPN and DON were observed in the room without face mask and eye protection. Once the foley care was complete, the LPN and DON exited the room and gathered supplies for the scheduled wound care. The LPN and DON were then observed performing wound care on the 5 pressure ulcers without wearing the required PPE. Immediately after the wound care this surveyor asked the DON why Resident #9 was on EBP and he stated that he would be on EBP due to his/her foley and open wounds. The DON confirmed that he and the LPN should have worn PPE during the catheter flush and the wound care per care plan and facility protocol. On 1/23/2025 at 1:45 PM the LPN was again observed in Resident #9's room performing wound care without the indicated PPE. After exiting the room, the LPN was interviewed and stated that she should have donned PPE and she did not. Reference: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Based on interview and record review, the facility failed to provide pain management that met professional standards for 4 of 7 sampled residents by not recognizing pain or evaluating existing pain and the causes (Resident #1) and revise a resident's care plan to address and manage pain (Residents #1, #3, #5, and #6). As a result, Resident #1 had a pattern of significant, untreated pain. Findings include: Per record review, Resident #1 has diagnoses that include morbid obesity, type 2 diabetes, and history of uterine cancer. A 7/23/24 Nurse Practitioner note reveals that Resident #1 was transferred from the facility to the hospital on 7/11/24 for symptoms of a CVA (stroke). S/He was readmitted to the facility on [DATE] post CVA treatment with aphasia (speech disorder) and left sided hemiparesis (muscle weakness or partial paralysis on one side of the body). Resident #1's care plan reads, [Resident #1] has acute pain/chronic pain Diabetic neuropathy [nerve damage], revised on 2/3/2023, with the goal The resident should voice a satisfactory level of comfort through the review date, revised on 7/30/24, and has the following interventions: Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, created on 3/18/22, and Tylenol prn [as need] for pain as ordered, created on 3/18/22. Resident #1's care plan reveals, [Resident #1] has impaired communication as evidenced by: difficulty making self understood (expressive); aphasia secondary to CVA, initiated on 7/26/2024. Staff failed to recognize Resident #1's increase of pain following a fall. A pain assessment interview dated 7/26/24 reads, Ask resident: 'Have you had pain or hurting at any time in the last 5 days?' The answer unable to answer is marked off. The assessment indicates that when the resident is unable to complete the pain assessment interview, A Staff Assessment for Pain must be manually scheduled and completed since the interview is considered incomplete. This is the last pain assessment interview in Resident #1's record. Per interview on 9/9/2024 at 1:49 PM, the Registered Nurse (RN) who filled out this assessment was asked where the staff interview was that this tool referred to. S/He explained that there are no additional pain interviews completed by staff. The RN explained that after Resident #1's stroke in July, s/he was unable to communicate verbally. S/He explained that staff would be expected to use a PAINAD scale (a pain assessment tool to assess people with cognitive impairment that consists of five categories: breathing, negative vocalization, facial expression, body language, and consolability on a 1-10 scale) when evaluating Resident #1's pain. S/He confirmed that this was not an intervention in his/her care plan and should have been. A facility incident report dated 8/1/24 reveals that Resident #1 suffered an unwitnessed fall on 8/1/24 at approximately 7:30 PM and the resident was unable to give a description of the incident. The note reads, pt [patient] was anxious and was noted to be trying to get [his/her] legs out of the bed. pt was found on the floor beside [his/her] bed. [s/he] was transferred by hoyer lift [equipment to lift and transfer a person] back to bed assessed for injuries no injuries noted. An 8/1/24 fall evaluation note completed by a Physician Assistant after a virtual visit reads, [Resident #1] was in bed tonight, kicked [his/her] legs out of the sheets, and rolled out of bed and onto the floor. [S/He] was not injured per nursing report. I did ask the patient if [s/he] had any pain and [s/he] was not verbal at all with me. Per nurse this is [his/her] baseline. Per review of the vital section of the electronic medical record, documented pain assessments reveal that Resident #1 had pain levels of 0 for all days between 8/1/24 and 8/20/24, except for one day on 8/10/24, where it is documented to be a 3 out of 10. When pain value entries are entered into the electronic medical record they are categorized as either using a numerical scale or a PAINAD scale. None of the entries between 8/1/24 and 8/20/24 are categorized as using the PAINAD scale to evaluate Resident #1's pain. (Licensed Nursing Assistant) LNA staff witnessed an increase in pain after Resident #1 fell out of bed on 8/1/24. This was not communicated to a provider. Per interview on 9/9/24 at 2:14 PM, a LNA that worked with Resident #1 explained that when s/he helped with Resident #1 with his/her ADL care after his/her fall, s/he was in significant pain. S/He explained that s/he had worked at the facility for a while and had a good relationship and knowledge of Resident #1. This LNA explained that when s/he had to move him/her to do his/her care Resident #1 was screaming in pain, grabbing, and biting the air. S/He stated that s/he had made nursing staff aware of this. Per phone interview on 9/23/24 at 12:55 PM, the Licensed Nursing Assistant (LNA) that found Resident #1 on the floor on 8/1/24 explained that Resident #1 was unable to speak after his/her stroke but was able to communicate with facial expressions, sounds, and small body movements and occasionally s/he could answer yes or no. The LNA stated that Resident #1 did not show signs of pain immediately after the fall while Resident #1 was on the floor, but s/he did have progressively increased pain the days following the fall, sometimes screaming in pain when helping with his/her care. S/He explained that s/he reported to nursing staff that Resident #1 was having increased pain multiple times and was told by nursing staff that they were already aware or that the pain was Resident #1's baseline. S/He reiterated that prior to the fall Resident #1 had signs of discomfort and the pain s/he had post fall was a significant change from his/her baseline. Per phone interview on 9/11/24 at 2:27 PM, the Nurse Practitioner (NP) who had visits with Resident #1 on 8/7/24 and 8/14/24, was asked about his/her concern for injury post fall. S/He explained that s/he was unaware that Resident #1 was in pain. S/He revealed that nursing staff did not alert him/her to an increase of pain. S/He did not see evidence of Resident #1 having pain per his/her pain assessments in his/her vitals, except for one report of 3 out of 10 pain, which on its own was not concerning. S/He confirmed that Resident #1 was non-verbal and would require staff to use the PAINAD to evaluate his/her pain. An 8/20/24 nursing note states that Resident #1 was transferred to the Emergency Department (ED) for immediate evaluation and treatment for altered mental status. An 8/20/24 ED Registered Nurse (RN) note states that on admission to the ED Resident #1, does respond to painful stimuli and slightly moves arms when transferring from EMS stretcher to ED stretcher. Per interview on 9/9/24 at approximately 12:30 PM with this RN, s/he explained that Resident #1 appeared to be in pain anytime they moved his/her legs. An 8/21/24 ED Physician Assistant note reveals that a CT scan was preformed to rule out pneumonia. An 8/20/24 radiology report, signed at 11:34 PM reveals that Resident #1 has an Acute right femoral neck fracture [fracture in the hip joint]. Unexpected finding. A 9/16/24 Nurse Practitioner note reveals that Resident #1 was seen for a follow up visit related to [his/her] recent CVA, a fall with a right femur fracture with resulting physical deconditioning. Nursing evaluations up through 9/25/24 reveal that Resident #1 is still experiencing significant hip pain, some days reporting and/or displaying up to 10 out of 10 pain. Staff failed to evaluate existing pain for Resident #1. Resident #1 has the following physician order Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain, with a start date of 9/21/22. Resident #1's Medication Administration Record (MAR) reveals that the PRN Tylenol was administered 6 times between 8/1/24 and 8/20/24, on 8/7/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, and 8/14/24. Of the 6 times the Tylenol was administer, the only time a pain evaluation was completed was on 8/10/24, where Resident #1 is documented to have 3 out of 10 pain. Facility policy titled NSG227 Pain Management, revised on 11/1/23 reads, 5. At a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain. 6. PRN pain medications will: 6.1 Be documented in the Medication Administration Record (MAR), 6.2 Have defined parameters for use, 6.3 Have reasons for PRN medication requests documented, and effectiveness and/or side effects/adverse drug reactions will be assessed and documented. Per a phone interview on 9/23/24 at 4:44 PM, the Market Clinical Advisor confirmed that there was not a documented evaluation of Resident #1's pain each time s/he was administered PRN pain medications and should have been. Staff failed to revise Resident #1's care plan to address and manage pain after a change in condition to meet the resident's goals for pain management. An 8/27/24 NP follow up visit note reveals that Resident was readmitted to the facility on [DATE] following a hospitalization where Resident #1 was found to have a displaced fracture of his/her right hip. The note references hospital records documenting pain with repositioning and the NP's exam revealed Resident #1 grimacing when lifting right leg off bed. The NP's assessments included an order for norco (hydrocodone-acetaminophen, opioid pain medication) for pain management related to his/her hip fracture. Facility policy titled NSG227 Pain Management, revised on 11/1/23 reads, 3. An individualize, interdisciplinary, person-centered care plan will be developed and include: 31. Addressing/Treating underlying cause of pain to the extent possible; 3.2 Non-pharmacological and pharmacological approaches; 3.3 Using specific strategies for preventing or minimizing sources of pain or pain related symptoms. Per review of Resident #1's care plan, related to pain was not updated to reflect pain related to his/her recent fracture or the use of the PAINAD scale until 9/9/24. 2. Per record review, Resident #6 has diagnoses that include right sided lumbago with sciatica (lower back pain that radiates down the right leg), polyneuropathy (nerve damage that can cause pain), stage 4 kidney disease, morbid obesity, and Alzheimer's disease. Resident #6 has the following physician orders, Lidocaine External Patch 4 % Apply to affected area topically in the evening for pain. This order does not indicate where his/her body s/he is having pain. S/He also has an order for Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) Apply to knees topically two times a day for pain relief. Recorded pain levels reviewed between 9/1/24 and 10/18/24 show that Resident #6 reported his/her pain to be an 8 or 9 (on a 1-10 pain scale) multiple times. A 9/24/24 nursing note reveals that Resident #6 has right lower back pain described as a 9, aching, and worse with movement. Resident #6's care plan reads, [Resident #6] exhibits or is at risk for alterations in comfort related to eye pain, revised on 5/19/23. His/her care plan does not include a pain focus related to his/her pain in his/her back or knees and does not include interventions to provide non- pharmacological pain interventions. Per Resident #6's Medication Administration Record, there is an area to document non- pharmacological pain interventions (NPI) every shift when pain is identified. This area is documented under NPI as n (no) or N/A from 9/1/24 through 10/18/24. Nursing notes show that non- pharmacological interventions were only documented twice during this time. Per interview on 10/18/24 at 2:51 PM, the Market Clinical Lead confirmed that residents experiencing pain should have care plans that identify the cause of pain and include non-pharmacological pain interventions and Resident #6 did not. 3. Per record review, Resident #3 has diagnoses that include dementia, legal blindness, and acute kidney failure. A 9/10/24 nurse note reveals that Resident #3 sustained a that morning fall with complaints of pain to his/her hip and went sent to the emergency department (ED). A 9/13/24 Nurse Practitioner note states that s/he had a hip fracture and underwent hip surgery. Records show Resident #3 was transferred back to the facility on [DATE]. A 9/27/24 NP note states that Resident #3 had sustained two more falls since his/her surgery and was guarding hip and grimacing with movement. Recorded pain levels reviewed between 9/10/24 and 10/18/24 show that Resident #3 reported to be in pain multiple times, the highest being a 10 (on a 1-10 pain scale). Resident #3's care plan reads, [Resident #3] exhibits or is at risk for alterations in comfort related to chronic pain, revised 10/26/23. After returning to the facility following his/her hip surgery, Resident #3's care plan was not updated to reflect the underlying cause of his/her pain. Per interview on 10/18/24 at 2:51 PM, the Market Clinical Lead confirmed that residents experiencing pain should have care plans that identify the cause of pain and Resident #3 did not. 4. Per record review, Resident #5 has diagnoses that include dementia, spinal stenosis (narrowing of the spinal canal that puts pressure on the spinal cord and nerves), and osteoarthritis. Per Resident #5's care plan, s/he requires assistance/is dependent for ADL care in ADLs related to limited mobility, revised on 4/11/24. Per a 9/30/24 nursing note, Resident #5 suffered a fall resulting in a protrusion to the anterior part of his/her left arm and severe pain. S/He was transferred to the emergency department. A hospital Advanced Registered Nurse Practitioner note dated 9/30/24 reveals that Resident #5 had a closed nondisplaced fracture of the left humerus. Discharge instructions included a left upper extremity splint and sling and Percocet as needed for pain. Per Resident #5's care plan, s/he exhibits or is at risk for alterations in comfort related to pain, revised on 9/21/23. After returning to the facility following his/her 9/30/34 emergency department visit, Resident #5's care plan was not updated to reflect the underlying cause of his/her pain related to his/her fracture and was not updated to include the use of a splint and sling. Recorded pain levels reviewed between 9/30/24 and 10/18/24 show that Resident #5 reported to be in pain multiple times, the highest being a 10 (on a 1-10 pain scale). Per Resident #5's Medication Administration Record, there is an area to document non- pharmacological pain interventions (NPI) every shift when pain is identified. This area is documented under NPI as n (no) or N/A from 9/30/24 through 10/18/24 for 15 of the 19 pain level reports. Per interview on 10/18/24 at 2:51 PM, the Market Clinical Lead confirmed that residents experiencing pain should have care plans that identify the cause of pain and Resident #5 did not.

Based on interviews and record review, the facility failed to identify a resident at risk for impaired hydration status, address risk factors for impaired hydration status, and ensure that a resident receive sufficient fluid intake to maintain proper hydration and health for 5 of 7 sampled residents (Residents #1, #2, #3, #4, and #5). As a result, Resident #1 was admitted to the hospital with dehydration, a urinary tract infection (UTI), and developed a stage 2 pressure ulcer. Findings include: 1. Per record review, Resident #1 has diagnoses that include morbid obesity, type 2 diabetes, chronic kidney disease, anxiety disorder, major depressive disorder, delusional disorder, and history uterine cancer. A 7/23/24 Nurse Practitioner note reveals that Resident #1 was transferred from the facility to the hospital on 7/11/24 for symptoms of a CVA (stroke). S/He was readmitted to the facility on [DATE] post CVA treatment with aphasia (speech disorder) and left sided hemiparesis (muscle weakness or partial paralysis on one side of the body). Resident #1's care plan reads, [Resident #1] has an ADL Self Care Performance Deficit r/t Activity Intolerance, Impaired Mobility, and Morbid Obesity, revised on 2/21/24 and [Resident #1] has impaired communication as evidenced by: difficulty making self understood (expressive); aphasia secondary to CVA, initiated on 7/26/2024. A 7/22/24 Nutritional Assessment reveals that Resident has a new swallowing issue and should receive honey thickened liquids, is dependent on staff eating and drinking, and has a daily fluid need of 2100 cc (cubic centimeter; 30 cc = 1 fluid ounce). An 8/16/24 Occupational Therapy (OT) note indicates that Resident #1 requires Substantial/Maximal Assist for eating, including safely utilizing adaptive equipment using a two handled mug. Dependence in activities of daily living, communication problems, mental illness, diabetes, history of stroke, kidney disease, difficulty swallowing, and use of thickened liquids are risk factors for impaired hydration status*. Individuals who do not receive adequate fluids are more susceptible to urinary tract infections** and pressure injuries*** Resident #1 was not identified to be at risk for impaired hydration status. As a result, an interdisciplinary plan of care was not developed that identified a fluid intake goal or a hydration plan that could be monitored for effectiveness. Facility policy titled, FNS810 Hydration Plan, effective 5/1/23, reads, A hydration plan is developed for patients/residents (hereinafter resident) who are at risk for dehydration . For residents whose usual intake of fluids does not meet their needs, an individualized hydration plan is developed . Individual hydration plan interventions are documented on . Care plan . Plan is monitored for effectiveness and adjusted as needed. Facility policy titled, NSG223 Nutrition/Hydration Care and Services, revised 2/1/23, reads, interdisciplinary plan of care for enhancing oral intake, promoting adequate nutrition and hydration, and identifying individualized goals, preferences, and choices. Resident #1 has care plan interventions that include, Encourage resident to consume all fluids during meals. Offer/encourage fluids of Choice, created on 1/30/24. Provide rehab eating devices: 2 handled cup with sippy lid, lip plate and plastic bowl during meals currently [s/he] is being fed at meals prn [s needed] & working w/ OT on self-feeding, revised on 8/1/24. While these interventions are part of Resident #1's plan of care, a hydration plan was not developed to identify his/her risk for inadequate fluid intake. The lack of a hydration plan and identified hydration goals did not provide Resident #1's care team a plan to evaluate if s/he met his/her daily fluid intake need of 2100 cc. Per a phone interview on 9/23/24 at 4:44 PM, the Market Clinical Lead confirmed that Resident #1 was at risk for dehydration prior to his/her hospitalization on [DATE], should have been care planned for the risk, and was not. Resident #1 did not receive proper hydration and there was no evidence that providers were made aware of his/her insufficient fluid intake. Resident #1's POC (point of care; electronic documentation system for Licensed Nursing Assistants) documentation and Medication Administration Record were reviewed for daily fluid intake. The following were based on the combined total of the physician ordered once daily house supplement and recorded fluid intake for each shift for the two weeks prior to Resident #1's 8/20/24 hospitalization . 680 cc on 8/7/24, 1020 cc on 8/8/24, 360 cc on 8/9/24, 410 cc on 8/10/24, 900 cc on 8/11/24, 600 cc on 8/12/24, 920 cc on 8/13/24, 620 cc on 8/14/24, 660 cc on 8/15/24, 660 cc on 8/16/24, 1380 cc on 8/17/24, 270 cc on 8/18/24, 248 cc on 8/19/24, and 1048 cc on 8/20/24. Resident #1 did not meet his/her daily fluid needs for the two weeks prior to 8/20/24. There are no nursing notes for the two weeks prior to 8/20/24 reflecting that Resident #1 was not drinking and no notification was made to a provider to alert them s/he was not receiving adequate fluid intake. Per a phone interview on 9/23/24 at 12:55 PM, a Licensed Nursing Assistant (LNA) that was familiar with Resident #1 explained that Resident #1 wasn't drinking because s/he wouldn't drink the thickened liquid. S/He stated that nursing staff was aware that Resident #1 wasn't drinking and s/he was not aware of anything in place to help him/her stay hydrated. Per a phone interview on 9/11/24 at 2:27 PM, a Nurse Practitioner that had frequent visits with Resident #1 and was very familiar with their recent facility history explained that Resident #1 was at risk for developing a UTI, even more risk after s/he suffered a stroke. S/He and explained that it would be important to monitor Resident #1's fluid intake as a preventative strategy to reduce the risk for a UTI. S/He explained that s/he was not privy to documented fluid intakes and would rely on staff reports that they were not meeting their fluid goals. S/He confirmed that s/he was unaware that Resident #1 had poor fluid intake. Per a phone interview on 9/23/24 at 4:44 PM, the Market Clinical Lead reviewed Resident #1's fluid intake and confirmed that Resident #1 did not consume the recommended amount of fluids prior to his/her hospitalization on [DATE]. S/He explained that the expectation would be that the aides would report to the nurse low fluid intake. The nurse would document the low fluid intake and evaluate the resident. S/He confirmed that s/he did not see any notes in August 2024 prior 8/20/24 that this was done. Resident #1 was hospitalized for 5 days related to complications of dehydration, including a UTI. An 8/20/24 nursing note states that Resident #1 was transferred to the Emergency Department (ED) on 8/20/24 for evaluation and treatment of altered mental status. An 8/20/24 ED Registered Nurse (RN) note reveals Resident #1 was not alert on arrival and screened positive for severe sepsis. A urinary catheter was placed in the ED a few hours after arrival. The note reads, While preparing to insert the indwelling urinary catheter, it was observed by ED staff that the patient had a gelatinous substance coming out of the vagina and urine was foul smelling, yellow, and cloudy resembling orange juice. Per a phone interview on 9/9/2024 at approximately 12:30 PM with this RN, s/he explained that staff attempted to put in the catheter multiple times because chunks of gelatinous discharge was coming from the vagina and urethra clogging the catheter. An 8/21/24 hospital Physician Assistant note show that Resident #1 was admitted to the hospital following the visit to the ED. The note details laboratory results obtained shortly after entering the ED revealing elevated BUN (blood urea nitrogen levels), creatine, sodium, and chloride levels (indicators of dehydration****). An 8/25/24 hospital Physician notes reveals that Resident #1 was admitted to the hospital for acute encephalopathy (a disturbance of brain function), AKI (acute kidney injury), hypernatremia (high sodium concentration in the blood), UTI with MRSA (methicillin-resistant Staphylococcus aureus), and dehydration. Resident #1 was also found to have a stage 2 pressure ulcer (Partial-thickness skin loss) on admission. 2. Per record review, Resident #2 was admitted to the facility on [DATE] with diagnoses that include acute kidney failure, urinary tract infection, type 2 diabetes, and morbid obesity. A 9/27/24 nutrition assessment reveals that Resident #2 fluid needs would be approximately 2,650 cc (the calculation was not completed; fluid needs were based on the metabolic adjusted body weight and fluid factor). Per Resident #2's care plan, a care plan focus for risk for dehydration as evidence by recent infectious process, was not added until 10/2/24. There is no care plan goal described to alert staff to his/her daily fluid needs. Resident #2's fluid intakes were not documented throughout his/her entire stay. A Licensed Nursing Assistant task to document fluid intake was not added to his/her care documentation until 10/12/24. Per interview on 10/18/24 at 2:51 PM, the Market Clinical Lead confirmed that Resident #2 was at risk for dehydration on admission, did not have a care plan for dehydration until 10/2/24, and his/her fluid intakes should have been documented and were not. 3. Per record review, Resident #4 has diagnoses that include dementia and adult failure to thrive. Per Resident #4's care plan, s/he has an ADL [activities of daily living] Self Care Performance Deficit [relate to] dementia], revised on 12/29/23. A 9/13/24 nutrition assessment reveals that his/her fluid needs are 1600 cc per day. While Resident #4's care plan does have interventions to encourage fluid intake, there is no care plan goal described to alert staff to his/her daily fluid needs. Per review of Licensed Nursing Assistant documentation, Resident #4 did not meet his/her fluid needs on any day between 9/1/24 and 10/18/24. 4. Per record review, Resident #3 has diagnoses that include dementia, legal blindness, and acute kidney failure. Per Resident #3's care plan, s/he requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, related to: Recent illness, fall, hospitalization resulting in fatigue, activity intolerance, confusion. A 7/29/24 nutrition assessment reveals that his/her fluid needs are 2000 cc per day and a 9/16/24 nutrition assessment reveals that his/her daily fluid needs were changed to 1720 cc. While Resident #3's care plan does have interventions to encourage fluid intake, there is no care plan focus for dehydration risk and there is not a goal described to alert staff to his/her daily fluid needs. Per review of Licensed Nursing Assistant documentation, Resident #3 did not meet his/her fluid needs on any day between 9/1/24 and 10/18/24. 5. Per record review, Resident #5 has diagnoses that include dementia and type 2 diabetes. Per Resident #5's care plan, s/he requires assistance/is dependent for ADL care in ADLs related to limited mobility, revised on 4/11/24. A 10/4/24 nutrition assessment reveals that his/her fluid needs are 2200 cc per day. Resident #5's care plan does not have interventions to encourage fluid intake and there is not a goal described to alert staff to his/her daily fluid needs. Per review of Licensed Nursing Assistant documentation, Resident #5 did not meet his/her fluid needs on any day between 10/4/24 and 10/18/24. Per interview on 10/16/24 at 1:57 PM, a Licensed Practical Nurse explained that s/he was unsure how to tell if a resident has met their fluid requirements for the day. Per interview on 10/16/24 at 2:14 PM, an LNA explained that s/he documents what residents have had for fluid in their charting system but does not report the fluid intakes to the nurse, only that a resident hasn't had anything to drink. Per interview on 10/18/24 at 2:51 PM, the Market Clinical Lead confirmed that Residents #3, #4 and #5's care plan did not include a measurable goal for daily fluid intake. * https://www.hhs.texas.gov/sites/default/files/documents/signs-symptoms-risk-factors-for-dehydration.pdf **Lean K, [NAME] RF, [NAME] S, [NAME] C. Reducing urinary tract infections in care homes by improving hydration. BMJ Open Qual. 2019 [DATE];8(3):e000563. doi: 10.1136/bmjoq-2018-000563. PMID: 31363503; PMCID: PMC6629391. ***Alice C. [NAME] BSN, RN, [NAME] E. [NAME] APRN, BC, [NAME] RN, MSN, CRRN, eds. 2022. Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales - 16th Ed. F. A. [NAME] Company. ISBN 978-1-7196-4307-8. eISBN 978-1-7196-4768-7. STAT!Ref Online Electronic Medical Library. https://online.statref.com/document/4aBTjpoI3pTWtB0kek_F0t. 10/4/2024 9:24:26 AM CDT (UTC -05:00). **** https://emedicine.medscape.com/article/906999-workup?form=fpf

Based on observation, interview, and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 1 of 6 sampled residents (Resident #1) by failing to provide adequate supervision and implement care plan interventions that would reduce potential serious consequences if a fall did occur. As a result, Resident #1 suffered a fall that resulted in a hip fracture and significant pain. Findings include: Per record review, Resident #1 has diagnoses that include morbid obesity, anxiety, and history of uterine cancer. A 7/23/24 Nurse Practitioner (NP) note reveals that Resident #1 was transferred from the facility to the hospital on 7/11/24 for symptoms of a CVA (stroke). S/He was readmitted to the facility on [DATE] post CVA treatment with aphasia (speech disorder) and left sided hemiparesis (muscle weakness or partial paralysis on one side of the body). Resident #1 has the following care plan focuses, [Resident #1] is at risk for falls secondary to deconditioning, gait/balance problems, revised on 2/21/24 and [Resident #1] has impaired communication as evidenced by: difficulty making self understood (expressive); aphasia secondary to CVA, initiated on 7/26/2024. Interventions include, bed centered in room, mattresses on both sides of bed as resident intentionally puts self from bed to mattress per [his/her] preference, revised on 5/18/24, Anticipate and meet the resident's needs, created 3/18/22 Bed in low position, created 8/2/24, and Frequent checks on [Resident #1], revised on 5/16/2023. A facility incident report dated 8/1/24 reveals that Resident #1 suffered an unwitnessed fall on 8/1/24 at approximately 7:30 PM and the resident was unable to give a description of the incident. The note reads, pt [patient] was anxious and was noted to be trying to get [his/her] legs out of the bed. pt was found on the floor beside [his/her] bed. [s/he] was transferred by hoyer lift [equipment to lift and transfer a person] back to bed assessed for injuries no injuries noted. An 8/1/24 fall evaluation note completed by a Physician Assistant after a virtual visit reads, [Resident #1] was in bed tonight, kicked [his/her] legs out of the sheets, and rolled out of bed and onto the floor. [S/He] was not injured per nursing report. I did ask the patient if [s/he] had any pain and [s/he] was not verbal at all with me. Per nurse this is [his/her] baseline. Per interview on 9/9/24 at 5:29 PM, the Licensed Nursing Assistant (LNA) that was assigned to Resident #1 on the shift (LNA #1) that s/he fell out of bed explained that s/he had put Resident #1 to bed after dinner with another LNA (LNA #2) using a Hoyer lift. LNA #1 stated that Resident #1 was moving his/her legs around in bed and seemed anxious. S/He told the nurse about it. Per phone interview on 9/23/24 at 12:55 PM, LNA #2 explained that Resident #1 was unable to speak after his/her stroke but was able to communicate with facial expressions, sounds, and small body movements and occasionally s/he could answer yes or no. S/He explained that when s/he was helping LNA #1 put Resident #1 into bed on the night of his/her fall, it was clear that s/he did not want to go into bed at that time. S/He said the Licensed Practical Nurse (LPN #1) was made aware of this but the LPN gave directions to the aides for Resident #1 to stay in bed. On 9/9/24 at 3:46 PM, LPN #1, who was assigned to Resident #1 at the time s/he fell out of bed, was interviewed. S/He explained that prior to his/her stroke in July, Resident #1 had anxiety, was able to move around in bed, and was able to talk. After Resident #1 had the stroke, s/he did not display signs of anxiety or move around in bed and was unable to communicate. The LPN explained that on the night of 8/1/24 the aides reported that Resident #1 was uncharacteristically anxious and was attempting to swing his/her legs out of bed. The LPN revealed that s/he did not notify the provider of this change of increased restlessness and anxiety. When asked what interventions s/he implemented to prevent the Resident #1 from falling out of bed, s/he explained that s/he told the aides to check on him/her. S/He said that when Resident #1 was found on the floor, his/her bed had been in the highest position and there were not any fall mats on the floor next to his/her bed. S/He explained that when s/he evaluated Resident #1 after the fall, Resident #1 was unable to communicate if s/he was in any pain from the fall but did not appear to be in any more pain than normal. Facility policy titled NSG215 Falls Management, last revised 3/15/24 reads, Implement and document patient centered interventions according to individual risk factors in the patient's care plan. Adjust and document individualized intervention strategies as patient condition changes. In addition to not following Resident #1's care plan for having his/her bed in the lowest position and fall mats placed on either side of his/her bed, there was no evidence in staff interviews or documentation in Resident #1's medical record that additional intervention strategies to prevent falls were implemented. There was no evidence of increased supervision, any type of assessment related to his/her increased anxiety and restlessness, or provider notification of Resident #1's change in behavior. Per interview on 9/9/24 at 1:49 PM, the Interim Director of Nursing explained that LPN #1 did not alert the provider of Resident #1's change prior to fall and should have. Per interview on 9/11/24 at 2:27 PM, the Nurse Practitioner (NP) was asked about Resident #1's baseline post stroke and prior to fall and if the LPN's description of Resident #1's behavior (increased anxiety and restlessness) the day of his/her fall was concerning. S/He stated that a provider should have been alerted to Resident #1's change in behavior prior to him/her falling. As a result of the fall on 8/1/24, Resident #1 was found to have a hip fracture, which was not discovered until 19 days after his/her fall. Resident #1 suffered pain which was not communicated to a provider for 19 days and continues to have significant right hip pain. While there is only one documented incident of pain for Resident #1 between 8/1/24 and 8/20/24, interviews with LNAs reveal that Resident #1 was in an increased amount of pain post-fall. Resident #1's Medication Administration Record reveals that PRN (as needed) pain medications were given 6 times between 8/1/24 and 8/20/24. Of the 6 times the Tylenol was administered, the only time a pain evaluation was completed was on 8/10/24, where Resident #1 is documented to have 3 out of 10 pain. The Nurse Practitioner stated during a phone interview on 9/11/24 at 2:27 PM that s/he had two post fall visits with Resident #1 and was unaware that s/he was in pain because it was not documented in his/her chart. See F697 for more information. An 8/20/24 nursing note states that Resident #1 was transferred to the Emergency Department (ED) for immediate evaluation and treatment for altered mental status. An 8/20/24 ED Registered Nurse (RN) note states that on admission to the ED [Resident #1] does respond to painful stimuli and slightly moves arms when transferring from EMS stretcher to ED stretcher. Per phone interview on 9/9/24 at approximately 12:30 PM with this RN, s/he explained that Resident #1 appeared to be in pain anytime they moved his/her legs. An 8/21/24 ED Physician Assistant note reveals that a CT scan (computerized x-ray) was preformed to rule out pneumonia. An 8/20/24 radiology report, signed at 11:34 PM reveals that Resident #1 has an Acute right femoral neck fracture [fracture in the hip joint]. Unexpected finding. A 9/16/24 Nurse Practitioner note reveals that Resident #1 was seen for a follow up visit related to [his/her] recent CVA, a fall with a right femur fracture with resulting physical deconditioning. Nursing evaluations up through 9/25/24 reveal that Resident #1 was still experiencing significant hip pain, some days reporting and/or displaying up to 10 out of 10 pain. The facility continued to fail to implement care plan interventions that would reduce potential serious consequences if a fall did occur. Per observation on 9/9/24 at approximately 11:00 AM, Resident #1 was observed in bed. The bed was in a high position and there were no mats on the floor. Per interview on 9/9/24 at 4:19 PM, the Market Clinical Advisor confirmed that s/he just observed that Resident #1's bed was not in the lowest position and there were no mats on the floor and should have been per his/her care plan.

Based on observations, resident and staff interviews, and record review, the facility failed to provide adequate supervision to prevent a resident to resident physical altercation for two of six residents (Resident #1 & Resident #2) in the applicable sample. Findings include: Per record review, Resident #1 has diagnoses that include dementia with behavior disturbance and [CONDITION(S)] ([CONDITION(S)]). S/he has a history of verbal and physical altercations with staff and other residents. A care plan focus that was initiated on 1/25/2021 states Wandering related to cognitive impairment, inability to locate own room. The care plan goal states that s/he will wander only within specified boundaries through next review. Interventions reflect that staff should provide [the resident] assistance in locating room. Resident #1's care plan focus initiated on 2/19/2021 reflects that Resident #1 is at risk for/demonstrates physical/combative behaviors at times related to Dementia, with a history of harm to others. On 7/5/2021 Resident #1 was involved in a resident to resident altercation that occurred in the dining room and was observed by staff. This altercation resulted in Resident #1 hitting another resident with her/his walker and then being the recipient of three strikes to the head by the other resident. Resident #1's care plan was updated on 7/5/2021 to reflect that if [resident] appears to be agitated or threatening others with walker, escort [resident] to safe private area (resident room) until de-escalation, as tolerated. Resident #1's ADL (Activities of daily living) care plan revised on 7/6/2021 to reflect that s/he requires supervision with ambulating with walker. On 7/12/2021 at 12:30 PM Resident #1 wandered into Resident #2's room unsupervised. An Incident Note dated 7/12/2021 at 4:11 PM states Resident [#1] was found going toward dining room with blood on left side of head. Upon further investigation it was noted that the resident [#1] had been in an altercation with another resident [#2]. The resident in the other room stated that [Resident #1] had come into [her/his] room and sat down. [Resident #1] then tried to take [Resident #2's] oatmeal cookie from [her/him]. When [Resident #2] tried to walk past [Resident #1, s/he] started swearing at [Resident #2] and hitting [her/him] in the face. [Resident #2] did have a 2 cm laceration under [her/his] left jaw and a laceration to the top of [her/his] right wrist. Both residents required first aid from nursing. Resident #1's care plan was updated on 7/12/2021 to reflect a door alarm to alert staff of leaving room. An Interdisciplinary Note dated 7/16/2021 does state We discussed her/his current behaviors that include wandering with impact, cursing at others, verbal threats of violence, physical aggression. Triggers identified are low/high blood sugars, over stimulus environments, and noise. We discussed current interventions of the doorway sensor monitor, there is concern that it is not helpful to the noise on the unit. The Interdisciplinary Note does not indicate wether or not the discussion lead to the removal of the alarm and the care plan was not updated to reflect the removal of the door alarm. After the 7/12/2021 resident to resident altercation Resident #1 continues to be aggressive and combative. S/he also continues to wander in and out of resident rooms at times. S/he has entered rooms and been intrusive with other residents belongings. A Behavior Note dated 8/14/2021 1:55 PM states It was reported to this writer that [Resident #1] wandered into another patients room and put on that patients jacket the other patient told [her/him] to take off the jacket and to leave the room and [Resident #1] did what the patient requested. [S/He] then went into the hallway and was combative with the nurse when [s/he] attempted to redirect [her/him] to [her/his] room A Behavior note date 8/13/2021 4:50 PM states At 0915 it was reported by ,,, LNA orienting that [s/he] found [Resident #1] in [another resident's] bathroom. [S/he] was able to redirect [her/him] back to [her/his] room. During observations of the third floor on 12/1/2021 from 3:00 PM - 3:3:00 PM , Resident #1 was seen in his room sitting in a chair facing the doorway and observing the activity in the hallway. The door did not have a door alarm in place. Throughout the observations staff were seen passing through the hallway, in other resident's rooms, or located around the corner from Resident#1's room at the nurses station. Per interview with a licensed nursing assistant (LNA) on 12/1/2021 at 3:10 PM Resident #1 does have aggressive behaviors. S/he stated that it is usually the way you approach [her/him]. S/he seems to respond better to certain staff. The LNA confirmed that there was no specific monitoring or supervision of Resident #1 and there was no door alarm on Resident #1's door. S/he stated that the resident across the hall does yell sometimes and that bothers Resident #1. When that happens they shut Resident #1's door a bit so it doesn't upset her/him. Per interview with the Director of Nursing Services (DON) on 12/1/2021 at 5:25 PM Resident #1 has a history of [CONDITION(S)] from being in the war. S/he has had altercations with other residents and can be aggressive and combative with staff. The resident to resident incidents being investigated happened prior to her/him being the DON and s/he is not aware of what interventions were implemented. However, it would be her/his expectation that after a resident to resident altercation the resident would have increased supervision.

Based on staff interviews and record review the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 applicable resident in the sample (Resident#1) surrounding wound vac (Therapeutic technique using a vacuum dressing with negative pressure to promote healing.) dressing changes. Per record review the physician's orders [REDACTED]. Cleanse with normal saline or wound cleanser. Place black foam sponge into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dsg (dressing) and secure tubing per manufacturer guide every 72 hours for Wound healing. Per review the physician's discharge summary from 8/3/16, the wound vac dressing for Resident #1 was to be done on a Tuesday, Thursday, Saturday schedule. Per review of the Resident #1's Treatment Administration Record (TAR) the resident was due for a dressing change on 8/6/16. Per interview on 8/24/16 at 9:48 AM with the Director of Nursing (DNS), s/he stated that it was discovered on 8/11/16, that the wound vac dressing changes were not done for Resident #1 on 8/6/16 and 8/9/16 as ordered; and as a result, Resident #1 was sent to the hospital on [DATE] and required surgical intervention to remove the wound vac. S/he stated that on 8/6/16, the nurse delivering care and treatments (Staff Nurse #1) to Resident #1 misread the physician's orders [REDACTED]. The DNS stated that on 8/11/16, Staff Nurse #1 was delivering care and treatments to Resident #1 and realized s/he had not done the dressing on 8/6/16, even though s/he had signed off the order as if s/he did the dressing change. S/he then brought this information to the Charge Nurse's attention. Upon further review of Resident #1's TAR, the DNS stated that the wound vac dressing change was also not signed off and was not done on 8/9/16. S/he stated that a second nurse (Staff Nurse #2) was assigned to deliver care and treatments to Resident #1 on 8/9/16, and did not perform any treatments for Resident #1 including the wound vac dressing change. Per interview with the DNS on 8/24/16 at 9:48 AM, s/he stated that if the facility was receiving a resident with a treatment or therapy that the facility did not regularly deal with, s/he or the Nurse Educator would give a review/refresher for the staff member(s) receiving the resident who needed the particular treatment and/or therapy. Per interview on 8/24/16 at 11:50 AM with Staff Nurse #1, s/he stated that s/he did not receive any education or training from the facility regarding wound vac care and dressing changes prior to delivering care and treatments to Resident #1. Per interview on 8/24/16 at 3:52 PM with Staff Nurse #2, s/he stated that s/he did not receive any education or training from the facility regarding wound vac care and dressing changes prior to delivering care and treatments to Resident #1. Per review of nursing competencies from date of hire, 4/11/16, for Staff Nurse #1 and Staff Nurse #2, neither Staff Nurse #1 nor Staff Nurse #2 had any documented competencies for wound vac (negative pressure wound therapy) care and dressing changes. During an interview on 8/24/16 at 3:14 PM with the Nurse Practice Educator, who was responsible for the orientation of Staff Nurse #1 and Staff Nurse #2, s/he confirmed there were no competencies for Staff Nurse #1 or Staff Nurse #2 for wound vac care and dressing changes. The above is to be considered past non-compliance due to the following: 1. Both of the staff nurses involved received disciplinary action following the incident. Per interview with the Director of Nursing and each of the involved staff nurses, the nurses have changed their practice to reflect more diligence with carrying out physician's orders [REDACTED]. 2. The Director of Nursing immediately implemented facility wide practices that at the change of shift the ongoing and offgoing nurses were to check the Medication Administration Record [REDACTED]. 3. All nurses at the facility have received education and training/competencies regarding nursing documentation, negative pressure wound therapy (wound vac), wound measuring and wound dressing-aseptic technique. 4. Audits are to be conducted daily to assure that the ongoing and offgoing nursing staff are completing and signing off all medications and treatments and have signed the audit tool attesting that they have done so prior to leaving at the end of their shift.

Based on staff interviews and record review the facility failed to meet professional standards of quality by not carrying out a physician's order for wound vac (Therapeutic technique using a vacuum dressing with negative pressure to promote healing.) dressing changes for one applicable resident in the sample (Resident #1). Findings include: Per record review, the physician's order for Resident #1 read, Negative Pressure Therapy To Abdomen Set Unit to 125mmHg CONTINUOUSLY. Cleanse with normal saline or wound cleanser. Place black foam sponge into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dsg (dressing) and secure tubing per manufacturer guide every 72 hours for Wound healing. Per review of the physician's discharge summary from 8/3/16, the wound vac dressing for Resident #1 was to be done on a Tuesday, Thursday, Saturday schedule. Per review of the Resident #1's Treatment Administration Record (TAR) the resident was due for a dressing change on 8/6/16. Per interview on 8/24/16 at 9:48 AM with the Director of Nursing (DNS), s/he stated that it was discovered on 8/11/16, that the wound vac dressing changes were not done for Resident #1 on 8/6/16 and 8/9/16 as ordered; and as a result, Resident #1 was sent to the hospital on [DATE] and required surgical intervention to remove the wound vac. S/he stated that on 8/6/16, the nurse delivering care and treatments (Staff Nurse #1) to Resident #1 misread the physician's order for wound vac dressing changes and only assessed the wound vac to make sure the dressing was intact, the suction was at the correct setting and was draining. The DNS stated that on 8/11/16, Staff Nurse #1 was delivering care and treatments to Resident #1 and realized s/he had not done the dressing on 8/6/16, even though s/he had signed off the order as if s/he did the dressing change. S/he then brought this information to the Charge Nurse's attention. Upon further review of Resident #1's TAR, the DNS stated that the wound vac dressing change was also not signed off and was not done on 8/9/16. S/he stated that a second nurse (Staff Nurse #2) was assigned to deliver care and treatments to Resident #1 on 8/9/16, and did not perform any treatments for Resident #1 including the wound vac dressing change. Per interview with the DNS on 8/24/16 at 9:48 AM, s/he stated that if the facility was receiving a resident with a treatment or therapy that the facility did not regularly deal with, s/he or the Nurse Educator would give a review/refresher for the staff member(s) receiving the resident who needed the particular treatment and/or therapy. Per interview on 8/24/16 at 11:50 AM with Staff Nurse #1, s/he stated that s/he did not receive any education or training from the facility regarding wound vac care and dressing changes prior to delivering care and treatments to Resident #1. Per interview on 8/24/16 at 3:52 PM with Staff Nurse #2, s/he stated that s/he did not receive any education or training from the facility regarding wound vac care and dressing changes prior to delivering care and treatments to Resident #1. Per review of nursing competencies for Staff Nurse #1 and Staff Nurse #2, neither Staff Nurse #1 nor Staff Nurse #2 had any documented competencies for wound vac (negative pressure wound therapy) care and dressing changes. During an interview on 8/24/16 at 3:14 PM with the Nurse Practice Educator, who was responsible for the orientation of Staff Nurse #1 and Staff Nurse #2, s/he confirmed there were no competencies for Staff Nurse #1 or Staff Nurse #2 for wound vac care and dressing changes. Lippincott Manual for Nursing Practice, 10th Edition The above is to be considered past non-compliance due to the following: 1. Both of the staff nurses involved received disciplinary action following the incident. Per interview with the Director of Nursing and each of the involved staff nurses, the nurses have changed their practice to reflect more diligence with carrying out physician's orders. 2. The Director of Nursing immediately implemented facility wide practices that at the change of shift the ongoing and offgoing nurses were to check the Medication Administration Record [REDACTED]. 3. All nurses at the facility have received education and training/competencies regarding nursing documentation, negative pressure wound therapy (wound vac), wound measuring and wound dressing-aseptic technique. 4. Audits are to be conducted daily to assure that the ongoing and offgoing nursing staff are completing and signing off all medications and treatments and have signed the audit tool attesting that they have done so prior to leaving at the end of their shift.