Every finding on record at St. Johnsbury Health & Rehab

Based on interview and record review, the facility failed to treat a resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's right to make choices, for 1 of 4 sampled residents (Resident #4) with the resident subsequently sustaining injury. Findings include: Per record review, Resident #4 has diagnoses that include unspecified dementia with agitation and cognitive communication deficit. Per an MDS (Minimum Data Set, a resident assessment tool) dated 12/9/25, Resident #4 has a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. Per record review, Resident #4 has a care plan focus initiated 5/13/25, which indicates that Resident #4 is resistive to care related to difficulty adjusting to facility, and cognitive loss and dementia, with an intervention to Allow time for expression of feelings; provide empathy, encouragement, and reassurance, last revised 8/3/25. Resident #4 has a care plan focus last revised on 8/3/25 which states, [Resident #4] is at risk for distressed/fluctuating mood symptoms related to: history of military experience, change in living environment, with an intervention to Provide with opportunities for choice during care/activities to provide a sense of control. Per record review, a behavior note dated 12/17/25 states the following, Resident found with feces covering body from head to toe before end of shift. Due to extensive soiling, resident was escorted to shower for hygiene care. Care was provided by nurse and three LNAs due to resident's known aggressive behavior. During care, resident became physically aggressive, including punching, trying to bite and pulling staff members' hair. Resident was physically digging into [his/her] skin and staff skin with [his/her] nails. Staff maintained safety precautions and continued care as tolerated. Resident remained physically aggressive throughout hygiene care. Care completed with staff assistance. Resident monitored post-care. A progress noted dated 12/18/25 states, notified by staff that resident had been combative with cares, when going into room for skin check, resident was noted with scattered bruising. Skin tears to right arm and left outer knee. A nursing post event skin condition assessment dated [DATE] notes new skin alterations identified including, Left lateral calf skin tear, right and left forearm skin tear, Scattered bruising on upper right arm, side and right lower extremity. Additionally stating, Recent illness with COVID now recovering from illness, recent falls, combative behavior, weight loss, (labs pending), having an increase in combative behaviors. Resident covered [himself/herself] in [his/her] feces, [s/he] was brought to the shower to receive care in which [s/he] became combative with staff, and was hitting [his/her] arms of [his/her] chair in the shower room. Resident was reported to have bit, scratched [himself/herself] and others in the shower room. MD notified, family notified. Per review of a facility disciplinary document given to LNA #1, dated 12/19/25, it stated that Resident #4 was not cooperative with care, the shower did not go well, and that the resident received scratches, skin tears, and bruising. Per an interview with the DON (Director of Nursing) on 5/4/26 at 12:00 PM, she confirmed that Resident #4 was refusing care, was combative and agitated and that staff then continued to bathe the resident. Per an interview with LNA #1 on 5/4/26 at 1:35 PM, she stated she had found the resident covered with BM (bowel movement) and attempted to bathe him/her. When the resident refused, she asked LPN #1 to assist in bathing him/her. When in the shower room, two additional LNA's also assisted in bathing Resident #4. LNA #1 confirmed that Resident #4 was combative throughout the entire process. The facility did not honor Resident #4's choice to not bathe and the resident subsequently sustained multiple skin tears and bruising.

Based on interview and record review the facility failed to revise and implement a person-centered care plan for 1 of 4 sampled residents (Resident #4). The care plan was not revised and implemented to address Resident 4's physically aggressive behavior. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 7/25/25. Findings include: Per record review, Resident #4 has diagnoses that include dementia with agitation and cognitive communication deficit. Per an MDS (Minimum Data Set, a resident assessment tool) dated 12/9/25, Resident #4 has a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. Per record review, a nursing progress note on 11/3/25 noted that the resident displayed increased behavior and agitation. Resident made a fist and threatened to knock a staff member out, then proceeded to push a staff member out of the way. Resident #4 sustained a skin tear during this incident. A subsequent nursing note dated 11/3/25 stated The EMR call the state police department for rescue Resident was abusive with the entire staff even slap the police Versed (a medication used to induce relaxation or sleep) was administered IM [injected directly into the muscle]. The administered was notified and transport Resident to hospital via stretcher. A nursing progress noted dated 11/5/25 stated, Resident refused to allow LNA [Licensed Nursing Assistant] to change soiled brief. LNA made several attempts to change resident. Resident became agitated and aggressive and swatted LNA's hand multiple times. A nursing progress note dated 12/2/25 stated, Resident exhibited visible aggression toward both aides this morning. [s/he] was yelling and slamming doors, demanding that staff leave [his/her] room. The resident refused to take a shower or allow staff to provide hygiene care. Writer attempted to re-approach a few minutes later and received the same aggressive responses. Staff will continue to monitor and attempt care as tolerated. An MDS dated [DATE] stated that Resident #4 exhibited physical behavioral symptoms directed toward others on 1 to 3 days, The MDS defines such symptoms as Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). A nursing progress note dated 12/12/25 stated that the resident was verbally and physically aggressive. Per record review, a behavior note dated 12/17/25 states the following, Resident found with feces covering body from head to toe before end of shift. Due to extensive soiling, resident was escorted to shower for hygiene care. Care was provided by nurse and three LNAs due to resident's known aggressive behavior. During care, resident became physically aggressive, including punching, trying to bite and pulling staff members' hair. Resident was physically digging into [his/her] skin and staff skin with [his/her] nails. Staff maintained safety precautions and continued care as tolerated. Resident remained physically aggressive throughout hygiene care. Care completed with staff assistance. Resident monitored post-care. A progress noted dated 12/18/25 states, notified by staff that resident had been combative with cares, when going into room for skin check, resident was noted with scattered bruising. Skin tears to right arm and left outer knee. A nursing post event skin condition assessment dated [DATE] notes new skin alterations identified including, Left lateral calf skin tear, right and left forearm skin tear, Scattered bruising on upper right arm, side and right lower extremity. Additionally stating, Recent illness with COVID now recovering from illness, recent falls, combative behavior, weight loss, (labs pending), having an increase in combative behaviors. Resident covered [himself/herself] in [his/her] feces, [s/he] was brought to the shower to receive care in which [s/he] became combative with staff, and was hitting [his/her] arms of [his/her] chair in the shower room. Resident was reported to have bit, scratched [himself/herself] and others in the shower room. MD notified, family notified. Per an interview with the DON (Director of Nursing) on 5/4/26 at 12:00 PM, she confirmed that during the incident on 12/17/25, Resident #4 was refusing care, was combative and agitated and that staff continued to bathe the resident. Per an interview with LNA #1 on 5/4/26 at 1:35 PM, with regard to the incident on 12/17/25, she stated that she had found the resident covered with BM (bowel movement) and attempted to bathe him/her. When the resident refused, she asked LPN #1 to assist in bathing him/her. When in the shower room, two additional LNAs also assisted LNA #1 and LPN #1 in bathing Resident #4. LNA #1 confirmed that Resident #4 was combative throughout the entire time they were providing care. The facility did not revise Resident #4's care plan with interventions to address a pattern of physically aggressive behavior until 12/18/26, over 6 weeks after an increase in physical behaviors.

Based on observation and interview, the facility failed to ensure that food items were stored in accordance with professional standards for food service safety by having unlabeled food available for use and not ensuring proper refrigerator temperatures. Findings include:Per review of the facility's Food Procurement policy [revised date 11/2025] states: RESPONSIBILITIES: Food Service Director maintains the approved vendor list. Oversees purchasing and receiving practices. Ensures regulatory compliance. Dietary staff inspect deliveries up receipt. Reject unacceptable products. Ensure proper storage of accepted item. Receiving 1. All food deliveries shall be inspected at the time of receipt for: *proper temperatures. *Signs of spoilage, contamination, or damage. *Expiration or use-by dates. 2.Products not meeting standards shall be rejected and documented. 3.Accepted food items shall be labeled and stored immediately according to temperature and storage requirements. During the initial tour of the food service department on 1/25/26 at 4:22pm there was a very strong offensive odor noted on entry to the kitchen. At 4:35pm, a dirty bucket of liquid laundry stain remover was noted on some crates outside of the walk-in fridge. The Food Service Director was asked what it was and why it was there. She said that it should have been thrown away as they were using it for cleaning their dishwasher which was having some trouble getting up to temp. Per observation on 01/26/26 at approximately 11:21am, observed Balsamic vinaigrette in Wing B kitchenette with an expiration date of 1/18/26 11:24 AM Licensed Nurse #1 confirmed the Balsamic vinaigrette was expired with an expiration date of 1/18/26 and threw it away. Per observation on 01/27/26 at 10:33am, the refrigerator and freezer in the activity room was observed with activity staff and a bag of cookies was in the freezer with no dates. Staff stated that those were recently baked and someone will be getting a label for it. Unpackaged frozen bananas were also found in the freezer. The staff member confirmed she is not sure who's they were and thought they might be for residents. A bucket of ice with a water bottle was found in the freezer of which staff confirmed that she was not sure who's it was or who put it there. The items were not removed. On 01/28/2026 at 8:48am, the bag of cookies in the freezer were still not dated after the initial observation. Per interview on 01/28/2026 at 9:06am, the Food Service Director verbalized that she didn't know there were cookies in the freezer and thought that the residents had a bake day last Thursday and advised to check with the Activity Director. Per interview on 01/28/26 at 9:11am, the Maintenance Director verbalized that they do not keep temperature logs and that housekeeping is the one that takes care of that. Per unit observations made on 1/27/2026 and 1/28/2026 it was noted that Resident #37 had a personal in room refrigerator. There was no evidence of a temperature log seen in the room. Per interview on 1/28/26 at 9:38am, a housekeeping staff member was asked if they keep temp log forms for the refrigerator for Resident #37. She stated that they do and took surveyors to the laundry department where the logs where kept. There we found the logs for several residents' fridges. The Housekeeping Director was asked why some of the dates were missing and she stated that it was because her office was locked one weekend and so staff could not access the logs. Per record review of the fridge temperature logs, there were six personal refrigerators that had missing documentation on 1/1, 1/17, 1/18, and 1/22/26. According to the facility temperature logs the fridge should be in a range between 32 to 40 degrees F (Fahrenheit). There were multiple days on each fridge that were elevated above 40 degrees. Per interview on 1/28/2026 at 10:06am, the Housekeeping Director confirmed that the temperatures were out of range. When asked what interventions were implemented when this occurs, she verbalized that they inform maintenance. Per interview on 1/28/2026 at 10:10am, the Maintenance Director confirmed that staff should be coming to him if they encounter any temps that are out of range. When asked if he has received any reports of temps being out of range, he verbalized no he has not.

Based on observation, interview, and record review the facility failed to ensure that 2 of 4 sampled residents were free from accident hazards related to supervision and fall hazards (Resident #25), wheelchair and device maintenance (Residents #25 and Resident #50), and smoking safety for 1 of 1 sampled resident (Resident #71). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey dated 12/11/24 and two partial surveys dated 3/28/25 and 7/24/25. Findings include: 1. Per a record review, Resident #25 has diagnoses that include Alzheimer's disease, cognitive communication deficit, abnormalities of gait and mobility, lack of coordination, muscle weakness, and history of falling. Resident #25 has a care plan focus of ADL [activities of daily living] self-care deficit related to physical limitations with an intervention dated 9/19/25 for extensive assist of 1 with transfers. Resident #25 also has a care plan focus of At risk for falls due to history of falls, impaired balance/poor coordination with interventions dated 9/19/25 of call bell in reach, encourage to transfer and change positions slowly, and therapy evaluation and treatment per physician orders. A nursing progress note dated 9/25/25 reflects that Resident #25 sustained a fall while attempting to self-transfer and states, It was brought to this writers attention by staff that resident slid to the floor in front of the nursing station. Resident was trying to stand and grab on to the snack cart. This was a witnessed fall. Resident was assisted by staff back to wheelchair. There was no new fall interventions added to Resident #25's care plan at this time. A nursing progress note dated 1/18/26 references periods that the resident had been transferring themself to bed without staff assistance and reads, Resident presented with increased confusion, weakness and foul smelling urine. new orders for u/a [urinalysis] to be obtained. spoke with [Resident #25's responsible party] via telephone and updated on orders and plan of care. Also spoke regarding periods of putting self into bed and removing own brief. There was no new fall interventions added to Resident #25's care plan at this time. Per observation on 1/25/2026 at 4:55 PM Resident #25 was self-propelling around the unit in a wheelchair. The wheelchair was noted to have an anti-rollback device (a safety mechanism that functions as a break and prevents backward movement of the wheelchair when a person attempts to stand from a seated position) installed. When the Resident was asked how s/he was s/he stated, I fell today. S/he denied having any pain. The Director of Nursing approached and confirmed that the Resident had experienced a fall earlier that day. Per observation on 1/25/26 at 5:50 PM, Resident #25 was observed walking alone in his/her room. An LNA (Licensed Nursing Assistant) entered the room and assisted her/him to the wheelchair and wheeled her/him out of their room. The LNA then parked her/him in the hall outside of her/his room, locked the left brake of the wheelchair, and walked away. As soon as the LNA walked away, Resident #25 began to self-propel down to the other nursing unit without difficulty with the left brake engaged. At 6:07 pm, Resident #25 returned to the nursing unit and was observed self-propelling their wheelchair backwards down the hallway without difficulty, with the left brake still engaged. Review of Resident #25's care plan revealed that the focus At risk for falls due to history of falls, impaired balance/poor coordination was updated on 1/25/26 with an intervention stating, Reinforce wheelchair safety as needed such as locking brakes. However, the left brake was currently defective. A late entry nursing progress note written on 1/26/26 states, Late entry from 1/25/2026. At 1330 [1:30 PM] resident had an unwitnessed fall in [her/his] room. [S/he] was attempting to get out of bed with no assist. [S/he] was assessed for injury at this time with an abrasion noted to [his/her] left shoulder with no complaints of pain and or discomfort at this time. [S/he] was assisted up to [his/her] wheelchair. Per observations made on 1/26/26 at 2:49 pm, Resident #25's anti-rollback device was not engaging when the wheelchair was pulled backward without the Resident in it. Further observation revealed that when attempting to engage the left-hand standard brake it was very loose and unable to engage properly allowing the wheel to move freely. During an interview with the DON (Director of Nursing) and the Regional Director of Quality and Compliance on 1/26/26 at 3:49 pm, the Regional Director of Quality and Compliance confirmed that anti-rollback devices should engage when the person removes their weight by standing up prohibiting the chair from moving. The DON stated that the anti-rollback device had already been installed on Resident #25's wheelchair prior to the fall on 1/25/26, but it had been added to the care plan when she noted it was already on the wheelchair. She also stated that the devices are installed by their maintenance department after a work order is initiated. During the interview with the DON, Resident #25's wheelchair was observed by the DON who confirmed that the anti-rollbacks did not engage when the empty wheelchair was pulled backwards. The DON also confirmed that the left standard break was loose and did not engage correctly, allowing the wheelchair to move when the left break appeared to be locked. Per observation of the unit on 1/27/2026 at 8:51 AM Resident #25 was seen self-propelling into her/his room. The Resident stood from her/his wheelchair and self-transferred onto the unmade bed. There was an overbed table with the table-top positioned across the bed between the head and foot of the bed, impeding the Resident from putting their legs up on the bed. While lying on the bed, the Resident raised her/his legs and put them on top of the over-bed table. The Resident then took their legs off the over-bed table and brought themself to a sitting position on the window side of the bed and attempting to move the over-bed table out of their way. S/he stood up from the bed and tried to move the over-bed table without success. Resident #25 then lay down on their back positioned with their knees bent up on the top half of the bed. At 8:59 AM staff were unaware that the Resident had self-transferred into bed. At 9:00 AM the Resident was moving about in bed shifting around to move the over-bed table. At 9:01 AM an LNA entered the room with linens and closed the door. Per interview on 1/27/2026 at approximately 2:00 PM the DON stated that Resident #25 was being placed on 1-1 staff supervision for safety. Per interview on 1/28/26 at 8:41 am with the facility Director of Maintenance, when discussing the facilities preventative maintenance (PM) program he stated that wheelchairs are not inspected as part of their PM program. He stated that when a Resident requires anti-rollback devices to be installed, nurses complete a work order. The Director of Maintenance confirmed that on 1/27/2026 when he inspected Resident #25's anti-rollback device, they found that it was not working correctly. He stated that when the devices are installed, they are tested. If nursing staff or therapy add a cushion to the wheelchair, it changes the spring tension on the anti-rollback device making it ineffective. The wheelchair should be returned to maintenance for installation of a different spring and re-testing. He stated that they inspected 21 wheelchairs in the facility on the prior day (1/27/26) and found 2 or 3 more with the same issue. The Director of Maintenance stated he had not inspected or repaired the loose ineffective left standard brake on Resident #25's wheelchair as he had not been told to do so. Per observation with the Director of Nursing on 1/28/26 at 12:46 pm, she confirmed that the left standard brake on Resident #25's wheelchair was still not operating correctly. 2. Per observation on 1/26/26 at 2:52 pm, there was a carpeted/rubber entry style mat seen between Resident #25's bed and window. The mat was placed in a way that one corner of it was lifted several inches on the corner of the bed, creating a trip hazard. When the mat was lifted, it was revealed that the flooring was damaged with a large portion of flooring missing. Per interview with the DON on 1/26/26 at 3:49 pm, when asked if there were any repairs planned for Resident #25's room she was aware of the mat and the damaged flooring in Resident #25's room she stated that the plan was to move Resident #25 out of the room with the damaged floor but that right now, the highly visible room is safer. During the interview the mat was observed with the corner still lifted on the corner of the bed and she confirmed that it should not be. Per interview on 1/27/2026 at 2:10 PM the facility Administrator stated that he had not been aware of the damaged flooring. He confirmed that there should not be a mat over the damaged flooring and that it should have been fixed when it occurred. Per an interview on 1/28/26 at 8:41 am with the facility Director of Maintenance, he became aware of the damaged floor in June 2025. There had been a plan to purchase the flooring, and a maintenance director from another one of their facilities would come and show them how to install the new floor. The Director of Maintenance stated there was communication back and forth for 5 to 6 weeks and it never happened. 3. Per record review Resident #71 has a BIMS [Brief Interview of Mental Status] score of 13 as of 11/5/25, indicating they have little cognitive impairment. Resident #71 has major medical diagnoses of hemiplegia (paralysis that affects one side of the body), nicotine dependence, and MDD [Major depressive Disorder]. S/he is independent with ADLs [Activities of Daily Living] and hygiene. Per record review, Resident #71 is a cigarette smoker. Resident #71's care plan states, [Resident #71] may smoke independently per smoking evaluation. Goal: [Resident #71] will smoke safely per smoking assessment through the next review. Lighters, lighter fluid or matches must be maintained by center staff. An interview was conducted with Resident #71 on 1/28/26 at 12:10 PM. Resident #71 stated s/he keeps his/her cigarettes and lighter in his/her room. The resident was observed coming back into the facility after smoking and returning to his/her room without handing his/her cigarettes or lighter to a staff member on the unit. Per record review of the facility's Smoking Policy-Residents policy [last revised 3/21/16] states, Residents who have independent smoking privileges shall not be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession. Resident smoking paraphernalia will be maintained in a locked area in the smoking cart to be distributed to the smoking monitors as per the smoking schedule. Residents will have limited access to smoking materials except as per policy and smoking schedule. Per observation of Resident #71's room on 1/27/26 at approximately 12:50 PM there was a used cigarette on the resident's bedside table. RN [Registered Nurse] #1 confirmed that the cigarette should not be in the resident's room. An interview was conducted with the Unit Manager on 1/27/26 at 12:46 PM. She stated the resident's cigarettes were kept in the medication room; and confirmed that the cigarettes were missing from the medication room.

Based on interview and record review the facility failed to ensure that Medication Regimen Reviews were performed by the Consulting Pharmacist and acted on for one of five sampled residents (Resident #49). Findings include:1.Per record review, Resident #49 did not have MRRs (Medication Regimen Reviews, a review of the resident's medications with recommendations from the pharmacist) for January 2025, February 2025, March 2025, and May 2025.Per review of Pharmacy Consultant Policy & Procedure policy [no revised or reviewed date] states, The pharmacist will report any irregularities to the attending physician and the Director of Nursing, and these reports must be acted upon. The attending physicians are not required to agree with the pharmacist's report, nor are they required to provide a rationale for their acceptance or rejection of the report. They must, however, act upon the report. This may be accomplished by indicating acceptance or rejection of the report and signing their name. Additionally, it states The pharmacy consultant will do a monthly review of the medication administration record to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each individual resident. Per interview on 1/27/26 at 12:30pm, The Director of Nursing confirmed that there was no evidence that MRRs for the months of January, February, March, and May of 2025 had been conducted.

Based on interview and record review the facility failed to ensure that a resident was provided informed consent for 1 of 5 residents (Resident #43). Findings include:Per record review, Resident #43 has a BIMS [Brief Interview of Mental Status] score of 15 as of 1/15/26, indicating they had no cognitive impairment. Resident #43 has major diagnoses of Type II Diabetes and a BKA [Below the knee amputation]. They are independent with ADLs [Activities of Daily Living] and hygiene. Per record review of Resident #43's MAR [Medication Administration Record] contains an order stating, Venlafaxine HCl [a medication used to treat depression] ER [extended release] Oral Capsule Extended Release 24 Hour 75 MG [milligrams]: Give 75 mg [milligrams] by mouth one time a day. Per record review, the medication was written on 7/3/25 and was discontinued completely on 7/21/25. Per record review, a psychiatric note dated 7/2/25 at 9:19 AM states, MDD [Major Depressive Disorder], severe, recurrent-start Venlafaxine as above, also helps anxiety. Per record review of the facility's Psychotropic Medication Administration Disclosure form [no revision date] states, It is important that you are fully informed about psychotropic medications. If you have any questions regarding the information contained herein, please direct them to your attending physician or psychiatrist. An interview was conducted with Resident #43 on 1/25/26 at 5:49 PM. The resident discussed that they did not receive notice of being put on Venlafaxine, and did not sign a consent form for this medication. On 1/28/26 at 8:49 AM a second interview was conducted with Resident #43. S/he discussed that s/he noticed an extra pill in his/her pill cup during medication administration. S/he was told it was Venlafaxine. S/he stated s/he never signed a consent form and the physician did not speak to him/her about adding Effexor. S/he stated that the facility then removed it from his/her medication list and never spoke to him/her about the medication. Per record review, there was no documented evidence that the resident was provided informed consent An interview was conducted with the DON [Director of Nursing] on 1/27/26 at approximately 1:35 PM. The DON confirmed they did not have a psychotropic consent form for the resident for his/her Venlafaxine.

Based on interview and record review, the facility failed to ensure accurate advanced directive choices were indicated in the electronic medical record for 1 of 3 sampled residents (Resident #3). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey dated [DATE]. Findings include:Per record review of Resident # 3's COLST (Clinicians Orders for Life-Sustaining Treatment) form dated [DATE] revealed the resident chose to decline CPR (cardiopulmonary resuscitation) and desires DNR (do not resuscitate) status. Resident # 3's care plan initiated [DATE] and revised [DATE] stated Resident #3 is a full code indicating the resident would want CPR. A physician's order dated [DATE] reads full code. The EMR (electronic medical record) care profile for Resident #3 has a section for code status that reads full code. This does not match Resident #3's COLST.Per interview with RN Unit Manager of B wing on [DATE] at 2:33 PM stated that they use the residents care profile to identify code status. The unit manager confirmed that the care profile, physician order and care plan did not match Resident #3's COLST form in the EMR.Per interview on [DATE] at 10:40 AM LPN on B wing stated they use the residents care profile to obtain and confirm a resident's code status.Per interview on [DATE] at 10:48 AM with Director of Nursing (DON) confirmed that a resident's code status in the care plan, physician orders, and care profile should match their current COLST form in the EMR.

Based on interview and record review the facility failed to provide notice of bed hold to 1 of 1 residents in the sample (Resident #22). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 5/28/25. Findings include: Per record review a nursing progress note dated 6/15/25 reflects that Resident #22 was sent to the hospital emergency department during an emergent medical event. Per record review there was no bed hold notice in the resident's chart. There was no documented evidence showing the Long-Term Care Ombudsman was notified of the hospitalization. Per review of the facility's Bed Holds and Returns policy [no revision date] states, In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed hold policies to the resident and/or the resident representative as soon as practicable.The facility will keep a copy of the bed hold notice information given to the resident and/or resident representative in the medical records. The facility's policy did not include information related to informing the LTC ombudsman of transfers and discharges. On 1/27/26 at 11:58 AM the social worker confirmed that she could not find a bed-hold on computer or hard copy. On 1/27/26 at 3:00 PM the DON [Director of Nursing] and social worker confirmed the Ombudsman was not notified and that there was no bed-hold.

Based on observations and interviews the facility failed to ensure that drugs and biologicals used in the facility are within their expiration date and failed to secure medications for 1 of 2 medication treatment carts. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated [DATE]. Findings include:1. Per observation on [DATE] at 10:14AM Unit B's medication room contained five covid-19 vaccinations with an expiration date of [DATE] in the freezer. Review of a policy titled Storage of Medications states: Unused medications: The pharmacy and all medication rooms are inspected by the pharmacist consultant for discontinued, outdated, defective or deteriorated medications. Per interview on [DATE] at approximately 10:30 AM the Registered Nurse (RN) Unit Manager of B wing confirmed the items were ready for use and expired. 2. Per observation on [DATE] at 3:52 PM, the medication treatment cart was observed to be unlocked at the nursing station. There were two residents at the nursing station, one who self-propels via wheelchair, and one who walked with a rolling walker. At 4:02 PM, nursing staff left the nursing station, no staff were observed interacting with the medication treatment cart. The medications observed in the medication treatment cart with a Licensed Practical Nurse (LPN) included a wound wash, nystatin, and medicated hemorrhoid cream. Per interview on [DATE] at 4:08 PM, a Licensed Practical Nurse (LPN) confirmed that there were medications in the treatment cart and stated that the medication treatment cart should be locked and then locked the medication treatment cart. Per review of the facility policy titled Storage of Medications policy [no revised or reviewed date] states, All drugs and biologicals will be stored in locked compartments.Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Per review of the facility policy titled Administering Medications [no revised or reviewed date] states, During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aid.

Based on observation and interview, the facility failed to ensure proper infection prevention measures of hand hygiene were performed during medication administration for one of four residents in the applicable sample (Resident #24). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 4/25/25. Findings include:Per observation on 1/27/26 at 8:37 AM of medication administration the Licensed Practical Nurse (LPN) did not perform hand hygiene before or after administering Resident # 24 their medications. The LPN returned to her cart and proceeded with medication administration with non-washed hands. Per interview on 1/27/26 at approximately 8:45 AM, the LPN confirmed that she did not perform hand hygiene before or after medication administration.Per record review of the facility's Administering Oral Medications policy [no revised date] states: Wash your hands. prior to administration, and Perform hand antisepsis. after administration.

Based on document review and interview, it was determined that the facility failed to ensure the Medical Director duties per the Medical Director Agreement and Medical Director facility policy were performed, including ensuring resident care policies were implemented and coordination of care was provided to ensure resident care and services were provided to all resident that were consistent with current professional standards of practice for 2 of 2 units. On 7/18/25 the facility was notified of non-compliance at the immediate jeopardy (IJ) level for Medical Director. This is a repeat deficiency for this facility, with the violation cited during the previous complaint survey, dated 4/8/25. On 7/23/25 the facility's IJ plan of correction was accepted. An unannounced onsite assessment of the IJ removal was conducted on 7/24/25 and the IJ was confirmed to be removed as of 7/23/25. Findings include:Review of a document titled, MEDICAL DIRECTOR AGREEMENT, signed by the Sr (senior) Director of Human Resources on 6/17/2025 and signed by the new Medical Director on 6/16/2025. Within this document, titled, SCHEDULE A, states the Medical Director Services are as follows: * Performance of administrative tasks consisting of the establishment, maintenance, and updating of medical care policies * Participation in the quality assurance program of the Company in a manner that seeks to ensure the consistency and quality of medical services provided by the technical and professional personnel of the Company, including making recommendations regarding the competency of the licensed professionals employed by and/or under contract with the Company * Ensuring that each resident's responsible physician attends to the residents' medical needs, participates in care planning, and follows the Company's policies and procedures * Attendance at committee meetings as liaison / resource person as appropriate and reasonably required * Periodic review and development of medical care policies and procedures as required to ensure compliance with Federal, State, and local laws, rules, and regulations governing the performance of medical services provided by the Company * Supervision of high-level quality of care delivered to residents, with supervision exercised over medical, dental, nursing, pharmaceutical, dietary, and rehabilitative services * Maintenance of a health and accident surveillance program for residents, including reviews and evaluation of incident reports or summaries of incident reports, identifying hazards to health and safety [and making recommendations to the commissioner] * Provision of advisory services and consultations for medical and nursing staff * Performance of all necessary general administrative tasks including assigning medical duties and scheduling, and communication of this information to appropriate staff * Assistance in the resolution of resident, family, and staff concerns as they relate to medical care services provided by the Company * Assistance in planning and providing medically related in-service programs * Participation in policy decision-making and direct supervision regarding quality of care and delivery of medical services to residents * Taking necessary action and corrective measures when a physician fails to provide services, which meet generally accepted standards of practice, including referring to the appropriate regulatory agency * Ensuring that the delegation of physician tasks to non-physician providers complies with Federal, State, and local laws and the Company's policies and procedures * Communication of medical staff responsibilities and medical care policies, procedures, and guidelines to all providers involved in resident care; responsible for written rules and regulations for all providers involved in resident care Review of the Medical Director job description states that the Medical Director is Board Certified as an MD or DO who provides the following functions in a facility: * Clinical Oversight * Staff Supervision * Policy and Procedure Development * Program Development and Planning * Quality Improvement * Community Engagement 1.) A complaint investigation revealed that Resident #1, admitted to the facility on [DATE] with a diagnosis of insulin dependent diabetes, did not have admission orders for insulin or blood sugar checks as indicated in their discharge orders and did not have a care plan for diabetes management (baseline or comprehensive) until 5/28/25. There is no evidence that Resident #1 had any insulin during their stay at the facility and no evidence that his/her blood sugars checked until 5/31/25, when it was asked to be done by their representative due to the significant decline in Resident #1’s status. See F655 and F656 for more information. Per offsite phone interview on 7/18/25 at 12:30 PM with the Medical Director, he stated they started in this role on 6/9/2025. They were aware that there was a contract for Medical Director and confirmed they had signed it. The following was revealed during this interview: A. Development, revision, and implementation of facility policies and procedures When asked about the role in the development, and revision of facility policy and procedures, they stated that they had not yet reviewed any of the facility policy and procedures. The Medical Director stated they were not aware of this document until 2 days ago when he was asked by the survey team if he had reviewed the document. The Medical Director was asked if s/he was aware of a policy or procedure specific to the care for residents with the diagnosis of diabetes. He stated that insulin is a dangerous medication and is over utilized. He stated that he plans to wean residents off insulin and if the resident is on a low dose of insulin, he would just discontinue it. He confirmed he had not reviewed the current facility policy and procedure for diabetes. He stated he would be creating a new policy and procedure to reflect the process of discontinuing sliding scale insulin and weaning residents off insulin. He confirmed that they would discontinue insulin for residents currently receiving low doses. B. Coordination of care The Medical Director was asked if he was aware of telehealth services being utilized in this building and how the services were being provided, he stated, Yes, telehealth services are being used in this building just for putting out fires. When asked who the telehealth providers were and which ones he had met or introduced themselves to, he stated, If you could name them, I can tell you which ones I've met or contacted to introduce myself to. The Medical Director was able to name two of the current providers and stated he had met with them to discuss residents at this facility. The Medical Director was asked how many residents medical records he has reviewed or discussed with the providers; he was able to name one resident. The Medical Director was asked which residents’ medical records he had reviewed he provided one resident name. The Medical Director was asked how he was coordinating care with their providers. He stated they look at the QAPI (Quality Assurance Performance Improvement) pieces, looking at psychotropic medications and he will be meeting with the providers quarterly to talk about regulatory changes, and address any issues that arise. The Medical Director stated that the QAPI meeting was scheduled for “this week but you people came in and we had to change it”. Per interview with the Administrator on 7/18/25 at approximately 4 PM, when asked about the QAPI meeting that was scheduled for “this week”, s/he stated, “oh we hadn’t scheduled one yet.” C. Medical Director oversight of other health care providers and facility staff The Medical Director was asked if he was aware of the 30 laboratory orders from 6/30/25 that had not yet been drawn, he stated that he had not been made aware of this issue until two days ago when he had attended a meeting with the surveyors and the previous DON (Director of Nurses) revealed this information. The Medical Director was asked at this time if he would consider this an acceptable practice or good resident care, he stated, this is not acceptable, and physician orders are to be carried out as ordered and in a timely manner. See F770 and F773 for more information. D. Participation in QAPI Issues were identified at an immediate jeopardy level related to not having an effective QAPI program. Multiple repeat deficiencies were identified during this survey. During a complaint survey on 11/19/24 the facility was cited for a deficiencies related to comprehensive care plans (F656) and abuse (F600), During a recertification survey dated 12/11/24, the facility was cited for deficiencies related to accidents, hazards, and supervision (F689), sufficient nursing staff (F725), notifying the ordering provider of laboratory results (F773), and state staffing requirements (S320). During a complaint survey dated 3/28/25 the facility was cited at a harm level for a deficiency related to accidents, hazards, and supervision (F689). During a complaint survey dated 4/9/25 the facility was cited at a widespread level for a deficiency related to the Medical Director (F841). During a complaint survey dated 5/28/25 the facility was cited at an immediate jeopardy level for a deficiency related to neglect (F600). See F865 for more information. The Medical Director was asked what role they performed in the QAPI Program. The Medical Director stated they would be attending the monthly meetings. The Medical Director was asked how they are involved in issues that arise related to coordination of care and implementation of resident care policies that are identified in QAPI or the QAA (Quality Assessment and Assurance) process. The Medical Director stated, I will address issues as they come up. The Medical Director was asked how they will use these meetings to ensure the best care is provided to the residents. He stated they will be reviewing the CASPER reports and previous meeting minutes. The Medical Director was asked if they have reviewed the current CASPER report or any of the facility's previous QAPI meeting minutes, he stated, no, I have not. The Medical Director was asked if they were aware of the facility's current outstanding citations and they stated, No, I am not. The Medical Director was asked if they had attended a QAPI meeting since starting in the medical director role, they stated that the QAPI meeting was scheduled for “this week but you people came in and we had to change it.” E. Sufficient staffing and timely medication administration Issues were identified with not having sufficient staff to provide resident care and services, including administering medications on time. See F725 and F760 for more information. The Medical Director was asked if he was aware that over the last few months there were many days when staffing levels fell below the federal and state regulations, he stated they were not aware of this issue until 2 days ago when s/he was part of a meeting and the previous DON confirmed this issue. The Medical Director was asked if they were aware of the magnitude of the resident's late medications report for the past 90 days (6,017 pages), and/or the resident missed medication report for the last 60 days (2,177 pages), he stated they were not aware of the extent of the medication issues in this building. F. Assisting in the development of educational programs for facility staff The Medical Director was asked how they assist in the developing, updating, and revision of educational trainings for the facility staff or other health care providers working in the facility. The Medical Director stated they have not participated or developed any of the staff trainings since assuming the role of Medical Director. G. Development, revision, and review of the Facility Assessment The Medical Director was asked to share their part in creating, updating, and/or revision the Facility Assessment tool (a comprehensive evaluation used to determine the resources, including staffing, equipment, and services, needed to provide competent care to residents). He was not aware of what this document was and had not reviewed this document since accepting the role of Medical Director in this facility. The Medical Director stated, I was not aware of what a Facility Assessment was until two days ago when we were discussing my role as the Medical Director. 2.) A complaint investigation revealed that Resident #6, admitted to the facility on [DATE], did not have admission orders for blood sugar checks as indicated in their discharge orders and did not have a care plan for diabetes management (baseline or comprehensive) until 5/28/25. There is no documented evidence that a provider reviewed Resident #6’s latest PCP (primary care physician) note dated 4/15/25, (which reveals that Resident #6 has well controlled diabetes using daily insulin), created a plan of care for the resident to manage their diabetes without insulin, or discussed this with the facility staff or other providers managing his/her care. Resident #6 was seen at the emergency room on 5/24/25, having acute hyperglycemia. See F655 and F711 for more information. Per phone interview on 6/20/25 at 11:22 AM, a Nurse Practitioner (Provider #2) was asked why Resident #6 did not have orders for insulin or blood sugar checks. He explained that he had not put in the admission orders. When asked how he knew that the admitting provider (previous Medical Director) had decided not to consider an order for insulin or perform blood sugars for Resident #6, he explained that he wasn’t aware as it wasn’t communicated in the visit note. Provider #2 had evaluated Resident #6 based on not having orders for insulin or diabetic medications. He stated that there is not enough collaboration with the care team, especially since residents are mostly receiving telehealth at the facility. When asked if he was aware that Resident #6 had just recently been on daily insulin prior to admission as indicated in the 4/15/25 PCP note he stated he was not sure that he saw that information but he hopes that if he did see it, he would have addressed it. Provider #6 was not aware that Resident #6 wasn’t getting blood sugar checks as indicated in the 4/30/25 TOC (transition of care). He explained that he is only in the facility every other week and needs to see 20 or more residents in a day and sometimes he does not get to review all the past medical documents. Provider #2 confirmed that Resident #6 should have had a baseline care plan for diabetes management. Per phone interview with the (previous) Medical Director on 6/23/25 at 1:19 PM, he explained that he decided to hold off on providing insulin and doing blood sugars for Resident #6 on admission. He explained that his plan was to hold on these orders for a month because insulin is a dangerous medication for this population (nursing home residents) and it would be more beneficial to manage symptoms. When asked how he communicated this with the facility and other providers, he explained that he doesn’t have a way to communicate with other providers properly and there is no place in the EHR (electronic health record) to communicate with other providers. When asked if this resident should have a plan of care related to diabetes management, he said yes and wasn’t aware that Resident #6 didn’t have a plan of care related to diabetes. When asked if the facility had a protocol related to diabetes management that reflected his clinical decisions, he confirmed that there was not as he was working on developing a new protocol. When asked how staff or other providers would know how Resident #6’s diabetes was to be managed, he explained that he talked to a nurse. However, there is no documented evidence that the Resident’s diabetes management had been discussed between any providers and nursing staff. 3.) Per interview on 7/18/25 at 10:04 AM, Provider #1 reveals that she is employed by a company contracted by the facility to provide medical staff. She has not collaborated with the Medical Director regarding resident care. A second interview with Provider # 2 on 7/18/25 at 10:39 AM reveals that he has been working in the facility since April. He does not regularly collaborate with the Medical Director regarding the care of the residents. He believes the current Medical Director is a Regional Medical Director who does not live in the state. When discussing the Medical Director, he referred to the previous Medical Director; was not aware that there was a new Medical Director. A third interview with Provider #4 on 7/18/25 at 2:00 PM revealed that he had been working in the facility on a day-by-day basis. He is scheduled to provide services regularly every other week. He spoke to the Medical Director for the first time in the morning of 7/18/2025. He has not collaborated with the Medical Director regarding resident care.

Based on record review and interview, the facility failed to protect the residents' right to be free from neglect by not providing goods and services to residents' that are necessary to avoid physical harm, pain, mental anguish or emotional distress by failing to develop and implement adequate systems to meet the care and service needs of residents.During the investigation the team identified many failures, some of which are widespread system failure, which included: providing adequate nursing staff to safely care for all residents;development of baseline care plans for newly admitted residents;development, revision, and implementation of comprehensive care plans to meet resident's needs;ensure all applicable residents have care plan interventions and supervision to prevent falls;administration of all ordered medications and treatments;ensure timely administration of all ordered medications and treatments;ensure ordered laboratory tests are performed timely and included in the residents' electronic health record (EHR);ensure ordered laboratory test results are reported to the ordering provider;ensure adequate treatment and prevention of pressure ulcers is provided to all applicable residents;ensure resident care is supervised by a physician;ensure all residents are receiving regulatory visits at the required intervals by the appropriate provider;provide 8 hours of consecutive RN coverage every day;ensure resident admitted or readmitted to the facility have admission orders to provide essential care to all residents;ensure the Medical Director is providing services per regulatory requirements;ensure the QAPI program is effective; and ensure the facility is adequately administered; ensuring all abuse and neglect allegations are reported to the Division of Licensing and Protection and Adult Protective Services in a timely manner; andensure the facility is administered in a manner that enables it to maintain the physical well-being of each resident.These failures put all residents at risk for serious harm and/or death. This is a repeat deficiency for this facility, with the violation cited during the previous complaint surveys dated 11/19/24, at a level D, and 5/28/25, at immediate jeopardy, level J. The facility was notified neglect at immediate jeopardy during this investigation on 7/18/25. The facility immediate Plan of Correction (POC) was accepted on 7/23/25 with a removal date of 7/23/25. Findings include:1.) A complaint investigation revealed that Resident #1, admitted to the facility on [DATE] with a diagnosis of insulin dependent diabetes, did not have admission orders for insulin or blood sugar checks as indicated in their discharge orders and did not have a care plan for diabetes management (baseline or comprehensive) until 5/28/25. There is no evidence that Resident #1 had any insulin during their stay at the facility and no evidence that his/her blood sugars were checked until 5/31/25, when it was asked to be done by their representative due to the significant decline in Resident #1's status, which lead the resident to be sent to the hospital. See F655 and F656 for more information. The complaint investigation also revealed that Resident #6, who was admitted to the facility on [DATE] with diagnoses that include diabetes, a right foot pressure ulcer, and a history of falls, did not have a baseline care plan or comprehensive care plan for diabetes management, fall prevention, or pressure ulcer prevention and treatment. Resident #6 also had laboratory service orders that were not preformed. As a result, the resident was sent to the Emergency Department to be treated for hyperglycemia, a stage two pressure ulcer of the right foot, and cellulitis of the right foot, which required antibiotics. This resident also suffered a fall at the facility. See F655, F656, F686, F689, F710, and F770 for more information.2.) During the investigation the team identified many widespread issues and system failures.a.) Laboratory services were not provided to Residents #2,# 3, #5, #6, and #7. A system issue was discovered that 30 laboratory orders had not been completed during the past 2 weeks. Also, providers were not being notified of results and lab results were not being entered into residents' medical records. These issues have the potential to impact all residents. See F770 and F773 for more information.b.) The Medical Director made clinical decisions to not manage Resident #1 and #6's diabetes with insulin and blood sugar monitoring based on a new protocol that he was implementing but had not been developed for facility staff to implement. Medical Director services were not being provided as per regulations regarding policy implementation, care coordination between all providers and the facility and have the potential to impact all residents. See F841 for more information.c.) Multiple issues were identified with medications not being administered or being administered late that have the potential to impact all residents. See F760 and F725 for more information.d.) Issues were identified related to insufficient nursing staff that have the potential to impact all residents. See F725 and F727 for more information.e.) Issues were identified related to the effectiveness of the QAPI program as evidenced by multiple repeat citations. The failure of the QAPI program has the potential to impact all residents. See F865 for more information.f.) Issues were identified related to the failure of the facility to be administered in a manner that enables it to maintain the physical well-being of each resident. The failure of administration has the potential to impact all residents See F835 for more information.g.) Issues were identified related to the development and revision of baseline and comprehensive care plans for Residents #1, #2, #3, #4, #5, #6, #8, #9, and #10. See F655, F656, and F657 for more information.h.) Issues were identified related to the failure to report allegations of abuse for Residents #12 and #13. See F609 for more information.i.) Issues were identified related to the facility's failure to ensure physician service were provided for Residents #6 and #8. See F710 and F712 for more information.

Based on the interview and record review, the facility failed to provide a sufficient number of Licensed Nursing Assistants (LNAs) and Registered Nurses (RN) for 8 consecutive hours a day to provide nursing services, considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. This is a repeat deficiency cited during a facility Recertification Survey on 12/11/24. Findings include:Per interview on 7/16/2025 at 12:19 PM, the Assistant Director of Nursing (ADON) revealed that she frequently works overtime to provide the facility with RN coverage. She is one of the two staff members who are trained to draw blood for labs. The facility has 30 outstanding labs that were ordered between 6/30/25 and 7/14/25 that have not been processed. She states she cannot keep up with them as there are not enough staff.Per record review, a Missed Medications Report between the dates of 5/17/25-7/17/25 revealed 2,177 pages of missed medications and treatments.Per review of the late medication report provided on 7/17/25, contained 6,017 pages of various late administered medications and treatments. Per interview on 7/18/25 at approximately 12:15 PM, the current DON, confirmed that the medications and treatments on the above noted late medication and treatment report were not administered per the prescriber's order or per the facility policy. Per interview on 7/18/25 at 2:51 PM, a Licensed Practical Nurse (LPN) revealed that she is a traveler, medication passes are late due to a lack of staff, and she encounters many interruptions to assist residents who need care.Per review of the facility's Hours Per Patient Day (PPD) report, the facility was below the minimum requirement staffing level to allow for 2.0 hours of direct care per resident per day on a weekly average by Licensed Nursing Assistants (LNAs) for 6 of the 10 sampled weeks. It failed to maintain required minimum staffing levels to allow 3.0 hours of direct care per resident per day (PPD) on a weekly average, including nursing, care, personal care, and restorative nursing care for 6 of 10 sampled weeks. See S321.Per the interview on 7/18/25 at 2:05 PM, the Administrator revealed she had requested more staff several times from corporate. She explained that the company has an internal agency staffing group that provides staff. She was told that the agency could not offer RN staff. The company will only procure staff from the internal agency.

Based on staff interviews and record reviews, the facility failed have a functioning system to obtain laboratory services which has the potential to impact all residents and failed to obtain laboratory services to meet the needs of its residents for 4 of 14 sampled residents (Residents # 3, #5, #6, and #7). Findings include:1.) Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, unstageable pressure ulcer to the right heel, and history of repeated falls. A transfer of care note (TOC) dated 4/30/25 reveals that Resident #6 had a fall on 4/24/25. A fall assessment included in the 4/30/25 TOC indicated that s/he is a fall risk, scored at 10 (a score of 4 or more is considered a risk for falling) based on 3 or more diagnosis, prior history of falls within 2 months, incontinence, visual impairment, impaired functional mobility, environmental hazards, poly pharmacy, pain affecting level of functioning, and cognitive impairment. The TOC reveals that Resident #6 “has Accu-Chek Glucometer and Freestyle Libre (both are used to monitor blood sugars).” Active medications list daily insulin on “hold” but does have an active order for a glucose sensor. The TOC refers to a Primary Care Provider (PCP) note being sent with this information. This PCP note, dated 4/15/25, included in Resident #6’s medical record at the time of admission to the facility, indicates that s/he has well controlled diabetes with the use of daily insulin and is seen by podiatry for his/her pressure ulcer. The PCP note [NAME] Resident #6’s last A1c value to be 8.2 on 1/22/25 (a blood test that reflects average blood sugar levels over the past two to three months). Per record review, a 5/2/25 Nurse Practitioner (NP; Provider #2) note stated Resident #6 “is at risk for falls, ambulates with the use of [his/her] walker. We will draw labs including vitamin D to see if there are any contributing factors.” An order was put in for laboratory services for “BMP, BNP, CBC, TSH, Vit D, A1C” but was never completed. Review of physician orders reveals that this order was struck out. Per an email dated 6/23/25, a Licensed Practical Nurse confirmed that the above lab order had been struck out because of incomplete documentation. A new order was put in for laboratory services for “BMP, BNP, CBC, TSH, Vit D, A1C” on 5/23/25 which revealed that Resident #6 had a blood glucose on 330 (range 74-106) in addition to multiple other test results to be found out of range. The lab results did not include a result for A1c values. Per an email dated 6/23/25, a Licensed Practical Nurse confirmed that these lab values were not in Resident #6’s medical record. She indicated that the A1c result from this date was 11.8 (The American Association of Clinical Endocrinologists (AACE) recommends initiating insulin for patients with an A1C over 8.0). A 5/24/25 telehealth Nurse Practitioner note reveals that Resident #6 was sent to the Emergency Department (ED) on 5/24/25 due to right leg edema from knee to toe. The ED Physician Visit note dated 5/24/25 reveals that Resident #6 has a stage 2 right foot ulcer, cellulitis of right foot requiring antibiotic treatment, and acute hyperglycemia. The note reads, “I noted that insulin was no longer on the patient’s MAR [Medication Administration Record]and [s/he] has not been receiving this. Fingerstick blood sugar 265 today. I am concerned that infection will worsen without tighter glucose control… I spoke with the NP on call at the [facility]. Discussed ED presentation course, She was surprised to hear insulin is not currently prescribed.” Per phone interview on 6/20/25 at 11:22 AM, the Nurse Practitioner (Provider #2) that ordered Resident #6’s labs on 5/2/25 stated he was not made aware that the labs ordered for Resident #6 on 5/2/25 had been struck out. He continued stating the labs would be valuable, including A1C values, which depending on the value, could change the medication management of diabetes for a resident. He has had problems with getting lab results from the facility. He explained that over the past two months, he has ordered around 250 labs and has only seen a few results. He explained that if lab results are not in the medical record, he has no way of knowing the results. He expressed that it is a big concern since lab work is necessary for this population (nursing home residents) and they deserve quality care. https://pmc.ncbi.nlm.nih.gov/articles/PMC6528396/#:~:text=The%20American%20Association%20of%20Clinical,the%20glycemic%20target%20(38). 2. Record review on 7/15/25, Resident #5 had a laboratory order that was entered on 6/30/2025 for the following labs: CBC (Complete Blood Count), CMP (comprehensive Metabolic panel that measures overall body function), a Lipid Profile (test that measures the overall cholesterol levels) and a TSH (blood test to measure how the thyroid is functioning). Interview on 7/16/2025 at 12:10 PM with the Assistant Director of Nursing (ADON), the labs ordered on 6/30/2025 for Resident #5 had not been drawn/collected. There were 30 outstanding lab orders between June 30, 2025, and July 15, 2025, that had not been processed. There was no documentation in the medical records that the provider was notified that these labs had not been drawn. 3. Record review on 7/15/25, Resident #7 had a laboratory order that was listed in their current orders and signed by the ordering prescriber on 2/14/25 that stated, CBC Lab draw monthly one time a day starting on the 1st and ending on the 3rd every month for resident is on clozapine with a start date of 2/14/2025 and was listed as an Active order. A new order was revealed during record review for a CBC law draw one day one dated 6/30/25 and there was no evidence in the resident's medical record that this had been drawn. Interview on 7/16/25 at approximately 12:12 PM with the ADON, for labs ordered on 6/30/25 for Resident #7 had not been drawn/collected and there were 30 outstanding lab orders between June 30, 2025, and July 15, 2025, that had not been processed. There was no documentation in the medical record that the provider had been notified that these labs had not been drawn. 4. Per record review, Resident #3 has diagnoses of disorder of the thyroid, hypertensive heart disease, and heart failure. Per the medical record, a lab order was entered on 6/30/2025 for the following labs: CBC ( Complete Blood Count), CMP ( comprehensive Metabolic panel), a screening blood test that measures overall body functions, a Lipid Profile ( a blood test that measures the overall cholesterol levels) and a TSH ( a blood test to measure how the thyroid is functioning). Per interview on 7/16/2025 at 12:10 PM with the Assistant Director of Nursing (ADON), the labs ordered on 6/30/2025 for Resident #3 had not been processed. There were 30 outstanding lab orders between June 30, 2025, and July 15, 2025, that had not been processed. There is no documentation in the medical records that the providers were made aware of the outstanding labs. She revealed that the facility staff’s responsibilities included performing venipunctures, obtaining and reviewing lab results, sending the results to providers, and following up on any interventions as determined by the providers. The facility has two staff members trained to perform venipunctures. She explained that there is one staff member with access to the hospital’s lab system. The facility has developed an internal system to track the outstanding labs. The same person has the only access to the system and is out of the building on vacation, leaving the facility without access to either program. Per interview on 7/18/20025 at 10:04 AM, Provider #1 revealed that she often has to “chase” lab results. She cannot locate the results in the medical record and notes that she frequently sees an outstanding order. She usually reorders them in a format that ensures they will be drawn that day. Per interview on 7/18/2025 at 10:39 AM, Provider #2 indicates the facility's system for obtaining labs is a multisystem failure. The facility does not have a system to ensure that labs are drawn promptly, results are obtained, provided to the provider, and entered into the medical records. He often reorders the same labs and submits his orders to be completed on that day to ensure they are done. He has to repeatedly call the facility to track down labs, discovering that the labs were never performed, results are not in the medical record, or the facility failed to notify him of the results. Per Facility Policy: “Lab and Diagnostic Test Results”, reviewed/revised 1/2024, “Nursing staff coordinate test processing, a nurse reviews all results, and all notifications are documented in the medical record…. The Director of Nursing (DON) or designee audits daily 24-hour reports for follow-up needs.” Per interview on 7/18/2025 at 10:02 AM with the DON and ADON, it was confirmed that the facility lacks a process to ensure they are meeting the needs of the residents by providing timely service, completing venipuncture, obtaining lab results, and ensuring the results are in the medical record. The facility does not have a policy that contains information about the timeliness of labs.

Based on interview and record review, the facility failed to ensure it used the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 18 days from 5/1/2025 to 7/13/2025. Findings include:A review of the facilities' staffing schedules from 5/1/25 to 7/13/25 revealed 8 days with no RN scheduled [6/21, 6/28, 6/29, 7/4, 7/5, 7/6, 7/12, 7/13] and 10 days [6/24, 6/30, 7/1, 7/2, 7/3, 7/7, 7/8, 7/9, 7/10, 7/11], where there were not 8 consecutive hours of RN services.Per interview with the Administrator on 7/17/2025 at 4:09 PM, where she confirmed that the facility did not have a Registered Nurse scheduled or present in the building for a minimum of 8 consecutive hours daily as required by regulation on the 18 days above.

Based on interview and record review, it was determined that the facility failed to ensure that residents were free from significant medication errors by not administering all medications as prescribed, and in a timely manner. This issue was determined to be widespread, potentially impacting all residents in the facility. Findings include: 1.Review of Resident #'1's diagnosis list revealed s/he had a diagnosis of diabetes mellitus. The Resident's hospital Discharge summary dated [DATE] revealed that the Resident was a long-term user of insulin and Insulin dependent diabetes mellitus: Status: Chronic. The hospital discharged the Resident to this facility with a medication list titled, Home Medication List that included insulin glargine [Lantus Solostar U-100 Insulin] 28 unit subcutaneous every morning. Last Taken: [DATE] 07:57 28 units. This Home Medication List consisted of 13 medications with dose and instructions/orders. Next to each medication was a check mark and on page #1 handwritten Entered PCC [Point Click Care] 5.10.25 1300 [nurse's signature]. Review of the Resident's MAR (medication administration record) for [DATE] revealed that the Resident had not been receiving insulin or finger sticks to check blood sugars. The residents list of current orders did not include the insulin order or an order to perform finger sticks to check the residents blood sugar levels. There were no orders in PCC for insulin administration for this resident or for finger sticks to monitor the residents blood glucose levels. During an interview on [DATE] at approximately 2:00 PM, with the nurse who signed their name to the Home Medication List stated she remembered entering these orders when she admitted the Resident to the unit at this facility. She confirmed she was the weekend Unit Manager.2. A request was made of the Director of Nursing (DON) on [DATE] at 3:59 PM via email for a 60-day report for missed medications and late medications. A 2,177-page missed medication report was received on [DATE] at 1:56 PM, this report also included missed treatments. Per review of the missed medication report, there were numerous missed medications. The missed medications would include the following:Gabapentin for painMetformin for diabetes managementXarelto an anticoagulantClozapine for schizophreniaClonazpam for anxietyAdvair Diskus for asthmaEliquis an anticoagulant (A-fib)Lisinopril for high blood pressureTopiramate for seizuresLevothyroxine for hypothyroidism (underactive thyroid)Lorazepam for anxietyRena - Vite a supplement for a resident on dialysisAmlodipine for high blood pressureZoloft for depression/moodOxycontin for chronic painLevetiracetam for seizuresProzac for depression/moodBreo-Ellipta for asthma or COPD (Chronic Obstructive Pulmonary Disease)Prazosin for high blood pressureDivalproex Sodium for anxietyDiazepam for anxietyDuloxetine for neuropathyOlanzapine for schizophreniaZiprasidone for bi-polar disorderCarbidopa - Levodopa for Parkinsons DiseaseApixaban an anticoagulantMetropolol Tartrate for high blood pressurePregabalin for neuropathyTizanidine for spasmsRopinerole for restless leg syndromeAlfuzosin for Benign Prostatic Hyperplasia (BPH)Oxycodone for painNovolog pen for the treatment of diabetes mellitus Included in this report were treatments and assessments that were not done and include:Wound care pain monitoringmonitoring for signs and symptoms of depressionmonitoring for effects of anti-coagulant useFluid intakeMonitoring vital signs Weekly weight checksMonitoring hemodialysis site for bleedingoxygen saturation and pulse monitoringapplication of oxygen at the right amountnight time snack offering and acceptancediabetic foot checks/monitoringWanderguard checks to ensure they are in place, have not expired, and are functioning appropriatelyApplication/removal of TED stocking (compression hose/stockings)Offloading of heels, bottom and other bony prominencesPer review of the facility policy and procedure titled, ADMINISTERING MEDICATIONS under the heading of Policy Interpretation and Implementation .3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Per interview on [DATE] at approximately 12:15 PM, the current DON (Director of Nursing), confirmed that the medications and treatments on the above noted report were not administered per the prescriber's order and per the facility policy. Per review of the late medication report provided on [DATE], contained 6,017 pages of various late administered medications and treatments. Per interview on [DATE] at approximately 12:15 PM, the current DON, confirmed that the medications and treatments on the above noted late medication and treatment report were not administered per the prescriber's order or per the facility policy. Per interview on [DATE] at approximately 12:30 PM, the Medical Director stated, they were not aware of the magnitude of the late and missed medications and treatments. He confirmed that nursing staff should be notifying the prescriber's when medications and/or treatments are not administered as ordered.

Based on record review and interview of the facility's Quality Assurance and Performance Improvement Program (QAPI), the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement in the areas of treatment/services specific to meeting required regulatory visits; appropriate staffing levels: ensuring there was an RN in the building for 8 consecutive hours 7 days/week; residents care supervised by a physician to include required regulatory visits; laboratory orders were performed timely; neglect (cited at immediate jeopardy level); administration; and Medical Director (cited at immediate jeopardy level). The identified failure to have an effective Quality Assurance and Performance Improvement Program to identify problems and provide system oversight has the potential put all residents at risk for more than minimal harm. Findings include:During a complaint investigation with 3 complaints the facility was found to have deficient practices that resulted in 2 citations at immediate jeopardy level and 15 deficient practices with potential for more than minimal harm. Multiple repeat deficiencies were identified during this survey. During a complaint survey on 11/19/24 the facility was cited for a deficiencies related to comprehensive care plans (F656) and abuse (F600), During a recertification survey dated 12/11/24, the facility was cited for deficiencies related to accidents, hazards, and supervision (F689), sufficient nursing staff (F725), notifying the ordering provider of laboratory results (F773), and state staffing requirements (S320). During a complaint survey dated 3/28/25 the facility was cited at a harm level for a deficiency related to accidents, hazards, and supervision (F689). During a complaint survey dated 4/9/25 the facility was cited at a widespread level for a deficiency related to the Medical Director (F841). During a complaint survey dated 5/28/25 the facility was cited at an immediate jeopardy level for a deficiency related to neglect (F600).The facility's plans of correction for all repeat deficiencies above identified that either the nursing leadership team (Director of Nursing/Assistant Director of Nursing) and/or the Administrator were responsible for both auditing to ensure that regulatory requirements were met and reporting the audit results to the Quality Assurance Committee.Also refer to F841 regarding failure to provide administrative oversight to the Medical Director. Per review of facility's QAPI plan, page 2 states, Vision: We aim to be a regional leader in the advancement of long-term and subacute care by integrating excellent resident care, quality professional development, and substantive engagement with residents, families, staff, providers, and partners on the care continuum. Mission: It is our sacred responsibility - our daily opportunity - to provide better care than we did the day before in a manner that is fresh, new, even revolutionary. Purpose: With QAPI as our guiding principle, our facility has a Performance Improvement Program which systematically monitors, analyzes, and improves its performance to improve resident/patient outcomes. Key issues will be addressed on an ongoing basis to improve overall outcomes in the following areas including but not limited to: i. Clinical Care - QI/QM results, internal monitors for falls medication errors, pressure ulcers, incidents/accidents, infections, rehospitalizations, significant weight loss. ii. Quality of Life (QOL)---resident/family satisfaction surveys, resident/family concerns brought up at Resident Council meetings, concerns from care conferences and individual rounding with residents and family members.iii. Resident Choice---Individualized goals for care are addressed at care conferences, resident satisfaction with dining, resident engagement in recreation opportunities. iv. Organizational management practices: staffing admissions, discharges, resident funds, in house transfers, medical records and privacy etc. Per interview on 7/16/25 at approximately 3:00 PM, the Medical Director stated that they had not yet participated in a QAPI meeting and confirmed that they had not reviewed the previous months QAPI meeting minutes or agenda. The Medical Director was asked what his role will be in the QAPI meetings, and they stated they would review the CASPER reports, previous meeting minutes, outstanding projects, and they would be attending the monthly meetings. They had not reviewed the facility's previous 2567's (statement of deficiency reports) to include the facility's plans of correction from the last 4 surveys or the current outstanding citations. The Medical Director confirmed that they lived in the state of Florida and would be attending the monthly QAPI meetings via an internet-based audio-visual program. Per interview on 7/17/25 at approximately 5:30 PM, that Administrator confirmed the QAPI team has been working on staffing, staff education, resident rights, and abuse prevention. See F600, F609, F655, F657, F686, F689, F711, F712, F725, F727, F760, F770, F773, F835, and F841 for more information.

Based on observation, interview, and record review, it was determined that 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 deficiencies that resulted in immediate jeopardy (F600 and F841). In addition, there are several repeat deficiencies. The identified failures by the lack of administrative oversight for a large amount of regulatory requirements in multiple areas of compliance put all residents at risk for more than minimal harm. Findings include:1.Interviews with the Medical Director; past and present, VP of Clinical Services, Administrator, and facility staff reveal that Resident #1 did not receive quality care and services specific to their long-standing diagnosis of Diabetes Mellitus, and they did not receive insulin although they had been a chronic user of insulin per their hospital discharge summary, ED (Emergency Department) notes/documentation, and interview with the Resident's son. See F655 for additional information The facility failed to ensure it used the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 18 days from 5/1/2025 to 7/13/2025. See F727 for additional information The facility provided report of missed medications from 5/17/25 to 7/17/25 which revealed a 2177-page report, and a late medications and treatment reports for May 2025 through July 17, 2025, consisting of a combined total of 6,017 pages. See F760 for additional information There were 30 outstanding lab orders between June 30, 2025, and July 15, 2025, that had not been processed. There was no documentation in the medical records that the provider was notified that these labs had not been drawn. See F770 and F773 for additional information An onsite complaint investigation was conducted on 6/3/25 - 6/4/25 and an extended survey conducted on 7/15/25 - 7/24/25, the survey team identified and notified the facility of deficiencies at the immediate jeopardy level for violations around F600 related to neglect, F835 related to Administration, F841 related to medical director, and F865 related to QAPI. On 7/24/25 a revisit was mad to the facility and the IJ's were removed for the above 4 deficiencies. Multiple repeat deficiencies were identified during this survey. During a complaint survey on 11/19/24 the facility was cited for a deficiencies related to comprehensive care plans (F656) and abuse (F600), During a recertification survey dated 12/11/24, the facility was cited for deficiencies related to accidents, hazards, and supervision (F689), sufficient nursing staff (F725), notifying the ordering provider of laboratory results (F773), and state staffing requirements (S320). During a complaint survey dated 3/28/25 the facility was cited at a harm level for a deficiency related to accidents, hazards, and supervision (F689). During a complaint survey dated 4/9/25 the facility was cited at a widespread level for a deficiency related to the Medical Director (F841). During a complaint survey dated 5/28/25 the facility was cited at an immediate jeopardy level for a deficiency related to neglect (F600). See F865 for more information. The facility's plans of correction for all repeat deficiencies above identified that either the nursing leadership team (Director of Nursing/Assistant Director of Nursing) and/or the Administrator were responsible for both auditing to ensure that regulatory requirements were met and reporting the audit results to the Quality Assurance Committee. Also refer to F841 regarding failure to provide administrative oversight to the Medical Director. Per interview on 7/16/25 at approximately 3 PM, the previous Director of Nursing (DON) was asked by the survey team if they felt they had enough nursing staff to meet the needs of the residents. She stated she had been working every day to help cover the units, but they were still short staffed. She stated that she would often be working a medication cart and not able to perform their job duties as the DON. She explained that she was a fairly new nurse when they were put into the role of DON. She stated that she did not want to be in this role but was told she was the only one qualified to fill this role. She confirmed that the facility was experiencing some significant nursing shortages, and it had been impacting the care of the residents. Per interview on 7/24/25 at approximately 2:45 PM, the Administrator explained that she was aware that there were some significant nursing shortages and it was impacting the care of the residents. 2. During offsite review of the initial complaint, additional information was requested from the facility on 6/20/25. There was no one available to answer questions or provide information to the surveyor regarding Resident #6's care history. The Director or Nursing and Administrator were not at the facility and were unavailable. The [NAME] President of Operations was available for a phone interview on 6/20/25 at 3:22 PM but was unable to verify medical records during the interview and was unable to answer clinical questions. She confirmed that there would be no one else to answer clinical questions that day and responses to the questions were not received until 6/23/25.

Based on interview and record review, the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care that includes communication, behavioral symptoms, psychotropic medication drug use, activities, dental care, pressure ulcers, falls, and diabetic care needs for 6 of 14 residents in the sample (Residents #1, #2, #3, #4, #6, and #8). Findings include: 1.) Per record review, Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes with diabetic neuropathy, unstageable pressure ulcer to the right heel, and history of repeated falls. A transfer of care note (TOC) dated 4/30/25 reveals that Resident #6 had a fall on 4/24/25. A fall assessment included in the 4/30/25 TOC indicated that s/he is a fall risk, scored at 10 (a score of 4 or more is considered a risk for falling) based on 3 or more diagnosis, prior history of falls within 2 months, incontinence, visual impairment, impaired functional mobility, environmental hazards, poly pharmacy, pain affecting level of functioning, and cognitive impairment. The TOC reveals that Resident #6 “has Accu-Chek Glucometer and Freestyle Libre (both are used to monitor blood sugars).” Active medications list daily insulin on “hold” but does have an active order for a glucose sensor. The TOC refers to a Primary Care Provider (PCP) note being sent with this information. This PCP note, dated 4/15/25, included in Resident #6’s medical record at the time of admission to the facility, indicates that s/he has well controlled diabetes with the use of daily insulin and is seen by podiatry for his/her pressure ulcer. Per record review, Resident #6’s baseline care plan does not include being at risk for falls, diabetes management, or skin management. Per record review, a Physician Progress note dated 5/1/25, completed by the (previous) Medical Director, indicated that Resident #6 has a diagnosis of diabetes. The progress note revealed under Assessment/Plan to “continue current care” for diabetes. There is other description in the note or in Resident #6’s medical record, including their care plan, for what “current care” for diabetes is for staff to follow. Per phone interview on 6/20/25 at 11:22 AM, a Nurse Practitioner (Provider #2) confirmed that Resident #6 should have had a baseline care plan for pressure ulcers, falls, and diabetes on admission. Per phone interview with the (previous) Medical Director on 6/23/25 at 1:19 PM, he explained that he decided to hold off on providing insulin and doing blood sugars for Resident #6 on admission. He explained that his plan was to hold on these orders for a month because insulin is a dangerous medication for this population (nursing home residents) and it would be more beneficial to manage symptoms. When asked how he communicated this with the facility and other providers, he explained that he doesn’t have a way to communicate with other providers properly and there is no place in the Electronic Health Record (EHR) to communicate with providers. When asked if this resident should have a plan of care related to diabetes management, he said yes and wasn’t aware that Resident #6 didn’t have a plan of care related to diabetes. When asked if the facility had a protocol related to diabetes management that reflected his clinical decisions, he confirmed that there was not as he was working on developing a new protocol. When asked how staff or other providers would know how Resident #6’s diabetes was to be managed, he explained that he talked to a nurse. Per phone interview on 6/20/25 at 11:22 AM, a Nurse Practitioner (Provider #2) was asked why Resident #6 did not have orders for insulin or blood sugar checks. He explained that he had not put in the admission orders. When asked how he knew that the (previous) Medical Director had decided not to consider an order for insulin or to perform blood sugars for Resident #6, he explained that he didn’t know this but had evaluated Resident #6 based on not having orders for insulin or diabetic medications. He stated that there is not enough collaboration with the care team, especially since residents are mostly receiving telehealth at the facility. When asked if he was aware that Resident #6 had just recently been on daily insulin (per the 4/15/25 PCP note in Resident #6’s medical record) and was not getting blood sugar checks as indicated in the 4/30/25 TOC (also in Resident #6’s medical record), he stated he was not sure that he saw that information. He explained that he is only in the facility every other week and needs to see 20 or more residents in a day and sometimes he does not get to review all the past medical documents. Provider #2 confirmed that Resident #6 should have had a baseline care plan for pressure ulcers, falls, and diabetes management on admission. A 5/24/25 telehealth Nurse Practitioner note reveals that Resident #6 was sent to the Emergency Department (ED) on 5/24/25 due to right leg edema from knee to toe. The ED Physician Visit note dated 5/24/25 reveals that Resident #6 has a stage 2 right foot ulcer, cellulitis of right foot requiring antibiotic treatment, and acute hyperglycemia. The note reads, “I noted that insulin was no longer on the patient’s MAR [Medication Administration Record]and [s/he] has not been receiving this. Fingerstick blood sugar 265 today. I am concerned that infection will worsen without tighter glucose control… I spoke with the NP on call at the [facility]. Discussed ED presentation course, She was surprised to hear insulin is not currently prescribed.” Record review also reveals in a 6/12/25 RMS (Risk Management System) report that Resident #6 suffered an unwitnessed fall on 6/12/25. At the time of the 5/24/25 ED event, Resident #6 still did not have a care plan for diabetes management or pressure ulcer prevention or treatment. At the time of the fall on 6/12/25 Resident #6 still did not have a care plan to prevent falls. 2. Per record review, Resident #1 was admitted to the facility on [DATE] after a fall at home resulting in hospitalization. Review of the resident’s hospital discharge information dated 5/10/25, page 1 under Diagnosis revealed…….“(6) Insulin dependent diabetes mellitus Status: Chronic.” Review of the resident's Baseline Care Plan revealed no care plan specific to the resident’s diagnosis of diabetes mellitus. Review of the resident's admission MDS (Minimum Date Set assessment, a standardized comprehensive evaluation of a resident’s functional status, health, and preferences in a nursing home. Used to develop care plans, track resident progress, and for Medicare and Medicaid reimbursement), ARD (assessment reference date, the date that the assessment was completed) of 5/15/25 under MDS section I0020 revealed the following diagnoses: Non-Traumatic Brain Dysfunction; Hypertension; Renal insufficiency, renal failure, ESRD (end stage renal disease); Diabetes mellitus (DM); Hyperlipidemia; Thyroid disorder; Other fracture; Seizure disorder; Traumatic brain injury (TBI); Malnutrition (protein, calorie), risk of malnutrit [sic]; Depression; BENIGN NEOPLASM OF MENINGES, UNSPECIFIED; RHABDOMYOLYSIS; UNSPECIFIED CONVULSIONS; NEOPLASM OF COLON, UNSPECIFIED; VITAMIN D DEFICIENCY, UNSPECIFIED; HYPOMAGNESEMIA; UNSP FRACTURE OF RIGHT TALUS, SUBS FOR FX W ROUTN HEAL; [NAME] SUBDR HEM WITH LOC STATUS UNKNOW, SUBS. Interview on 7/24/25 at approximately 1:45 PM, the DON (Director of Nurses) confirmed the Resident #1 had a diagnosis of diabetes mellitus and the facility did not care plan her/him for this diagnosis. 3. Per record review, Resident #8 was admitted to the facility on [DATE] after a recent hospital stay. Review of the residents’ MDS revealed the following areas in which the resident required additional assistance: Communication, Behavioral Symptoms, Activities, Dental Care, and Psychotropic Drug Use. Review of the MDS CAA (Care Area Assessment, used to determine if a triggered area requires interventions and care planning) revealed that the facility stated it would proceed to creating a care plan for the above noted areas, however, did not. Interview on 7/18/25 at 12:15 PM, the current Medical Director confirmed that baseline care plans are to be completed and implemented within 48 hours of a resident's admission to the facility. Interview on 7/18/25 at 12:30 PM, the DON (Director of Nurses confirmed that baseline care plans are to be completed and implemented within 48 hours of a resident's admission to the facility. Interview on 7/24/25 at approximately 1:45 PM, the DON (Director of Nurses) confirmed the facility documented they would care plan this resident for the above areas and had not. 4. Per record review, Resident # 2 was admitted to the facility on [DATE] for rehabilitation services following a below-knee amputation (BKA) with diagnoses that include poorly controlled diabetes, coronary artery disease, and necrotizing fasciitis (Infection of the soft tissue). Per review, Resident #2’s baseline care plan does not document the Resident’s admission goals until 7/11/25. There is no documentation related to Resident # 2’s transfers, eating, toileting, dressing, personal hygiene, bathing, or therapy goals. Per interview on 7/17/25 at 2:29 PM, the Director of Nursing (DON) confirmed that Resident #2’s baseline care plan was not developed and implemented within 48 hours, and it also lacked the necessary information to properly care for the residents. 5. Per record review, Resident #3 was admitted to the facility on [DATE] after hospitalization for a fall. The baseline care plan does not document activities of daily living (ADL) assistance that includes bed mobility, eating, toileting, dressing, personal hygiene, or bathing. It also does not address personal preferences that include choosing between a tub or shower, choosing a bedtime, including family in care, reading, and listening to music until 6/25/25. There was no care plan to address fall risks initiated until 6/30/25. Per interview on 7/17/25 at 2:29 PM, the Director of Nursing (DON) confirmed that Resident #2’s baseline care plan was not developed and implemented within 48 hours, and it also lacked the necessary information to properly care for the Resident. 6. Per record review, Resident # 4 was admitted to the facility on [DATE] with diagnoses that include a fracture of the right femur. Review of the care plan reveals that there are no ADLs documented, including bed mobility, eating, toileting, assistance for transfers and ambulation, personal hygiene, dressing, and bathing. Further review indicates there are no personal choice interventions that include personal belongings, choosing between a tub or shower, taking a nap, including family or friends in care, benefitting from cognitive limitations by using reminders, using adaptive material, or using glasses, until 6/26/25. Per interview on 7/17/25 at 2:29 PM, the Director of Nursing (DON) confirmed that Resident #2’s baseline care plan was not developed and implemented within 48 hours, and it also lacked the necessary information to properly care for the Resident.

Based on record review and interview it was determined that the facility failed to report 2 allegations of abuse of a resident to the State Survey Agency in a timely manner. Findings include:1. Per review of complaint #24087 regarding Resident #13, received on 5/29/25 from a provider who stated in their complaint that Resident #13 had alleged abuse by a facility staff member. The complaint also stated that the allegations of abuse were reported to the facility Director of Nursing (DON) on 5/28/25 by the provider over the phone. During an interview on 6/4/25 at approximately 1:00 PM the Director of Nursing confirmed that she had been contacted by the provider, however, was not provided with specific details and did not think she needed to report the allegation to the State agency. The facility Administrator filed a report on 6/4/25 after learning of this incident from the survey team. 2. Per record review, Resident #12's physician progress notes dated 6/21/25 revealed the resident had mentioned to the provider an allegation of staff to resident abuse where a CNA slapped (pronoun omitted) in the face.Interview on 7/23/25 1:10 PM with the Administrator who stated she had reported this allegation on 6/20/25 at 5:00 PM. Review of the state's complaint computer system revealed the report had not been received. Further review on 7/23/25 of the State's computer log of received complaints and facility reported incidents revealed the report had not been received. A call/interview to the State's Complaint Coordinator on 7/23/25 revealed the report had not been received. Interview on 7/24/25 at approximately 1:15 PM with the Administrator and a request for confirmation that this report was sent and received by the State's complaint unit revealed that there was no documented evidence to support this report had been received.

Based on interview and record review, the facility failed to ensure 1 [Resident #1] of 3 sampled residents received care and services according to accepted standards of clinical practice. Resident #1 suffered serious harm that rose to the immediate jeopardy level due to the facility's failure to provide care in accordance with professional standards, As a result, Resident #1 experienced symptoms related to very high, unsafe blood sugar and psychosocial harm. Findings include: According to the American Nurses Association: Scope and Standards of Practice (http://www.Nursingworld.org © 2010 American Nurses Association) The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The Standards of Professional Nursing Practice include: 1.) Recognizes the healthcare consumer as the authority on her or his own health by honoring their care preferences. An interview was conducted with Resident #1 on 5/14/25 at 9:37 AM. The resident stated s/he had h/her pancreas removed, and utilized a Dexcom device to monitor h/her blood sugar levels at all times. The resident raised the sleeve on h/her right arm to show a small white disk affixed to their upper arm. [the Dexcom is a wearable sensor sending real-time glucose readings automatically to a compatible smart device (such as an I-phone) or Dexcom receiver] (https://www.dexcom.com/get-started-cgm). Resident #1 demonstrated their present blood sugar reading on their I-phone, listed as 149. Resident #1 stated Last Friday my Dexcom read >400. It only goes up to 400. I told my nurse [Staff LPN] that my blood sugar was high. I don't have a pancreas. [Staff LPN] said 'you're only scheduled for blood sugar checks before meals. There are no checks after 5:00 PM.' This was at approximately 8:00 PM. The nurse said to 'go sleep it off.' I kept bugging her about 8 times to check my sugar. She got pissed, checked my sugar and it was the high 300's. I was mortified. I said I need to go to the Emergency Room. She said, 'Absolutely not.' 2.) Derives the diagnoses or issues from assessment data. - Uses standardized classification systems and clinical decision support tools, when available, in identifying diagnoses. - Initiates and interprets diagnostic tests and procedures relevant to the healthcare consumer's current status. Review of Resident #1's medical record reveals the resident has diagnoses that include: Diabetes mellitus [a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose in the blood and urine] due to a underlying condition with hyperglycemia [high blood sugar], a history of a pancreatectomy [surgical procedure involving the removal of the pancreas]- [Your pancreas makes hormones (like insulin) that help control the levels of sugar in your bloodstream. When your blood sugar is too high, your pancreas makes insulin to lower it. Your body needs balanced blood sugar to run properly] (https://my.clevelandclinic.org/health/body/21743-pancreas). Resident #1's medical history also includes hyperglycemic-hyperosmolar coma [a serious complication of diabetes characterized by extremely high blood sugar, significant dehydration, and altered mental state that can lead to coma. It's a life-threatening emergency]. According to the Mayo Clinic: It's important to treat High blood sugar, also called hyperglycemia. If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart. Hyperglycemia usually doesn't cause symptoms until blood sugar (glucose) levels are high - above 180 to 200 milligrams per deciliter (mg/dL When to see a doctor: Seek immediate help from your care provider or call 911 if: Your blood glucose levels stay above 240 milligrams per deciliter (mg/dL) (https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631) Per interview with Resident #1 on 5/14/25 at 9:37 AM, the resident stated after Staff LPN refused to call the physician, the resident spoke with [h/her] [Representative] on the phone and followed their instructions to call 911. Resident #1 reported So, I called the 911. [EMT #1 & #2] (Emergency Medical Technician- is a healthcare professional trained to provide basic emergency medical care) came and took me to the Emergency Department [ED]. They checked my blood sugar and it was 563. The resident reported at the time s/he was suffering from massive headaches, blurry vision, dots in my vision, nausea, and feeling mentally 'fuzzy'. Per interview with Resident #1's Representative on 5/14/25 at 2:59 PM, the representative reported on the phone call the resident was slurring [h/her] words, which the Representative reported s/he had witnessed in the past when the resident's blood sugars were extremely high. 3.) Modifies expected outcomes according to changes in the status of the healthcare consumer or evaluation of the situation. - Develops an individualized plan to provide direction to other members of the healthcare team. - Demonstrates caring behaviors toward healthcare consumers - Utilizes community resources and systems to implement the plan. An interview was conducted on 5/14/25 at 3:30 PM with the EMT #1 who responded to Resident #1's 911 call on 5/9/25. The EMT provided a written statement regarding what occurred between themselves and the Staff LPN and Resident #1, and during the interview confirmed the accuracy of h/her written account. Per review of the EMT #1's written statement: On May 9, 2025, I responded to an emergency call along with my assigned partner, [EMT #2]. At approximately 9:25 PM, we were dispatched to (Health and Rehab facility) for a patient-reported emergency. We were met by a facility staff member who would later be identified as Licensed Practical Nurse [Staff LPN]. Upon requesting a report from [Staff LPN], [s/he] responded: 'We didn't call you guys. I told the patient if [s/he] really thought [h/her] sugar was a problem, [s/he] could call 911 themselves.' When I, [EMT #1] asked what interventions were initiated to address the patient's elevated blood glucose, [Staff LPN] stated: 'Well, I don't have orders for [h/her] insulin after 5:00 PM., I wasn't going to call the physician after hours, and I definitely wasn't going to call the ambulance.' 'I wasn't even supposed to take a blood sugar after 5:00 PM., but [s/he] kept bugging me and if I hadn't, then it wouldn't be a problem now.' [S/he] further added: '[S/he] kept telling me that [s/he] needed to go to the hospital, but I wasn't going to send [h/her] out because [s/he] can just go to bed.' Prior to departing the facility with the patient, EMT personnel requested standard transfer documentation from [Staff LPN], including but not limited to: -Patient's medical history -Current medications -Known allergies -Recent medication administration or dispensation records In response, [Staff LPN] declined, stating: 'We're not sending [h/her] out, so we're not sending any paperwork. [S/he] chose to do this [h/herself].' The patient was escorted to the ambulance, where EMT performed an independent blood glucose check, which yielded a reading of 563 mg/dL. This result is critically elevated, falling well outside the normal range, and indicative of a condition requiring immediate medical and pharmacological intervention. It is also more than 200 points higher than the level previously documented by [Staff LPN]. Upon arrival at [the hospital], The patient was subsequently evaluated and treated in accordance with hospital protocols for severe hyperglycemia. Review of Emergency Department notes for Resident #1, dated 5/9/25 record We recommend to health and rehab staff that regular orders of glucose checks and as needed insulin be part of the patient's continued medical regiment. This was made clear in the discharge instructions. Review of Discharge Instructions for Resident #1 read: When you arrived your blood glucose level was over 500. You were given an appropriate amount of insulin which has now brought your glucose levels back down to a more normal limit. Please continue to monitor your sugars closely. ORDERS FOR HEALTH AND REHAB: It is critical that the patient has his blood sugars monitored regularly. Please make sure that there are in place orders from your facility physician for administration of insulin if the patient becomes hyperglycemic. If the patient does have concern for hyperglycemia, please reach out to your staff physician for insulin orders for administration. 4.) Assumes responsibility for the safe and efficient implementation of the plan. - Communicates consultation recommendations. Per review of the Lippincott Manual of Nursing, Common Departures from the Standards of Nursing Care include: failure to follow physician orders, follow appropriate nursing measures, communicate information about the patient. [Lippincott Manual of Nursing Practice-11th Edition 2018] Review of the only progress note written by Staff LPN regarding Resident #1's care and treatment that evening, dated 5/10/25 at 2:40 AM reveals: Around 2:00 AM ED called with report on resident stating that they checked [h/her] blood sugar and it was >500. Resident given 1 liter of saline and 12 units of insulin that was effective bringing down blood sugar to 130. Resident returned to facility with no further complaints. DON [Director of Nursing] made aware of situation. Further review of progress notes reveals no documentation of when or what information the DON was made aware of or any actions taken by the DON or Staff LPN upon Resident #1's return. Per review of Resident #1's medical record, there was no documentation of any materials received from the hospital after Resident #1's emergency room visit, or any required documents given to the resident prior to their transfer. Per the interview with EMT #1 on 5/14/25 at 3:30 PM, the EMT stated that [s/he] transported Resident #1 both to and from the Emergency Department on 5/9/25 and early morning 5/10/25. Per interview the EMT stated that Discharge Instructions including new physician orders were hand delivered upon Resident #1's return to the facility to the same Staff LPN who was responsible for Resident #1's care prior to the ED visit. The EMT stated that the new physician orders were handed directly to the Staff LPN and were highlighted and underlined and included orders for the resident's physician to be notified. An interview was conducted with the facility's Administrator [ADM], the Regional Director of Nursing [RDN], and [NAME] President of Operations [VPO] on 5/14/25 at 1:56 PM. Regarding the actions on 5/9/25, the ADM, RDN, and VPO stated the Staff LPN's actions toward Resident #1 were not handled professionally and the Staff LPN was not listening to [h/her] education, including professional standards regarding staff having the knowledge and ability to provide care and services, but choosing not to do it, or acknowledge the request for assistance from a resident resulting in care deficits to a resident. The facility staff confirmed they did not possess any paperwork or discharge information after Resident #1's ED visit on 5/9/25. At 4:15 PM on 5/14/25, the facility contacted the ED for copies of Resident #1's ED visit record. The facility immediately received copies of Resident #1's Hospital Record and ED Visit Note, dated 5/9/25, which included new physician orders from the ED. The ADM, RDN, and VPO confirmed that despite the Staff LPN being handed ED notes and physician orders, the Staff LPN failed to enter any documentation of the ED visit in Resident #1's medical record, and no new physician orders were entered into the record or implemented in the resident's care and treatment, and no documentation that Resident #1's physician was notified of the ED visit or of elevated blood sugar levels. Additionally, it was confirmed that Resident #1 was transferred out of the facility without any documentation from [Staff LPN], including the resident's medical history, current medications, known allergies, recent medication administration or dispensation records, and no required bed hold notification allowing the resident to return to the facility after the ED visit.

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 [Resident #1] of 3 sampled residents regarding staff having the knowledge and ability to provide care and services, but choosing not to do it, or acknowledge the request for assistance from a resident resulting in care deficits to a resident. Resident #1 suffered serious harm that rose to the immediate jeopardy level due to the facility's failure to prevent neglect. As a result, Resident #1 expereinced symptoms related to very high, unsafe blood sugar and psychosocial harm. Findings include: Review of the admission Packet given to every resident in the facility includes the facility's Abuse, Neglect and Exploitation Policy. The policy defines Neglect as the intentional or reckless failure or omission by a caregiver to: Provide care or arrange for goods or services necessary to maintain the health or safety of a vulnerable adult, including, but not limited to . medicine . supervision and medical services. Review of the facility's Annual Mandatory Education-All Staff includes training titled Resident Neglect. The training reads Neglect is the failure to provide the required structures and processes in order to meet the needs of one or more residents. This may include .the facility's failure to provide necessary staff .services .or staff supervision and oversight to meet the resident's needs. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances . Review of Resident #1's medical record reveals the resident has diagnoses that include: Diabetes mellitus [a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose in the blood and urine] due to a underlying condition with hyperglycemia [high blood sugar], a history of a pancreatectomy [surgical procedure involving the removal of the pancreas]- [Your pancreas makes hormones (like insulin) that help control the levels of sugar in your bloodstream. When your blood sugar is too high, your pancreas makes insulin to lower it. Your body needs balanced blood sugar to run properly.] (https://my.clevelandclinic.org/health/body/21743-pancreas). Resident #1's medical history also includes hyperglycemic-hyperosmolar coma [a serious complication of diabetes characterized by extremely high blood sugar, significant dehydration, and altered mental state that can lead to coma. It's a life-threatening emergency]. According to the Mayo Clinic: It's important to treat High blood sugar, also called hyperglycemia. If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart. Hyperglycemia usually doesn't cause symptoms until blood sugar (glucose) levels are high - above 180 to 200 milligrams per deciliter (mg/dL). When to see a doctor: Seek immediate help from your care provider or call 911 if: Your blood glucose levels stay above 240 milligrams per deciliter (mg/dL) (https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631) Review of the facility's NURSING CARE OF THE RESIDENT WITH DIABETES MELLITUS policy [revised 1/2024] reads, The purposes of this guideline are to: Recognize, manage, and document the treatment of complications commonly associated with diabetes. The policy includes Glucose Monitoring, which lists The management of individuals with diabetes mellitus should follow relevant protocols and guidelines and Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. The Nursing Care lists Normal ranges are defined as 80-130 before meals and <180 after meals. Hyperglycemia is considered anything above target reference ranges. An interview was conducted with Resident #1 on 5/14/25 at 9:37 AM. The resident stated s/he had h/her pancreas removed, and utilized a Dexcom device to monitor h/her blood sugar levels at all times. The resident raised the sleeve on h/her right arm to show a small white disk affixed to their upper arm. [the Dexcom is a wearable sensor sending real-time glucose readings automatically to a compatible smart device (such as an I-phone) or Dexcom receiver] (https://www.dexcom.com/get-started-cgm). Resident #1 demonstrated their present blood sugar reading on their I-phone, listed as 149. Resident #1 stated Last Friday my Dexcom read >400. It only goes up to 400. I told my nurse [Staff LPN] that my blood sugar was high. I don't have a pancreas. [Staff LPN] said 'you're only scheduled for blood sugar checks before meals. There are no checks after 5:00 PM.' This was at approximately 8:00 PM. The nurse said to 'go sleep it off.' I kept bugging her about 8 times to check my sugar. She got pissed, checked my sugar and it was the high 300's. I was mortified. I said I need to go to the Emergency Room. She said, 'Absolutely not.' I talked on the phone with my [Representative], who told me to call 911. So, I called the 911. [EMT #1 & #2] (Emergency Medical Technician- is a healthcare professional trained to provide basic emergency medical care) came and took me to the Emergency Department [ED]. They checked my blood sugar and it was 563. The resident reported at the time s/he was suffering from massive headaches, blurry vision, dots in my vision, nausea, and feeling mentally fuzzy. Per interview with Resident #1's Representative on 5/14/25 at 2:59 PM, the Representative reported on the phone call the resident was slurring [h/her] words, which the Representative reported he/she had witnessed in the past when the resident's blood sugars were extremely high. Review of the facility's NURSING CARE OF THE RESIDENT WITH DIABETES MELLITUS policy includes: symptoms of hyperglycemia may include the following: -Headache -Restlessness -Nausea and/or vomiting -Decreased awareness/senses An interview was conducted on 5/14/25 at 3:30 PM with the EMT #1 who responded to Resident #1's 911 call on 5/9/25. The EMT provided a written statement regarding what occurred between themselves and the Staff LPN and Resident #1, and during the interview confirmed the accuracy of h/her written account. Per review of the EMT #1's written statement: On May 9, 2025, I responded to an emergency call along with my assigned partner, [EMT #2]. At approximately 9:25 PM, we were dispatched to (Health and Rehab facility) for a patient-reported emergency. The initial dispatch information stated that a patient at the facility had personally called 911 and reported that '[h/her] sugar is out of control and the staff won't give [h/her] [h/her] insulin; [s/he] is experiencing nausea and has a headache.' We were met by a facility staff member who would later be identified as Licensed Practical Nurse [Staff LPN]. Upon requesting a report from [Staff LPN], [s/he] responded: 'We didn't call you guys. I told the patient if [s/he] really thought [h/her] sugar was a problem, [s/he] could call 911 themselves.' When asked to provide further details regarding the incident and the patient's condition, [Staff LPN] made the following statements: '[Resident #1] has been saying that [h/her] device, an implanted DexCom blood glucose monitor, shows [h/her] levels as 'High' and has been asking for me to check [h/her] blood sugar for a while. [S/he] doesn't have orders for [h/her] blood sugar to be checked after 5:00 PM., but [s/he] hounded me enough that I checked it anyways at 7:00 p.m., and it read 356.' When I, [EMT #1] asked what interventions were initiated to address the patient's elevated blood glucose, [Staff LPN] stated: 'Well, I don't have orders for [h/her] insulin after 5:00 PM., I wasn't going to call the physician after hours, and I definitely wasn't going to call the ambulance.' 'I wasn't even supposed to take a blood sugar after 5:00 PM., but [s/he] kept bugging me and if I hadn't, then it wouldn't be a problem now.' [S/he] further added: '[S/he] kept telling me that [s/he] needed to go to the hospital, but I wasn't going to send [h/her] out because [s/he] can just go to bed.' The patient reported multiple symptoms consistent with hyperglycemia, including but not limited to: Blurred vision with spots in the visual field, Excessive thirst and frequent urination, Headache and Nausea. The patient also presented [h/her] Dexcom continuous glucose monitor, which was actively displaying a reading of 'High.' The patient reported that [s/he] had repeatedly informed [Staff LPN] of [h/her] symptoms and the need for insulin to reduce [h/her] blood glucose levels. According to the patient, [Staff LPN] declined to provide insulin, did not consult with the on-call physician, and refused to initiate transport to the hospital. The patient reported that [Staff LPN's] only recommendation was to 'not worry and go to bed.' This is consistent with [Staff LPN's] own statements to [EMT #1 & #2]. Prior to departing the facility with the patient, EMT personnel requested standard transfer documentation from [Staff LPN], including but not limited to: -Patient's medical history -Current medications -Known allergies -Recent medication administration or dispensation records In response, [Staff LPN] declined, stating: 'We're not sending [h/her] out, so we're not sending any paperwork. [S/he] chose to do this [h/herself].' The patient was escorted to the ambulance, where EMT performed an independent blood glucose check, which yielded a reading of 563 mg/dL. This result is critically elevated, falling well outside the normal range, and indicative of a condition requiring immediate medical and pharmacological intervention. It is also more than 200 points higher than the level previously documented by [Staff LPN]: (356 at approximately 7:00 PM), indicating continued physiological deterioration over the period without intervention. Upon arrival at [the hospital], The patient was subsequently evaluated and treated in accordance with hospital protocols for severe hyperglycemia. Review of Emergency Department notes for Resident #1, dated 5/9/25 at 10:02 PM record This is a [AGE] year-old who currently resides at health and rehab. Patient states that [h/her] Dexcom is still on, it was registering high this evening. Patient states that [s/he] asked the nurse at health and rehab for insulin. Patient states that the nurse stated that [s/he] did not have an order for glucose check, or insulin and because [s/he] did not have these [s/he]was not going to give the insulin. Patient states that [s/he] requested that the facility doctor be contacted, and nursing recommended that if the patient wanted further evaluation [s/he] contact 911. Patient contacted EMS [Emergency Medical Services] they came to health and rehab and per EMS they also corroborated the story as well. Patient was then brought to the emergency department for further evaluation. [S/he] admits to feeling slightly dizzy and nauseous with a mild headache, and states that this is common when [h/her] sugars are high. Blood glucose was noted to be over 500. Concern for DKA versus HHNK. [DKA (Diabetic Ketoacidosis) and HHNK or Hyperosmolar Hyperglycemic Nonketotic Syndrome) are both serious complications of diabetes characterized by high blood sugar (hyperglycemia)] Will give a liter of normal saline, will give 12 units of insulin . Physician notes at 12:36 AM on 5/10/25 continue: We recommend to health and rehab staff that regular orders of glucose checks and as needed insulin be part of the patient's continued medical regiment. This was made clear in the discharge instructions. Review of Discharge Instructions for Resident #1 read: When you arrived your blood glucose level was over 500. You were given an appropriate amount of insulin which has now brought your glucose levels back down to a more normal limit. Please continue to monitor your sugars closely. ORDERS FOR HEALTH AND REHAB: It is critical that the patient has his blood sugars monitored regularly. Please make sure that there are in place orders from your facility physician for administration of insulin if the patient becomes hyperglycemic. If the patient does have concern for hyperglycemia, please reach out to your staff physician for insulin orders for administration. Review of the only progress note written by Staff LPN regarding Resident #1's care and treatment that evening, dated 5/10/25 at 2:40 AM reveals: Requested blood sugar check around 7:30 PM. Result 391. Resident requesting nurse contact physician for orders for insulin. Resident educated that it might not be a great idea to take short acting insulin at bedtime, that blood sugar might drop too low during night. Resident informed that I could check blood sugar in the AM if [s/he] wants. Resident spoke to [h/her] [Representative] and [Representative] told [h/her] to go to hospital if [s/he] wants this issue addressed. Resident then called 911 to bring [h/her] to ED across street. EMTs arrived for resident and nurse informed them of situation. Resident transported to ED. Around 2:00 AM ED called with report on resident stating that they checked [h/her] blood sugar and it was >500. Resident given 1 liter of saline and 12 units of insulin that was effective bringing down blood sugar to 130. Resident returned to facility with no further complaints. DON [Director of Nursing] made aware of situation. Further review of progress notes reveals no documentation of when or what information the DON was made aware of or any actions taken by the DON or Staff LPN upon Resident #1's return. Per review of Resident #1's medical record, there was no documentation of any materials received from the hospital after Resident #1's emergency room visit, or any required documents given to the resident prior to their transfer. Per the interview with EMT #1 on 5/14/25 at 3:30 PM, the EMT stated that he transported Resident #1 both to and from the Emergency Department on 5/9/25 and early morning 5/10/25. Per interview the EMT stated that Discharge Instructions including new physician orders were hand delivered upon Resident #1's return to the facility to the same Staff LPN who was responsible for Resident #1's care prior to the ED visit. The EMT stated that the new physician orders were handed directly to the Staff LPN and were highlighted and underlined and included orders for the resident's physician to be notified. Per interview with the facility's Administrator [ADM], the Regional Director of Nursing [RDN], and [NAME] President of Operations [VPO] on 5/14/25 at 1:56 PM, The [NAME] President of Operations [VPO] stated that the usual situation of a resident being sent to the hospital would include the facility documenting a change in condition and the physician being notified and confirmed this was not done for Resident #1. After reviewing Resident #1's medical record, the VPO stated that on 5/9/25 the resident's presentation was out of the 'norm' for the patient, with ADM adding In my opinion, the nurse should have called the doctor. Further review of Resident #1's medical record revealed 2 days earlier, on 5/7/25, Resident #1's blood sugar level at 7:53 PM was elevated and recorded at 346, and Resident #1's nurse at the time contacted the on-call physician service and received insulin orders to address the resident's elevated blood sugar level. Regarding the actions on 5/9/25, The ADM, RDN, and VPO stated the Staff LPN's actions toward Resident #1 were not handled professionally and the Staff LPN was not listening to [h/her] education, including the facility's Annual Mandatory Education-All Staff regarding resident Abuse and Neglect, and professional standards regarding staff having the knowledge and ability to provide care and services, but choosing not to do it, or acknowledge the request for assistance from a resident resulting in care deficits to a resident. The ADM, RDN, and VPO confirmed that despite the Staff LPN being handed ED notes and physician orders, the Staff LPN failed to enter any documentation of the ED visit in Resident #1's medical record, and no new physician orders were entered into the record or implemented in the resident's care and treatment, and no documentation that Resident #1's physician was notified of the ED visit or of elevated blood sugar levels.

Based on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 2 of 3 sampled residents (Residents #1 and #2) by failing to provide adequate supervision and create and implement effective, timely interventions that would reduce the likelihood of future falls. As a result, Resident #1 suffered a fall that resulted in pain and a hip fracture that required surgery. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey dated 12/11/24 and a partial survey dated 10/25/23. Findings include: 1. Per record review, Resident #1 has diagnoses that include history of falls, abnormalities of gait and mobility, muscle weakness, Alzheimer's disease, and paranoid schizophrenia. A 2/3/25 Physician admission note reads, Resident #1 is transferred here with [his/her spouse] due to increased care needs and inability to perform ADLs [activities of daily living]. [S/He] is [primarily] bed bound at times. [S/He] can and will ambulate in the [facility] with a front wheeled walker. Per record review, Resident #1 has care plan focuses that read, Resident is at risk for falls: cognitive loss, lack of safety awareness, initiated on 1/31/25, At risk for falls due to weakness, impaired mobility, history of falls, revised on 2/20/25, and, [Resident #1] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: Alzheimer's, initiated on 1/31/2025. Per review of facility risk management reports since 2/1/25, Resident #1 had falls on 2/14/25, 2/17/25, 2/25/25, 3/5/25, 3/6/25, 3/22/25, and 3/24/25. The reports indicate that the falls on 2/14/25, 2/17/25, 3/5/25, 3/6/25, 3/22/25, and 3/24/25 were unwitnessed by staff. A 3/6/25 progress note reads, Resident observed on the floor by bedside upon entering room after wife calls for help. Resident noted to be lying down on floor by bedside. A 3/7/25 progress note reveals that Resident #1 was transferred to the hospital [status post] fall evaluation per MD and resident. A 3/7/25 hospital emergency room Nurse Practitioner note indicates that Resident #1 presented with right hip pain and was found to have an acute fracture of the right hip requiring surgery. A 3/11/25 facility progress note indicates that Resident #1 returned to the facility on [DATE]. A 3/14/25 Nurse Practitioner note reveals Resident #1 is being seen for a follow-up related to hip pain. The note states, [S/He] was recently in the hospital due to a fall in which he experienced a right hip fracture. [S/He] had it surgically repaired on 03/08/2025 . re-orient and more frequent patient checks recommended. A 3/16/25 Pain Assessment Interview reveals that Resident #1 reported to have experienced pain frequently over the past 5 days. Per record review, Resident #1's care plan was not revised after the falls on 3/5/25 and 3/6/25 until 3/10/25, 4 and 5 days after his/her previous falls. The new intervention put into place was Encourage resident to ring call be to assist with ambulation. Following Resident #1's fall on 3/22/25, Resident #1's care plan was revised with a duplicate intervention, Encourage resident to ring call bell and wait when assistance is needed. Following Resident #1's fall on 3/24/25, his/her care plan was revised to include Place walker near bed to encourage use when resident ambulates. This intervention was already added to Resident #1's care plan on 2/20/25. No interventions were put into place following any of the above falls related to providing additional supervision for Resident #1. Per interview on 3/18/25 at 12:29 PM, Resident #1's roommate and spouse explained that Resident #1 keeps falling because s/he tries to be as independent as possible when s/he should be getting help from staff. S/he explained that staff do not check on Resident #1 enough and worries that s/he can't leave the room because Resident #1 will not be supervised and will fall again. S/He stated that Resident #1 has been in extreme pain since his/her recent fall. Facility policy titled Falls Management, undated, reads Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented . Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Adjust and document individualized intervention strategies as the patient condition changes. The policy does not speak to how soon after a fall that a resident's care plan would be required to be updated. Per interview on 3/27/25 at 10:30 AM, the Director of Nursing and the [NAME] President of Operations explained that new care plan interventions should be immediate, if possible, but the expectation is that a care plan is updated after a fall within 24 hours. Per an email from the Administrator on 3/28/25, the facility was unable to produce evidence of timely, effective care plan interventions following Resident #1's falls on 3/5/25, 3/6/25, 3/22/25, and 3/24/25. 2. Per record review, Resident #2's care plan reads, [Resident #2] is at risk for falls: cognitive loss, lack of safety awareness, Impaired mobility, Parkinson's disease, Osteoarthritis, initiated on 5/30/2024, and [Resident #2] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: Impaired balance, Limited mobility, unsteady gait, weakness, Dementia, Parkinson, initiated on 5/30/2024. Per review of facility risk management reports since 2/1/25, Resident #2 had falls on 2/3/25, 2/10/25 at 7:45 AM, 2/10/25 at 3:30 PM, 2/23/25, 2/25/25, 2/26/25, 3/12/25, 3/14/25, 3/17/25, and 3/23/25. The reports indicate that the falls on 2/3/25, 2/10/25 at 7:45 AM, 2/10/25 at 3:30 PM, 2/23/25, 2/25/25, 2/26/25, 3/12/25, and 3/23/25 were unwitnessed by staff and Resident #2 suffered a left elbow skin tear following the fall on 2/3/25. Per record review, Resident #2's care plan was not revised following the falls on 2/3/25, 3/15/25, and 3/23/25. Per an email from the Administrator on 3/28/25, the facility was unable to produce evidence of timely, effective care plan interventions following Resident #2's falls on 2/3/25, 3/15/25, and 3/23/25.

Based on interview and record review, the facility failed to develop and revise a baseline care plan, specific to the person-centered care related to elopement for 1 applicable resident (Resident #1), who left the facility undetected, was found on the road by a local citizen and brought to the Emergency Department with multiple lacerations. Findings include: Record review reveals that Resident #1 was admitted to the facility on [DATE] with diagnoses that include Wernicke's encephalopathy (a neurological disorder that presents with confusion, muscle movement coordination disorder, and vision problems), dementia, orthostatic hypotension (low blood pressure after standing that can cause dizziness or lightheadedness), and history of falling. An 8/31/23 progress note reveals that an elopement assessment determined that Resident #1 is at high risk for elopement as evidenced by Resident #1's verbalizing the desire to leave the facility, reported family history of elopement, and recent general cognitive decline. A physician order was created on 8/31/23 for a WanderGuard Device (a bracelet that residents wear that sets off an alarm when a resident approaches a monitored door). A comprehensive Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 9/4/23 reveals that Resident #1 is independent with locomotion on and off the unit, does not require a mobility device, and exhibits behaviors of wandering daily. Resident #1 was determined to have a BIMS of 11 (brief interview for mental status; a cognitive assessment score indicating moderate cognitive impairment). Progress notes reveal Resident #1 has repeated behavior of wandering, desire to remove his/her WanderGuard, and success with removing his/her WanderGuard putting him/her at increased risk for elopement. An 8/31 note states, Resident often asks where the door is to go home, and stated to staff 'I'm all done here, I'm ready to go home to my dog.' [S/he] is pleasantly confused. A 9/3/23 note states, Resident noted to be in hallway attempting to open glass doors to fire extinguisher, assisted and redirected back to room where LNA had given [her/him] coffee [s/he] had asked for, upon entering room, noted wander guard bracelet in 2 pieces laying on dresser, resident states 'Oh it fell off.' A 9/4/23 note states, [Resident #1 is] alert but noted with confusion but pleasant with staff. Resident ambulates about facility and in [his/her] room. Resident did not voice any complaints. Staff noted [s/he] attempted to pull off wander guard x1 [once] this shift. will continue to monitor. A 9/6/23 note, created at 3:32 PM states, resident is alert and confused looking for a way home, easily redirected. denies pain or discomfort . Wandering occurs daily or almost daily [Resident #1] is experiencing anxiety about surroundings. [Resident #1] is experiencing delusions. Resident #1's baseline care plan includes the following care plan focus, Resident is at risk for elopement related to: Cognitive Loss/Dementia, created on 8/31/23. Although the baseline care plan had a few interventions, the interventions did not address known behaviors such as Resident #1's multiple attempts to remove his/her WanderGuard, active exit seeking, or wandering behaviors as described in the progress notes above prior to 9/7/23. Per review of a facility incident report dated 9/6/23, Resident #1 eloped from the facility on 9/6/23. The report describes that a visitor overheard the staff discussing the missing resident and the visitor stated that [s/he] saw the resident walking down the hill with a duffel bag. [S/He] went on to say that [s/he] saw that the resident's wrists were bloody so [s/he] picked [him/her] up and took [him/her] to the ED [Emergency Department] (NVRH). Incident report notes reveal that an LNA observed Resident #1 after dinner with a duffle bag and s/he was redirected back to his/her room. The LNA stated that Resident #1 is known to remove his/her WanderGuard and the resident was repeatedly asking 'when can I leave?' [The LNA] says that [s/he] had never seen [him/her] wander like [s/he] did tonight. The incident report does not reveal the time when Resident #1 was noticed missing at the facility or the time that the visitors reported to staff that they took a person to the ED. Per an Emergency Department visit Physician note dated 9/6/23, initiated at 6:47 PM, Resident #1 was confused when they arrived at the hospital. Resident #1 reported inaccurately that s/he was on his/her way back from Maine and was headed to South Royalton, VT. S/He was unsure how s/he arrived in St. Johnsbury and was planning on taking a bus home. Resident #1 reported that s/he slipped and fell on the pavement. The Physician's exam reveals that Resident #1 has 3 lacerations on his/her left hand and fingers, a right hand abrasion, and a right hand laceration requiring two sutures. This note reveals that the facility contacted the ED at 7:42 PM to report that Resident #1 had eloped from the facility. Per interview on 11/20/23 at 5:04 PM, the Director of Nursing confirmed that Resident #1's baseline care plan for risk for elopement did not include interventions that addressed known risk factors for elopement such as wandering, desire to return home, and his/her repeated attempts to remove the WanderGuard, and should have. Per interview on 11/21/23 at 2:24 PM, the Administrator was unable to determine the exact times events took place on 9/6/23. S/He confirmed that Resident #1 was last seen in the facility after dinner, which is served at 4:30 PM, and that the facility investigation into the event revealed that staff did not hear the alarm go off on the evening of 9/6/23.

Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one applicable resident (Resident #1) by neglecting to provide services that are necessary to avoid physical harm and emotional distress related to refusing to allow Resident #1 to get out of bed, putting them at increased risk for medical complications related to immobility such as, urinary tract infection (UTI), pneumonia, and constipation and cardiovascular complications (which could promote a bowel obstruction); and failing to answer call bells and provide care for Resident #1 so that they maintain dignity and quality of life. Findings include: Per interview on 10/19/23 at 4:01 PM, Resident #1's Representative indicated that Resident #1 was neglected to be provided care while at the facility. S/He stated that Resident #1 was not allowed to leave his/her bed until 9/25/23, the day s/he was transferred to the hospital, was forced to wear a brief even though s/he was not incontinent and had requested multiple times to use the toilet, was not attended to in a timely manner by staff, and was left soiled for extended periods of time. S/He stated that Resident #1 was using a commode during the hospital stay for bowel elimination and was told by providers at the hospital prior to admission to the facility that Resident #1 should not being wearing briefs if s/he is continent of bowels because it would increase the chance of him/her getting a UTI . When the Representative asked the facility staff why Resident #1 was wearing a brief, staff told them that Resident #1 was incontinent of their bowels and was not allowed to be transferred out of bed. The Representative explained that Resident #1 was not incontinent of bowels, that they were only wearing briefs on admission because of the long drive from the hospital to the facility, in which Resident #1 had soiled themselves. S/He reports that both s/he and Resident #1 had asked to use the toilet and get out of bed multiple times and was told by facility staff that staff were not allowed to get them out of bed because s/he was not cleared to get out of bed. When the Representative explained that Resident #1 had been evaluated by therapy on 9/21/23, staff said there was no one to talk to about that and continued to refuse to transfer her/him out of bed to use the toilet or sit in a chair. The representative explained that s/he visited the facility multiple times during Resident #1's stay for extended periods of time and observed Resident #1 in a brief the entire time. Resident #1 had expressed back pain from being in bed so long and sadness that s/he might as well be at home because if I'm just going to be in bed all day, I can do that at home. Resident #1's Representative reported that staff did not attend to Resident #1's needs. S/he stated that Resident #1 was in the same johnny on 9/23/23 that s/he had worn in the hospital even though Resident #1 had his/her own clothes. S/he stated that s/he and other family members would have to go ask staff at the nursing station for help after not responding to call bells. S/He did not observe staff reposition Resident #1 while they were visiting. S/He stated that s/he repositioned Resident #1 in bed and found him/her laying on a knife. S/He stated that one day, Resident #1 was vomiting, and s/he went to get help from staff. Staff had told him/her that they would be there later. The vomit was dark, almost black. The Representative said that s/he had to help Resident #1 reposition themselves so that they would not choke on their vomit. S/He explained that Resident #1 was left to sit in dirty clothes and bed sheets covered in coffee and vomit for hours. Staff had reported that they were short staffed, and one LNA (Licensed Nurse Aide) had asked for help from Resident #1's family member to help him/her to a chair because s/he was going to collapse from being so busy. The Representative expressed great sadness that Resident #1 experienced this type of care during the last days of their life. Per record review, a transfer of care report signed by a physician from the sending hospital dated 9/21/23 reveals that Resident #1 was admitted to the hospital on 9/13/23 for atrial fibrillation (irregular, often rapid heart rate), NSTEMI (heart attack), and HFrEF (type of heart failure). On discharge from the hospital on 9/21/23 Resident #1 had an indwelling urinary catheter, was being discharged for acute rehabilitation, and their condition at discharge was described as improved. A facility admission nursing assessment dated [DATE] reveals that Resident #1 was admitted to the facility on [DATE] for therapy, teaching, and training, in addition to care management related to a stroke and cardiac conditions. Resident #1's health history included congestive heart failure, diabetes, cardiac disease, hypertension, and stroke. The assessment reveals that Resident #1 is incontinent of bowels and his/her current toileting method for bowel elimination is marked not applicable, (other choices include bathroom, commode, or bedpan). S/He has a urinary catheter on admission. On review of rehab service, Resident #1 indicates that s/he believes that s/he is capable of increasing independence in at least some activities of daily living (ADLs). Resident #1's mental status is described as alert and oriented to person and place. Per record review, physician orders include: May participate in activity and general conditioning program as desired. Activity as tolerated, with a start date of 9/21/23. An occupational therapy evaluation dated 9/21/23 reveals that Resident #1 is dependent for care for transfers, requiring 100% assistance or 2 or more helpers to transfer. Long term therapy goals established were for Resident #1 to return to their prior level of functioning (independent) with some modifications for ADLs by 10/20/23. The potential for Resident #1 reaching these rehab goals is described as fair rehab potential as evidenced by the ability to follow 1- step directions, able to make needs known, motivated to return to prior level of living and higher prior level of function. Per interview on 10/18/23 at 12:55, the Occupational Therapist who assessed Resident #1 on 9/21/23 revealed that Resident #1 was in a brief and soiled from the transfer to the facility when s/he was assessed. S/he stated that Resident #1 required a lift to transfer out of bed and communicated that to the staff on Resident #1's unit. Per interview on 10/19/23 at 9:13 AM, the Interim Therapy Director confirmed that Resident #1 was evaluated on 9/21/23 by Occupational Therapy and the assessment determined that s/he required total assistance for bed mobility and transfer. S/He explained that therapy services will alert nursing staff about the results and nursing will incorporate the results into a resident's plan of care. Nursing staff can also go by hospital notes or can assist a resident with bed mobility and transferring with maximum staff assistance until the therapy team can assess the resident. The Interim Therapy Director confirmed that Resident #1 was not seen by physical therapy until 9/25/23. A Lift Transfer Evaluation dated 9/21/23 indicates that Resident #1 is unable to independently reposition themselves in bed and recommendations reveal that Resident #1 requires at least 2 staff with repositioning device and suggests a total lift divided leg sling for transfer. Resident #1's care plan includes the following care plan focuses: Resident exhibits or is at risk for cardiovascular symptoms or complications related to CVA [stoke], MI [heart attack], Cardiac arrhythmia [irregular heartbeat], created on 9/21/23. Interventions include: monitor weight as ordered, created on 9/21/23, and Encourage activities as ordered and tolerated, created on 9/21/23. Resident is at risk for falls: CVA, Impaired mobility, created on 09/21/2023. Interventions include Ambulation assistance: (# staff) [left blank] with (Device) [left blank] Maximize physical activity to enhance general muscle tone, functioning of lower G.I. tract, and ability to mobilize to bathroom in response to urge to defecate, created on 09/21/2023. Resident requires assistance with cares [related to] weakness, created on 9/23/23, total lift divided leg for transfers with assist of 2, created on 9/23/23. Per interview on 10/18/23 at 2:37 PM, a Licensed Nurse Aide stated that Resident #1's family had asked for Resident #1 to get out of bed so they could sit in a chair and s/he told the family that s/he couldn't get Resident #1 out of bed because s/he was not cleared to do so. S/He explained that s/he was never told what type of assistance Resident #1 required and would need a wheelchair, which s/he did not have, for support since Resident #1 was not strong enough to support his/herself in an armless chair. S/He explained that Resident #1 required a brief due to being incontinent of their bowels and believed they were not allowed to be transferred out of bed to use the toilet because they had not been assessed by therapy yet. Nursing Aide documentation from 9/21/23 through 9/25/23 reveals that Resident #1 was not bathed during their stay and did not refuse bathing and s/he was not transferred in or out of bed and did not refuse transfer from 9/21/23 through the evening shift on 9/25/23. Per record review, A 9/25/23 progress note reveals that Resident #1 was transferred to the hospital on 9/25/23 due to chest pain. A 9/25/23 hospital provider note reveals that Resident #1 presents to the ER [emergency room ] with abdominal pain, chest pain, nausea, and vomiting, describing the pain as severe and constant for days. Resident #1 is described as alert, awake and with normal cognition. A 9/26/23 hospital provider note indicates that assessment reveals that Resident #1 has the following acute (newly acquired) complications: small bowel obstruction, urinary tract infection, pneumonia, and renal failure. The family reported to the provider that Resident #1's vomit was feculent smelling at the facility. Notes further reveal that Resident #1 was discharged home on hospice on 9/26/23. A [NAME] Certificate of Death reveals that Resident #1 passed away on 9/27/23 with the cause of death determined to be Sepsis in the Setting of Pneumonia, Acute Urinary Tract Infection, and Spontaneous Small Bowel Obstruction. Per interview on 10/19/2023 at 1:09 PM, the Market Clinical Lead stated that based on assessment, Resident #1 should have been able to transfer out of bed before 9/25/23 and confirmed there was no documentation that s/he was out of bed, offered to get out of bed, or refused getting out of bed. S/He stated that the use of a brief for Resident #1 was due to him/her being incontinent of their bowels on admission and confirmed that s/he should have been reassessed for incontinence following admission, which had not been done. S/He confirmed that wearing a brief increases the risk for bacterial growth, increasing their risk for a UTI.

Based on observation, interview, and record review, the facility failed to ensure 3 of 3 sampled residents (Residents #2, #3, and #4) remained free of accidents as possible related to creating and implementing interventions to reduce hazards for Residents #3 and #4; providing appropriate and sufficient supervision to prevent an avoidable accident for Residents #2, #3, and #4; and providing assistive devices necessary to prevent an avoidable accident from occurring for Resident #2. Findings include: 1. The facility failed to provide Resident #2 with sufficient supervision and assistive devices to prevent an avoidable fall from occurring. As a result, Resident #2 suffered a fall in which s/he was on the floor for an extended period, soiled and cold, and dislodged his/her G-tube (a feeding tube inserted through the abdomen and directly into the stomach). Resident #2 required a transfer to the ER (emergency room ) and have an Naso Gastric tube (NG tube; a feeding tube inserted through the nose, down the throat, and into the stomach) inserted. Per record review, Resident #2 was admitted to the facility on [DATE] for rehab related to complications from a recent stroke. His/her admitting diagnoses include myasthenia gravis (a neurological order causing voluntary muscles to become weak), history of a stroke affecting the left side, dysphagia (swallowing difficulties) following stroke, and a gastrostomy tube (G-tube; a feeding tube inserted through the abdomen and directly into the stomach) placement. Per interview on 10/12/23 at 2:59 PM, Resident #2's Representative stated that Resident #2 was using a bedrail at home prior to admission to the facility to reposition themself in bed since s/he is very large and has muscle weakness. The Representative explained that this was discussed with the nurse at the facility on admission and it was determined that Resident #2 could receive a bedrail but s/he would not get it installed until the next day because maintenance had already left for the day. The Representative explained that s/he was very nervous to leave his/her spouse for the evening because s/he didn't have the bedrails and staff were not attentive to his/her needs as it took almost 2 hours for staff to respond to a call bell request earlier that evening. S/He revealed that Resident #2 fell out of bed that night while trying to reposition him/herself which caused his/her G-tube to rip out of his/her stomach and the need to be sent to the ER for reinsertion. The hospital was unable to reinsert the tube because the skin was damaged due to trauma from being ripped out and Resident #2 needed to get a NG tube inserted. This set back his/her progress related to swallowing therapy greatly, caused him/her pain, and created additional setbacks in therapy and pain related to requiring an additional surgery to reinsert the G-tube. Per a 9/13/23 physical therapy evaluation note, Resident #2's functional bed mobility assessment reveals that s/he requires supervision/stand by assistance for rolling left and right, and needs moderate assistance to go from lying to sitting and sitting to lying while in bed. Per record review a 9/13/23 bed rail evaluation reveals that Resident #2 is identified to have a balance deficit, weakness, and need for aid for independent pressure redistribution while in bed, contributing to the need to use a bed rail. A recommendation to use upper half side rails is determined and resident consent and physician order for bed rail use is obtained. Resident #2's care plan includes the following care plan focus: Resident/Patient requires assistance/is dependent for mobility, created on 9/13/23 with the following goal Resident will utilize upper half side rails bed rail(s) bilaterally for turning and repositioning, transferring from to bed. Per interview on 10/11/23 at 3:12 PM, the Licensed Practical Nurse (LPN) that completed Resident #2's bed rail evaluation on 9/14/23 stated that Resident #2 and his/her Representative had explained that s/he needs a bedrail to reposition themselves at bed at home and determined through the assessment that bedrails were recommended. The LPN stated that s/he obtained a physician order for the use of the bedrail and put in a work order to have the bedrails installed but knew that it wouldn't happen that day because the maintenance staff had already left for the day. S/He stated that s/he knew Resident #2 needed bedrails and did not make any other staff or management aware that Resident #2 did not have them installed. A facility incident report dated 9/14/23 at 3:30 AM reveals that the nurse found Resident #2 on the floor beside his/her bed wrapped in sheets. It describes Resident #2 as being incontinent of his/her bowel and bladder and having his/her G-tube removed from his/her abdomen. Resident #2 was sent to the ER to reinsert the G-tube. Per interview on 10/18/23 at 7:00 PM, the Registered Nurse (RN) who found Resident #2 on the floor on 9/13/23 stated that there was only him/herself and one aide on the unit for the entire night shift when typically there are two aides for that shift and confirmed that staffing was short that night. Per interview on 10/18/23 at 11:00 AM, Resident #2 and their Representative explained that Resident #2 was trying to reposition themselves in bed without the aid of a bedrail, which they normally use at home to reposition themselves, when s/he fell out of bed. Resident #2 stated that the fall occurred sometime after midnight, and they were found by staff sometime around 4:00 AM. S/He explained that while s/he does not know the exact length of time that s/he was on the floor, it was very painful and cold. The fall caused his/her G-tube to rip out of his/her stomach and s/he had an injury to a large toe. S/He was sent to the ER for replacement of the G-tube. The ER providers informed him/her they were unable to reinsert the G-tube because the tissue was damaged and s/he had to get an NG tube. The insertion of the NG tube set back his/her speech therapy progress. Per review of a 9/14/23 hospital ER visit note, Resident #2 was unable to have the G-tube reinserted until the abdomen healed, requiring a NG tube to be inserted for continued feeding purposes. A review of Licensed Nursing Assistant (LNA) documentation does not provide evidence that Resident #2 was cared for by LNA staff during his/her stay at the facility. All interventions that were identified as care tasks, including staff assistance with bed mobility and personal hygiene, for the shifts from 3:00PM on 9/13/23- 7:00 AM on 9/14/23 were left blank. Per interview on 10/19/2023 at 1:09 PM, the Market Clinical Lead stated that s/he cannot produce evidence that staff had checked on Resident #2 during the evening and confirmed that Resident #2 should have had a bedrail on his/her bed the night of 9/13/23. 2. The facility failed to provide Resident #4 with sufficient supervision and implement and revise interventions to prevent an avoidable fall from occurring. As a result, Resident #4 suffered 7 falls within 48 days in which outcomes for one of the falls included multiple areas of bruising and dislodgement of his/her catheter, requiring a transfer to the ER the following day. Per record review Resident #4 has diagnoses that include dementia, seizure disorder, history of falls, history of stroke with left side weakness, and urinary retention requiring a foley catheter (indwelling urinary catheter). An 8/17/23 MDS assessment reveals that Resident #4 requires a one person physical assist for locomotion on and off the unit and a two person assist for transferring; and uses a walker and wheelchair as a mobility device. Resident #4's care plan includes the following care plan focuses: Resident is at risk for falls: Impaired mobility, decreased safety awareness. history of fall, created on 8/12/23. Interventions include: non skid strips on both sides of the bed, created on 8/14/23, and provide checks throughout shift, created on 8/13/23. Resident requires assistance with cares [related to] left side weakness [status post] cva [stroke], created on 8/13/23. Interventions include, provide cueing for safety and sequencing to maximize current level of function, created on 8/13/23. Per review of facility incident reports since 9/1/23, Resident #4 had falls on 9/1/23, 9/17/23, 9/18/23, 9/26/23, 9/30/23, 10/11/23, and 10/14/23. The incident reports reveal the following: On 9/1/23, Resident #4 had an unwitnessed fall in his/her room from his/her bed. On 9/17/23, Resident #4 had an unwitnessed fall. On 9/18/23, Resident #4 had an unwitnessed fall in his/her room from his/her bed. On 9/26/23, Resident #4 had an unwitnessed fall. On 9/30/23, Resident #4 had an unwitnessed fall resulting in bruising to his/her left hand and left knee. Resident #4 was found with his/her foley catheter pulled out and would not let staff replace it. A 10/1/23 progress note states, Resident agreed to replacement of foley following its inadvertent dislodgement last night during [his/her] fall. This writer re-inserted the foley and the catheter tube immediately filled with congealed blood and no urine was passed through. The foley was removed and an additional attempt was made with the same result. [On call provider] contacted and an order was provided to have resident transported to the ED [Emergency Department] for evaluation. On 10/11/23, Resident #4 had an unwitnessed fall. On 10/14/23, Resident #4 had a witnessed fall. Review of care plan revisions related to fall prevention for Resident #4 since 9/1/23 include the following: Monitor for positioning in bed and reposition as needed, created on 9/4/23. Provide checks to monitor for positioning, created on 9/18/23. This is a rephrase of prior interventions created on 8/13/23 and 9/4/23. Redirect during self transfers, attempt repositioning in bed, created on 9/28/23. This is a rephrase of prior interventions created on 8/13/23, and 9/4/23. Refer to pharmacy for [medication] review 10/13, created on 10/16/23. Per a 10/11/23 progress note, a medication review was performed on 10/11/23 for Resident #4. Continue to encourage not to self transfer. monitor for sitting on edge of bed and reposition/redirect as needed, created on 10/16/23. This is a rephrase of prior interventions created on 8/13/23 and 9/4/23. While new care plan interventions were created after Resident #4's fall on 9/1/23 and 10/11/23, interventions were either not created or previous ineffective interventions were rephrased after the falls on 9/17/23, 9/18/23, 9/26/23, 9/30/23, and 10/14/23. Per observation on 10/18/23 at 10:36 AM, Resident #4 is in bed. Resident #4's bed is pushed against the wall . Nonskid strips are located underneath the bed and in the middle of the room as if they were placed to be on both sides of the bed if the bed were in the middle of the room. Per interview on 10/18/23 at 1:56 PM, the Nurse Manager confirmed that the skid strips were not effective for where the bed is place. Per interview on 10/18/23 at 1:59 PM, the Interim Director of Nursing stated that Resident #4's bed has been against the wall for about a month. Per interview on 10/18/23 at 12:20 PM, a Licensed Practical Nurse stated that the facility started one hour checks for location with Resident #4 about a week earlier. S/He explained that the staff started to keep track of the hourly checks on a piece of paper but it is not documented in Resident #4's record and is unsure if this is part of his/her plan. Per interview on 10/19/2023 at 1:09 PM, the Market Clinical Lead confirmed that Resident #4's care plan was not revised with new interventions to reduce the likelihood of another fall after all falls referenced above. S/He indicated that during a meeting held a week earlier, the interdisciplinary team recognized the need for more supervision for Resident #4 and created the intervention to complete one hour checks and confirmed that this was not entered into Resident #4's care plan or being documented in the record and it should be . 3. The facility failed to provide Resident #3 with sufficient supervision and implement and revise interventions to prevent an avoidable fall from occurring. As a result, Resident #3 suffered 6 falls within 48 days in which outcomes for two of the falls included multiple areas of bruising and a skin tear. Per record review, Resident #3 has diagnoses that include dementia, Parkinson's disease, depression, orthostatic hypotension, and a history/risk of falls. S/He was assessed on 8/17/23 to have a BIMS of 8 (brief interview for mental status; a cognitive assessment score indicating moderately impaired cognition). An 8/17/23 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) assessment reveals that Resident #3 requires 1 person physical assistance for walking. A care plan intervention created on 6/2/2023 states that Resident #3 requires supervision with the use of roller walker for ambulation. A 5/4/23 elopement evaluation states that resident is a known wander and fall risk. Resident #3 has an active physician order, since 4/7/23, for a Wander Guard/Wander Elopement Device due to poor safety awareness, and a 10/7/23 nursing note states, Wandering occurs daily or almost daily, for Resident #3. Per observation on 10/11/23 at 11:07 AM, Resident #3 was observed from the hallway in his/her bed with his/her legs entirely exposed. On approach, a large bruise was visible on his/her left leg between his/her knee and ankle. When asked how s/he got the bruise, Resident #3 said that s/he had fallen. S/He appeared weak and asked if s/he could have a drink. There were no drinks on his/her bedside table. When asked how s/he normally asks for a drink, s/he gestured to the call bell cable which was wrapped around the bedrail tightly. S/he was unable to reach it; if s/he could reach it, pulling on the cable wouldn't activate the system as it was wrapped too tightly. Per record review, Resident #3's care plan includes the following care plan focus: Resident is at risk for falls/has actual fall [history] of repeat falls, Parkinson's Disease, Muscle weakness, history of orthostatic hypotension. Recommended to have limited assist, however due to confusion she ambulated by herself, created on 9/23/22. Interventions created before 9/1/23 include: Implement the following safety precautions: proper footwear, created on 12/1/22, ensure call light is within reach, created 9/23/22, and Therapy/Rehab-PT/OT screen, created on 4/23/23. A 5/4/23 elopement evaluation states that resident is a known wander and fall risk. Per review of facility incident reports since 9/1/23, Resident #3 had falls on 9/1/23, 9/2/23, 9/14/23, 9/24/23, 10/7/23, and 10/14/23. The incident reports reveal the following: On 9/1/23, Resident #3 had an unwitnessed fall in his/her room. On 9/2/23 Resident #3 had an unwitnessed fall. Resident #3 had wandered into another resident's room and fell , hitting his/her head on furniture. As a result, Resident #3 had a skin tear to his/her lower left leg and large bruises on his/her left shoulder and elbow. On 9/14/23, Resident #3 had an unwitnessed fall in his/her room. On 9/24/23, Resident #3 had a witnessed fall. Staff found Resident #3 ambulating in the hall without his/her walker and s/he lost his/her balance. On 10/7/23, Resident #3 had an unwitnessed fall in his/her room. A 10/10/23 progress note reveals bruising to Resident 3's leg. On 10/14/23, Resident #3 had an unwitnessed fall in his/her room. Review of care plan revisions related to fall prevention for Resident #3 since 9/1/23 include the following: Encourage resident to keep her nonskid socks on [her/his] feet, created on 9/1/23. This is a rephrase of a prior intervention created on 12/1/22. Continue to encourage to wear non skid footwear, created on 9/4/23. This is a rephrase of prior interventions created on created on 12/1/22 and 9/1/23. Therapy referral, created on 9/28/23. This is a rephrase of a prior intervention created on 4/23/23, In addition, a 9/5/23 progress note indicated that Resident #3 was recently referred to therapy. Although care plan interventions were created after Resident #3's fall on 9/1/23, 9/2/23, and 9/24/23, they were rewordings of prior interventions. No additional interventions were created after Resident #3's falls on 9/14/23, 10/7/23, and 10/14/23 falls. There are no care plan interventions addressing the wandering that occurred during the 9/2/23 fall as described above, until 10/12/23. Per interview on 10/18/23 at 12:33 PM, an LNA, when asked about interventions to prevent falls for Resident #3, indicated that there are not enough staff to provide Resident #3 with routine supervision. S/He explained that sometimes s/he might be the only LNA on the floor and in those times s/he is unable to complete care for all the residents on her/his assignment. Per observation on 10/18/23 at 3:30 PM, Resident #3 was sitting on his/her walker in his/her room, struggling to close his/her top dresser, which is located against the wall across the foot of her/his bed. S/He states that s/he is thirsty. There are six full cups of drinks on the bedside table which is located near the top of his/her bed. When asked if s/he realized there were drinks on the bedside table, s/he said that s/he could not reach them and asked for help getting into the bed. When asked if s/he could pull the call bell for help, s/he revealed that s/he did not know where it was. The call bell was clipped to the head of the bed, out of his/her reach. This was the second observation of Resident #3 unable to reach the call bell. Per interview on 10/19/2023 at 1:09 PM, the Market Clinical Lead confirmed that Resident #3's care plan was not revised with new interventions to reduce the likelihood of another fall after each fall referenced above .

Based on interviews and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident # 1) with a urinary catheter receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] following a hospital stay for cardiac complications. Resident #1's health history included congestive heart failure, diabetes, cardiac disease, hypertension, and stroke. A hospital discharge note dated 9/21/23 reveals that Resident #1 had an indwelling urinary catheter. Facility policy titled NGS209 Catheter: Urinary- Justification for Use, last reviewed 8/7/23 states: Patients who have urinary catheters upon admission or subsequently receive one will be assessed for removal of the catheter as soon as possible unless the patient's clinical condition demonstrates that catheterization is necessary. If patient's situation meets any of the indwelling catheter criteria, obtain physician order, include in care plan, and follow Catheter: Indwelling Urinary-Care of procedure. Facility Procedure titled Catheter: Indwelling Urinary-Care of indicates that catheter care should be performed and documented twice a day and as needed, and the catheter drainage bag should be emptied when it becomes 1/2 to 2/3 full. Per record review, Resident #1's medication and treatment administration records and physician orders reveal that Resident #1 did not have an order for an indwelling catheter, orders to empty the catheter drainage bag, or orders for catheter care every day and night shift until approximately 8:30 PM on 9/23/23. The treatment record reveals that Resident #1's catheter drainage bag was only emptied six times during their stay and catheter care was only performed 4 times during their stay. There is no evidence that nursing staff or a physician assessed Resident #1 for removal of the catheter during their stay. Per interview on 10/19/23 at 4:01 PM, Resident #1's Representative stated that Resident #1 was using a commode during the hospital stay for bowel elimination and was told by hospital providers that Resident #1 should not being wearing briefs if s/he is continent of bowels because it would increase the chance of him/her getting a UTI (urinary tract infection ). When the Representative asked staff why Resident #1 was wearing a brief, staff told them that Resident #1 was incontinent of their bowels and was not allowed to be transferred out of bed. The Representative explained that Resident #1 was not incontinent of bowels, that they were only wearing briefs on admission because of the long drive from the hospital to the facility, in which Resident #1 had soiled themselves. S/He reports that both s/he and Resident #1 had asked to use the toilet and get out of bed multiple times and was told by facility staff that staff were not allowed to get them out of bed because they were not cleared to get him/her out of bed. The Representative explained that s/he visited the facility multiple times during Resident #1's stay, for extended periods of time, and observed him/her in a brief the entire time. Per interview on 10/18/23 at 2:37 PM, a Licensed Nurse Aide indicated that Resident #1 was wearing a brief because they were incontinent of their bowels and believed they were not allowed to be transferred out of bed to use the toilet because they had not been assessed by therapy yet. Per interview on 10/18/23 at 3:05 PM, the Nurse Manager stated that residents that are not incontinent should not be put in briefs and confirmed that incontinence should not be determined just by the status of the resident on admission, but also based on report from the sending facility, resident, or resident representative. Per record review, Resident #1 was transferred to the hospital on 9/25/23. A 9/25/23 hospital provider note reveals that Resident #1 presents to the ER (emergency room ) with abdominal pain, chest pain, nausea, and vomiting, describing the pain as severe and constant for days. A 9/26/23 hospital provider note indicates that assessment reveals that Resident #1 has the following acute complications: small bowel obstruction, urinary tract infection (UTI), pneumonia, and renal failure. Notes further reveal that Resident #1 was discharged home on hospice on 9/26/23. A [NAME] Certificate of Death reveals that Resident #1 passed away on 9/27/23 with the cause of death determined to be Sepsis in the Setting of Pneumonia, Acute Urinary Tract Infection, and Spontaneous Small Bowel Obstruction. Per interview on 10/19/2023 at 1:09 PM, the Market Clinical Lead stated that the use of a brief for Resident #1 was due to him/her being incontinent of their bowels on admission and confirmed that s/he should have been reassessed for incontinence following admission, which had not been done. S/He confirmed that wearing a brief increases the risk for bacterial growth, increasing their risk for a UTI. S/He stated that the admitting nurse should have put in orders for Resident #1's catheter and catheter care. S/He confirmed that this was not done and there was no evidence that catheter care was performed before 9/23/23. S/He confirmed that a catheter care plan was not created until 9/25/23 and it should have been created within 48 of his/her admission.

Based on observation, record review, and interview, the facility failed to provide safe and effective skin and wound care consistent with facility policy and professional standards of practice for 3 of 3 sampled residents (Residents #1, #2, and #3) to prevent and treat existing pressure ulcers by failing to: accurately perform and document skin inspections (skin checks), accurately and regularly perform pressure ulcer wound evaluations per facility schedule, perform and document daily monitoring of pressure ulcer wounds or dressings, obtain treatment orders from physician, follow physician's orders for treatment, implement care plan interventions related to wound treatment, and revise care plans to meet resident's skin and wound care needs. Findings include: 1. Record review and interview reveal that Resident #2 was at risk for developing pressure ulcers and developed three pressure ulcers after admission. The facility failed to provide timely and accurate skin and wound assessments, provide pressure ulcer treatment and dressing changes, create and revise his/her care plan to reflect his/her clinical skin condition and needs, and provide daily monitoring of existing pressure ulcers placing Resident #2 at increased risk for wound complications and developing additional pressure ulcers. Record review reveals that Resident #2 was admitted to the facility on [DATE] and has diagnoses that include: Heart failure, hypertension, history of stroke, type 2 diabetes, and neurogenic bladder. Resident #2's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 2/6/2023 reveals that s/he is at risk for developing pressure ulcers. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. On admission Resident #2 had the following physician orders: left heel protector to left heel at all times every shift, and calazimine to redness on coccyx [the lowest part of the back, directly below the sacrum], penis and scrotum two times a day for redness. On 2/7/2023, A skin assessment notes Pressure Area(s): Location(s): Redness/excoriation on sacrum and under both butt cheeks. Calazime cream applied. A progress note dated 2/12/23 reveals that a CNA [Certified Nurse Aide] alerted RN [Registered Nurse] of blister on left heel. No pain on assessment. Sponge dressing applied for protection. MD and DON [Director of Nursing] aware. Left voicemail for family. Foam foot protector in place. A 2/14/2023, a skin check notes that no skin injuries/wounds are identified. Resident #2 was transferred to the hospital on 2/19/2023 due to an altered mental state. A wound consult note from the hospital reveals that Resident #2 has right and left heel deep tissue injuries, a reddened area to the sacrum, and a pink area to the right medial thigh. The following recommendations were made for treatment to the sacrum and right medial thigh: provide skin hygiene with soap and water, pat dry, apply zincoxide skin barrier (orange tube), apply skin prep to periwound skin, apply small sacral mepilex [foam dressing] to sacrum, apply 4x4 mepilex to right medial thigh, and change dressing every 3 days and prn [as needed]. The following recommendations were made for treatment to the heels: provide hygiene to the lower extremities, pat dry, apply Lubriderm to shins and feet, paint heels with betadine and allow to dry, cover with mepilex, apply booties to bilateral feet, change dressing every other day and prn. Resident #2 was readmitted to the facility on [DATE]. A readmission nursing assessment identifies the following Rash(es): Description: On buttock, red, fungal MASD [moisture associate skin damage]: Description: coccyx Skin Tear(s): Description: small abrasions on coccyx, healing Pressure(s): Description: Left heel has purple blisters and small scab .5 cm. On 2/27/2023, a provider note reveals the following Pressure ulcer of right and left heel: Stable. Skin of bilateral heels are intact. Continue with wound care and heel protector boot on left foot. Groin rash: Stable. A 3/4/2023 skin check reveals injury to the buttocks area. There is no documentation of right or left heel wounds. A 3/10/2023 wound evaluation reveals that Resident #2 has an unstageable left heel pressure ulcer. On 3/10/2023, the treatment administration record (TAR) shows the first physician order for wound treatment to Resident #2's left heel. On 3/11/2023, the TAR shows the first physician order for wound treatment to Resident #2's right heel. A 3/11/2023 skin check reveals a scratch on Resident #2's nose. There is no documentation of the injuries/wounds to Resident #2's heels or sacrum. On 3/15/2023, the first wound evaluation was completed for Resident #2, revealing an unstageable left heel ulcer. No evaluations were done for Resident #2's sacrum or right heel. On 3/22/2023, wound evaluations reveal an unstageable left heel ulcer and a stage 3 pressure ulcer [full thickness skin loss] to the coccyx. On 3/22/2023, the TAR shows the first physician order for wound treatment to Resident #2's coccyx. On 3/22/2023, 51 days after admission, a care plan was created for Resident #2 with the following focus: Resident at risk for skin breakdown related to advanced age (great than [AGE] years), frail fragile skin, impaired cognition, incontinence and has actual skin breakdown. On 3/24/2023, wound evaluations reveal an unstageable left heel ulcer, a stage 2 pressure ulcer [partial-thickness skin loss with exposed dermis] to the right heel, a stage 3 pressure ulcer to the coccyx, and a deep tissue injury to the left hand. There is no documentation of daily wound monitoring of Resident #2's wounds prior to 3/24/2023. 2. Record review and interview reveal that Resident #1 was readmitted to the facility from the hospital on 3/20/2023 with a stage 2 pressure ulcer. The facility failed to provide timely and regular skin and wound assessments, provide pressure ulcer treatment and dressing changes, revise his/her care plan to reflect his/her clinical skin condition and needs, and provide daily monitoring of existing pressure ulcers, placing Resident #1 at increased risk for wound complications and developing additional pressure ulcers. Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility from the hospital on 3/20/2023 with diagnoses that include: type 2 diabetes, dementia, peripheral vascular disease, absence of two left toes, heart disease, major depressive disorder, and abnormalities of gait and mobility. Resident #1's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. A facility incident report reveals that Resident #1 had falls on 3/6/2023 and 3/10/2023. A nursing note dated 3/11/2023 states that Resident #1 was sent to the hospital on 3/10/2023 for further evaluation. A Podiatry note dated 3/13/2023 reveals that Resident #1 had Partial thickness wounds medial and lateral ankle areas and posterior heel, and recommendations were made for daily dressing changes, avoidance of anything but paper tape, and use of a prevalon or comparable heel offloading boot. A hospital wound assessment dated [DATE] reveals that Resident #1 had a stage 2 pressure ulcer on his/her left ankle. A hospital discharge summary dated 3/20/2023 refers to the podiatrist's instructions regarding wound care/dressing changes to left foot and to consult a wound care nurse to evaluate and treat patient's foot wounds. A nurse note dated 3/20/2023 states that Resident #1 was readmitted from the hospital on 3/20/2023 and had Dressing to left foot, moderate amount sero/sang drainage [Serosanguineous; pink watery fluid] to dressing. Dressing not removed at this time, awaiting wound care instructions. On 3/23/2023 at approximately 1:00 PM, Resident #1 was observed in bed. His/her legs were bare, and his/her left foot was dressed with multiple bandages and pressed into the footboard of the bed. The outer dressing was visibly bloody, along with the fitted bed sheet. At 1:55 PM, a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) inspected the dressings. A gauze wrap was removed from the lower section of the foot which was soiled with blood and fluid. Two padded bandages were revealed wrapping the back of Resident #1's left ankle area. These bandages were dated 3/19/23. On 3/23/2023 at 2:10 PM, the DON stated that s/he thinks that the nursing staff were waiting to get dressing orders before doing a wound assessment and a dressing change per the nursing note on 3/20/23. S/He confirmed that the readmission skin assessment did not include the wound on Resident #1's ankle and that there were no physician orders for treatment of the wound on his/her ankle. Further review of Resident #1's medical record reveals the flowing: Upon return to the facility, the 3/20/2023 nursing skin assessment does not document the pressure ulcer located on Resident #1's ankle. There are no physician's orders for wound care for Resident #1's pressure ulcer upon returning to the facility on [DATE] through 3/32/2023. There is no wound assessments or documentation of daily wound monitoring of Resident #1's pressure ulcer from 3/20/2023 through 3/24/2023. Resident #1's care plan was not revised to include actual skin breakdown related to his/her left ankle pressure ulcer until 3/23/2023. On 3/23/2023 at 2:10 PM, the DON confirmed that no one in the facility has assessed Resident #1's wound, treated his/her wound, or updated his/her care plan to reflect the actual wound. 3. Record review and interview reveal that Resident #3 was at risk for developing pressure ulcers and developed three pressure ulcers after admission. The facility failed to provide timely and accurate skin and wound assessments, revise his/her care plan to reflect his/her clinical skin condition and needs, and provide daily monitoring of existing pressure ulcers placing Resident #3 at increased risk for wound complications and developing additional pressure ulcers. Record review reveals that Resident #3 was admitted to the facility on [DATE] and has diagnoses that include: heart failure, Alzheimer's disease, chronic embolism and thrombosis, osteoarthritis, hypertension, and anemia. Resident #3's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. Resident #3's care plan for risk for skin break down was created on 2/10/2023, 7 days after admission. On 3/7/2023, a skin check reveals that resident #3 has 3 blood filled blisters to left outer foot and heel and rt [right] heel. On 3/10/2023, wound evaluations reveal a deep tissue pressure injury of the right heel, a deep tissue pressure injury of the left lateral foot, and a deep tissue pressure injury of the left heel. Skin checks on 3/21/2023 and 3/22/2023 do not reveal any skin injuries/wounds for Resident #3. On 3/23/2023, a skin check reveals that resident #3 has deep tissue pressure injuries to the left and right heel and an unstageable pressure ulcer to the left malleolus [ankle area]. Resident #3's care plan was not updated to reflect actual wounds until 3/23/2023. Facility policy titled NSG236 Skin Integrity and Wound Management, last revised on 2/1/2023, states: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influences skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed.Practice Standards include: 6. A licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. 6.6 Perform daily monitoring of wounds or dressings for presence of complications or declines. 6.6.1 Document daily monitoring of ulcer/wound site with or without dressing. 9. Notify physician/APP to obtain orders. 11. Review care plan and revise as indicated. On 3/23/2023 at 2:10 PM, the Director of Nursing stated that skin checks should document all skin injuries and wounds, even if they have been there for a while. On 4/7/2023 at 11:12 AM, the Market Clinical Lead confirmed that skin assessments should include all wounds, even if they are not new, until they are resolved. S/He confirmed that Residents #1, #2, and #3 did not have consistently accurate skin checks, did not have daily monitoring of wounds and that their care plans were not updated to reflect actual wounds. S/He also confirmed the dates above for the creation of Resident #1, #2 wound treatment orders.

Based on observation, record review, and interview, the facility failed to provide safe and effective skin and wound care consistent with facility policy and professional standards of practice for 1 applicable resident (Resident #1) with existing non-pressure ulcer wounds by failing to: accurately perform and document skin inspections (skin checks), accurately and regularly perform non-pressure ulcer wound evaluations per facility schedule, perform and document daily monitoring of non-pressure ulcer wounds or dressings, follow physician's orders for treatment and implement care plan interventions related to wound treatment. Findings include: Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility from the hospital on 3/20/2023 with diagnoses that include: type 2 diabetes, dementia, peripheral vascular disease, absence of two left toes, heart disease, major depressive disorder, and abnormalities of gait and mobility. A facility incident report reveals that Resident #1 had falls on 3/6/2023 and 3/10/2023. A provider note dated 3/9/2023 reveals that Resident #1 had complaints of pain to his/her left ankle/heel and right rib cage; and left foot bruising and swelling 3 days post fall. A change in condition note dated 3/10/2023 reveals the following nursing observations: LLE [left lower extremity] presents swollen bruised on 3/8 with open area to the planter area of the left foot, now red hot to touch, initial xray negative for fx [fracture], Resident with marked decreased in physical abilities and requires max assist with adls [activities of daily living], WBC [white blood cells] elevated. Refusing meals. Significant decline from usual baseline. A nursing note dated 3/11/2023 states that Resident #1 was sent to the hospital on 3/10/2023 for further evaluation. An emergency department provider note dated 3/11/2023 states that Resident #1's diagnosis of septic shock likely secondary to cellulitis and potential pneumonia. A Podiatry note dated 3/13/2023 reveals that Resident #1 had L [left] foot with full thickness ulceration plantar [bottom of the foot] L 2nd metatarsal [foot bones that connect to the toes] head present for months with probe to bone, exposed bone, and purulence, and recommendations were made for daily dressing changes, avoidance of anything but paper tape, and use of a prevalon or comparable heel offloading boot. A hospital provider progress note dated 3/14/23 states that the source Resident #1's septic shock was from a diabetic foot wound with osteomyelitis/cellulitis LLE. A hospital discharge summary dated 3/20/2023 reveals that Resident #'s 1 wound on the plantar surface of his/her left foot had been there for months, probed down to the bone, and had purulent drainage. It stated that Resident #1 did not want surgical management of his/her foot but agreed to wound treatment, dressing changes, pain medication, and antibiotics as needed. The note refers to the podiatrist's instructions regarding wound care/dressing changes to left foot and to consult a wound care nurse to evaluate and treat patient's foot wounds. A nurse note dated 3/20/2023 states that Resident #1 was readmitted from the hospital and had Dressing to left foot, moderate amount sero/sang drainage [Serosanguineous; pink watery fluid] to dressing. Dressing not removed at this time, awaiting wound care instructions. On 3/23/2023 at approximately 1:00 PM, Resident #1 was observed in bed. His/her legs were bare, and his/her left foot was dressed with multiple bandages and pressed into the footboard of the bed. The outer dressing was visibly bloody, along with the fitted bed sheet. On 3/23/2023 at 1:19 PM, a Licensed Nurse Aide (LNA) stated that Resident #1 needed supervision with some ADLs before s/he went to the hospital. Since Resident #1 has returned, they have had a change in ability and now require staff assistance for ADLs. The LNA noted that Resident #1 has not left his/her bed since s/he was readmitted . On 3/23/2023 at 1:55 PM, a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) were observed inspecting Resident #1's dressings. A gauze wrap was removed from the lower section of the foot which was soiled with blood and fluid. Two padded bandages were revealed wrapping the back of Resident #1's left ankle area. These bandages were dated 3/19/23. At approximately 2:00 PM on 3/23/2023, an LPN stated that Resident #1 was not receiving appropriate wound care because the bandage that was on the wound was not appropriate for the amount of fluid that was coming out of it. S/he stated that sometimes s/he has to change the dressing twice in a shift because it gets so bad and that the wound has been there for a long time. On 3/23/2023 at 2:10 PM, the DON stated that Resident #1 does have a chronic diabetic foot ulcer and there are physician orders to treat it. S/He thinks that the wound has a history of opening and closing. S/he also thinks that the nursing staff were waiting to get dressing orders before doing a wound assessment and a dressing change per the nursing note on 3/20/23. Facility policy titled NSG236 Skin Integrity and Wound Management, last revised on 2/1/2023, states: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influences skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Practice Standards include: 6. A licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds; 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition; 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds; 6.6 Perform daily monitoring of wounds or dressings for presence of complications or declines. 6.6.1 Document daily monitoring of ulcer/wound site with or without dressing. Further review of Resident #1's medical record reveals the flowing: Resident #1's care plan includes the following focus: [Resident] has Diabetic Ulcer r/t Diabetes, Lack of sensation to affected area, created on 5/31/2022. Interventions include: Ensure appropriate protective devices are applied to affected areas, created on 5/31/2022, Monitor/document wound: Size, Depth, Margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene, Document progress in wound healing on an ongoing basis. Notify MD as indicated, created on 5/31/2022, and Treat wound as per facility protocol, created on 5/31/2022. Skin checks on 2/7/2023, 2/10/2023, 2/17/2023, 2/25/2023, and 3/4/2023 do not include documentation of Resident #1's diabetic foot ulcer. There are no physician's orders for wound care in February or the beginning of March 2023. The following physician's orders started on 3/9/2023: Ball of left foot. Cleanse with wound cleanser, pat dry, apply double layer xeroform to wound bed. Cover with DPD. every 1 hours as needed for wound care, and 3/10/2023: Ball of left foot. Cleanse with wound cleanser, pat dry, apply double layer xeroform to wound bed. Cover with DPD. every day shift for wound. There is no documentation in the treatment administration record (TAR) or medication administration record (MAR) that the wound was treated when Resident #1 returned from the hospital on 3/20/2023 through 2:00 PM on 3/23/2023. There are no weekly wound assessments or documentation of daily wound monitoring, of Resident #1's diabetic foot ulcer in February or March prior to 3/24/2023. On 4/7/2023 at 11:12 AM, the Market Clinical Lead confirmed that skin assessments should include all wounds, even if they are not new, until they are resolved. S/He confirmed that Resident #1 did not have: accurate skin assessments prior to transferring to the hospital on 3/10/2023, physician orders for his/her diabetic ulcer until 3/9/2023, and that wound assessments and monitoring did not occur until 3/24/2023.

Based on staff interview and record review, the facility failed to ensure that staff were certified to provide basic life support, including Cardiopulmonary Resuscitation (CPR), and familiar with facility policies related to CPR. Findings include: 1. Per record review, facility staff failed to follow advance directives and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's medical record includes: a DNR/COLST (Clinician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2] has an advanced directive of Full Code, with the goal listed as [Resident #2]'s advanced directives will be honored, and an intervention listed as CPR will be performed as need. Review of the facility's policy and procedure titled NSG107 Emergency: Medical Response, under Policy reads Response to medical emergencies will be delivered within the scope of practice of the licensed nursing staff. If the patient is in cardiac and/or respiratory arrest, refer to Cardiac and/or Respiratory Arrest policy and procedure. Systems will be in place for: Eliciting assistance from co-workers; and Identification of patient code status. Review of the facility's policy and procedure titled NSG208 Cardiac and/or Respiratory Arrest, under Policy reads: Centers support the right of every patient to accept or decline cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The Center will perform CPR on all patients, except in limited circumstances, unless there is a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR is to be provided in the location where the patient is discovered as long as the location is safe for the responder and patient. A written statement given to the facility by the first staff member to find Resident #2 unresponsive on [DATE] stated that, after s/he found Resident #2 unresponsive sometime between 10:00 PM and 10:10 PM, s/he located the A Wing Licensed Practical Nurse (LPN). S/he stated that this LPN assessed Resident #2 for heartbeat and breathing and then told him/her that '[Resident #2] passed and to start postmortem care.' A written statement given to the facility by the first licensed nurse present (A Wing LPN) after Resident #2 was found unresponsive stated that, s/he confirmed Resident #2 was unresponsive sometime after 10:00 PM on [DATE], that s/he did not know Resident #2's code status, and did not immediately initiate CPR. This LPN then found out from other staff that Resident #2 is a full code. This LPN did not initiate CPR when finding out the code status. Instead, s/he called the weekend supervisor at 10:46 PM who instructed him/her to perform CPR immediately unless rigor mortis or lividity was present. This LPN was joined by another LPN who then initiated CPR on Resident #2. Per interview, on [DATE] at 12:16 PM, the LPN to first initiate CPR on Resident #2 confirmed that the first licensed nurse to discover that Resident #2 was unresponsive did not start CPR after knowing that Resident #2 is a full code. S/he stated that s/he, himself/herself, initiated CPR at approximately 10:47 PM and emergency medical services (EMS) were called. Shortly after EMS' arrival, EMS pronounced Resident #2 deceased . Per interview on [DATE] at 2:45 PM, the first licensed nurse present after Resident #2 was found unresponsive stated that s/he has not received any training about facility specific code status from the facility. On [DATE] at 1:08 PM, the Director of Nursing confirmed that licensed nurses should follow facility policy about initiating CPR as indicated by their code status, and that staff did not initiate CPR according to policy for Resident #2. 2. Review of the facility's policy and procedure titled NSG208 Cardiac and/or Respiratory Arrest, under Policy reads: Licensed nursing staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in personal skills assessment, and Licensed nurses will be trained in the evaluation of the obvious clinical signs of irreversible death upon hire. On [DATE] at 10:40, a licensed nurse stated that s/he hasn't been recertified in CPR since before s/he was hired over three years ago, and that the facility doesn't follow up on these kinds of things. On [DATE] at 1:08 PM, the Director of Nursing stated that Human Resources (HR) should have CPR certifications for nursing staff on file, as they should get it upon hire. S/he is unsure if HR has CPR cards on file for contracted staff or if it is in their agency files. S/he stated that the Nurse Educator would be the person to go over facility policies about CPR. On [DATE] at 1:30 PM the Human Resource Director stated that s/he does not get CPR certification from employees, and s/he guesses that s/he should be. S/he was not able to produce CPR certification cards for four employees when requested by this surveyor. On [DATE] at 1:40 PM, the Nurse Educator stated that s/he does not get a CPR certification from new employees on hire and does not know who goes over facility policies, but it is probably HR (Human Resources). S/he could not produce cardiac and respiratory arrest competencies or trainings for any staff. S/he is unsure who oversees that staff are recertified when their certification expires. S/he confirmed there is no system in place to ensure that nursing staff are properly certified or trained to perform CPR. Per interview on [DATE] at 2:45 PM, an LPN stated that s/he has not received any training about facility specific code status from the facility. On the afternoon of [DATE], facility staff, including the Administrator and DON, agreed that their staff couldn't produce evidence that the facility has CPR certified staff on duty ,d+[DATE] as required or ensure that staff is familiar with facility policies related to CPR. The facility currently has 26 residents that are a full code. These 26 residents would require CPR certified staff in the event of cardiac arrest.

Based on interview and record review, the facility staff failed to provide services that meet professional standards of quality for 1 of 9 applicable residents in the sample (Resident #2). Findings include: Per record review, facility staff failed to follow advance directives and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's medical record includes: a DNR/COLST (Clinician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2] has an advanced directive of Full Code, with the goal listed as [Resident #2]'s advanced directives will be honored, and an intervention listed as CPR will be performed as need. Review of the facility's policy and procedure titled NSG208 Cardiac and/or Respiratory Arrest, under Policy reads: Centers support the right of every patient to accept or decline cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The Center will perform CPR on all patients, except in limited circumstances, unless there is a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR is to be provided in the location where the patient is discovered as long as the location is safe for the responder and patient. A written statement to the facility given on [DATE] by the first staff member to find Resident #2 unresponsive stated that after s/he found Resident #2 unresponsive sometime between 10:00 PM and 10:10 PM, s/he located the A Wing Licensed Practical Nurse (LPN). S/he stated that this LPN assessed Resident #2 for heartbeat and breathing and then told him/her that '[Resident #2] passed and to start postmortem care.' A written statement to the facility given on [DATE] by the first licensed nurse present (A Wing LPN) after Resident #2 was found unresponsive stated that s/he confirmed Resident #2 was unresponsive sometime after 10:00 PM on [DATE] and that s/he did not know Resident #2's code status and did not immediately initiate CPR. This LPN then found out from other staff that Resident #2 is a full code. This LPN did not initiate CPR when finding out the code status. Instead, s/he called the weekend supervisor at 10:46 PM who instructed him/her to perform CPR immediately unless rigor mortis or lividity was present. This LPN was joined by another LPN who initiated CPR on Resident #2. On ,d+[DATE] at 12:16 PM, the LPN to first initiate CPR on Resident #2 confirmed that the first licensed nurse to discover that Resident #2 was unresponsive did not start CPR after knowing that Resident #2 is a full code. S/he stated that s/he, himself/herself, initiated CPR at approximately 10:47 PM and emergency medical services (EMS) were called. Shortly after EMS' arrival, EMS pronounced Resident #2 deceased . On [DATE] at 1:08 PM, the Director of Nursing confirmed that licensed nurses should follow facility policy about initiating CPR as indicated by their code status, and that staff did not initiate CPR according to policy for Resident #2. Ref: Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 applicable residents did not develop pressure ulcers, and received treatment and services to promote healing and prevent new ulcers from developing (Resident #75). The findings include the following: Per review of the medical record for Resident #75, was admitted on [DATE]. During an interview on 4/22/19 at approximately 2:30 PM, Resident #75 identified that s/he has a sore somewhere on his/her buttocks. Per interview with the Registered Nurse (RN) and review of the Treatment Administration Record (TAR) for the month of (MONTH) 2019, there is a physician's orders [REDACTED]. The treatment began on 4/16/19. Per review of progress notes dated 4/15/19, the RN identifies a red area with dry skin noted to left buttocks, covered with [MEDICATION NAME] dressing. Progress notes signed by the RN and dated 4/17/19, identify open area to buttock clean dressing in place. Progress notes dated 4/19/19 care plan meeting show evidence that family questions the bed sore on his/her buttocks. Nursing explains why they think that the bed sore might have come about. (The documentation does not include the facility staff explanation). The family voices they are concerned with the sore on his/her buttocks and would like an update from nursing in one week. Further notes dated 4/20/19, signed by the RN, identify an open area to buttock, clean and dressing in place. Per review of the medical record, a pressure ulcer assessment was not completed until 4/23/19, some 8 days after the pressure ulcer was identified. The Skin-Pressure Ulcer assessment completed on 4/23/19 identifies a facility acquired, Stage 2 pressure ulcer on the left inner buttocks, measuring 0.5 centimeters (cm.) in length x 0.7 cm. in width and a depth less than 0.1 cm. At the time of the assessment on 4/23/10 at approximately 4:30 PM, in the presence of the Unit Manager (UM), Director of Nurses (DNS) and the Clinical Quality Specialist, a second facility acquired pressure ulcer was identified on Resident #75's inner right buttocks. The area is identified as a facility acquired Stage 2 pressure ulcer, measuring 0.1 cm. in length x 0.2 cm. in width and a depth less than 0.1 cm. Dressings were applied to both wounds. Per review of the Skin Integrity Management policy dated 11/28/16, according to Practice Standards, staff are instructed to perform wound observations and measurements and complete a Skin Integrity Report upon initial identification of altered skin integrity, weekly and with anticipated decline of the wound. The UM and the DNS both confirm that the wound to the left buttocks was not measured until 8 days after the wound had been identified. Confirmation was also made that the facility policy was not followed.

Based on staff and pharmacist interviews and medical record reviews, the facility failed to assure that 1 of 2 residents in an applicable sample (Resident # 1) was free from significant medication errors. Findings include: Per medical record review, Resident # 1 was incorrectly administered [MEDICATION NAME] during an admission to the facility for short term rehab following hip surgery. During this admission, Resident # 1 had a physician order [REDACTED]. The physician order [REDACTED]. Give 4 tablets by mouth in the morning for RA and give 4 tablets by mouth in the evening every Wed for RA. This order was transcribed by a registered nurse onto the Medication Administration Record [REDACTED]. Resident # 1 received 4 pills on the day shift on 12/13, 12/14, 12/15, 12/16, 12/17, 12/18 and 12/20 that were not ordered by the rheumatologist. On 12/21/2018 a nurse called the pharmacy to request more pills because they would not have enough to get them through the weekend. Resident # 1 experienced a significant drop in his/ her blood counts to critical levels for hemoglobin, hematocrit, white cell count and platelets: 12/08/2018 labs revealed a white cell count of 12.92, a hemoglobin of 9.4, a hematocrit of 30.1 and platelets of 165x1000. Labs ordered and drawn on 12/23/2018, after the additional [MEDICATION NAME] doses, revealed a white cell count of 1.9, a hemoglobin of 6.8, a hematocrit of 26.6 and platelets of 62. Resident # 1 experienced bleeding from the lining of the stomach, hospitalization in the intensive care unit and intubation for respiratory distress. The pharmacist confirmed, during interview that s/he had dispensed 32 tablets to cover a 4 week span (8 tablets /day 1 time per week). The nurse confirmed, during interview that 7 extra doses of the medication were administered because of a transcription error. The nurse further confirmed, that facility policy of having a second nurse verify the orders did not happen. Cross cite at F0658

Based on staff and pharmacist interviews and medical record review, the facility failed to meet professional standards of quality for 1 of 2 residents in an applicable sample regarding failing to follow physician's orders [REDACTED].#1 and #2). Findings include: Per medical record review, Resident # 1 was incorrectly administered [MEDICATION NAME] during an admission to the facility for short term rehab following hip surgery. During this admission, Resident # 1 had a physician order [REDACTED]. The physician order [REDACTED]. Give 4 tablets by mouth in the morning for RA and give 4 tablets by mouth in the evening every Wed for RA. This order was transcribed by a registered nurse onto the Medication Administration Record [REDACTED]. Resident # 1 received 4 pills on the day shift on 12/13, 12/14, 12/15, 12/16, 12/17, 12/18 and 12/20 that were not ordered by the rheumatologist. On 12/21/2018 a nurse called the pharmacy to request more pills because they would not have enough to get them through the weekend. Resident # 1 experienced a significant drop in his/ her blood counts to critical levels for hemoglobin, hematocrit, white cell count and platelets: 12/08/2018 labs revealed a white cell count of 12.92, a hemoglobin of 9.4, a hematocrit of 30.1 and platelets of 165x1000. Labs ordered and drawn on 12/23/2018, after the additional [MEDICATION NAME] doses, revealed a white cell count of 1.9, a hemoglobin of 6.8, a hematocrit of 26.6 and platelets of 62. Resident # 1 experienced bleeding from the lining of the stomach, hospitalization in the intensive care unit and intubation for respiratory distress. The pharmacist confirmed, during interview that s/he had dispensed 32 tablets to cover a 4 week span (8 tablets /day 1 time per week). The nurse confirmed, during interview that 7 extra doses of the medication were administered because of a transcription error. The nurse further confirmed, that facility policy of having a second nurse verify the orders did not happen. Cross cite at: F0760 Ref: Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins, pg 17.

Based on record review and staff interviews, the facility failed to ensure that one sampled resident (Resident #1) received treatment and care in accordance with professional standards of practice, physician orders, and the comprehensive person-centered plan of care regarding diet orders for textures appropriate for that resident. Findings include: Per record review, Resident #1 has swallowing difficulties and was ordered to have an Advanced Dysphagia diet, including some pureed foods and ground meat only. Per review of the resident's record and the investigative summary by the facility, Resident #1 was served a lunch meal on 5/20/18 that included unground roast beef. The resident choked on the meat after the first bite, and was unable to clear their airway. Nursing staff performed the [MEDICATION NAME] Maneuver but were unable to clear the resident's airway. Emergency Medical Services were called, and the resident was transported to the hospital. The resident needed to be intubated and hospitalized as a result, and returned to the facility a few days later with some further decline in their swallowing ability that required liquids to now be thickened and meat to be pureed. The physician's orders [REDACTED]. The resident's plan of care included the intervention Provide diet as ordered. Per interview with dietary staff and an activity aide who served the meal to the resident, the dietary aide stated that there was no ground meat alternative available on the steam table, and the activity aide confirmed that they served the resident the incorrect consistency. On 5/29/18, the Administrator and the Director of Nursing confirmed that the physician's orders [REDACTED].#1 having the choking episode on 5/20/18. This citation is considered to be past non-compliance. The facility has taken the appropriate steps to correct this deficient practice. All staff have been trained in administering the [MEDICATION NAME] Maneuver to respond to choking emergencies. All meal tickets have been reviewed by a Registered Dietician for correct textures and diet restrictions, and licensed nurses are monitoring every plate at every meal to audit for correct meal types being served. All dietary staff, nursing staff, and activity staff have received education on types of diets, including textures allowed under mechanically altered diets. The Dietary Manager has been provided with the appropriate training materials for the education of the dietary staff. Per observation on 5/29 and 5/30/18, the lunch meal service was monitored closely by nursing staff, and appropriate ordered diet textures were served to residents.

Based on record review and staff interview, the facility failed to ensure that 1 applicable resident (Resident #1) recieved the appropriate physician ordered diet. Findings include: Per record review, Resident #1 has swallowing issues for which they were prescribed a Dysphagia Advanced diet with ground meat by the physician, as well as the same recommended by the Speech Language Pathologist after evaluating the resident. At the lunch meal on 5/20/18, Resident #1 was served meat that had not been ground, and subsequently choked and required hospitalization and intubation as a result. The meal ticket generated by the kitchen was correctly listed as ground meat, and the resident's plan of care stated provide diet as ordered. The dietary staff serving the meal plated the unground meat, and the activity aide served this plate to the resident despite reading the meal ticket and telling the dietary aide that Resident #1 was supposed to have ground meat. The resident choked on the first bite of the meal and required the [MEDICATION NAME] Manuever and transport to the hospital. Refer also to F802. This citation is considered to be past non-compliance. The facility has taken the appropriate steps to correct this deficient practice. All staff have been trained in administering the [MEDICATION NAME] Maneuver to respond to choking emergencies. All meal tickets have been reviewed by a Registered Dietician for correct textures and diet restrictions, and licensed nurses are monitoring every plate at every meal to audit for correct meal types being served. All dietary staff, nursing staff, and activity staff have received education on types of diets, including textures allowed under mechanically altered diets. The Dietary Manager has been provided with the appropriate training materials for the education of the dietary staff. Per observation on 5/29 and 5/30/18, the lunch meal service was monitored closely by nursing staff, and appropriate ordered diet textures were served to residents.

Based on record review and staff interview, the facility failed to ensure that dietary staff and support personnel had the appropriate competencies and skills to safely carry out food service functions for one applicable resident (Resident #1). Findings include: Per record review, Resident #1 was prescribed a mechanically altered (Dysphagia Advanced) diet with ground meat by the physician, as well as the same diet as recommended by the Speech Language Pathologist after evaluating the resident. At the lunch meal on 5/20/18, Resident #1 was served meat that had not been ground, and subsequently choked and required hospitalization and intubation as a result. The meal ticket generated by the kitchen was correctly listed as ground meat, and the resident's plan of care stated provide diet as ordered. The dietary staff serving the meal plated the unground meat, and the activity aide served this plate to the resident despite reading the meal ticket and telling the dietary aide that Resident #1 was supposed to have ground meat. Per interview on 5/30/18 at 10:35 AM, the dietary aide stated they had only received two days of orientation before being independently serving food to residents. The dietary aide stated that they did not have a full understanding of the dietary textures and Dysphagia diet requirements before independently serving the residents. Per interview on 5/29/18, the Dietary Service Manager stated that the training had been provided verbally to the dietary aide and that there was no evidence of training documented for this new dietary aide, or documentation that the orientee was supervised appropriately while learning the requirements of the job. Per interview on 5/30/18, the Regional District Manager for the food service provider contracted by the facility confirmed that the proper materials for training staff were not provided to the Dietary Manager per the policy of the food service company, and that the training protocol was not followed for the dietary aide that served the incorrect texture to Resident #1. Per interview on 5/30/18 at 1:00 PM, the Administrator of the facility confirmed that there was no documented evidence that the activity aide who served the resident the incorrect textured meal had received training in understanding the appropriate textures for a Dysphagia Advanced diet with ground meat. This citation is considered to be past non-compliance. The facility has taken the appropriate steps to correct this deficient practice. All staff have been trained in administering the [MEDICATION NAME] Maneuver to respond to choking emergencies. All meal tickets have been reviewed by a Registered Dietician for correct textures and diet restrictions, and licensed nurses are monitoring every plate at every meal to audit for correct meal types being served. All dietary staff, nursing staff, and activity staff have received education on types of diets, including textures allowed under mechanically altered diets. The Dietary Manager has been provided with the appropriate training materials for the education of the dietary staff. Per observation on 5/29 and 5/30/18, the lunch meal service was monitored closely by nursing staff, and appropriate ordered diet textures were served to residents.

Based on medical record review, staff interviews, review of the facility internal investigation of an accident and review of transportation policies, the facility failed to assure that 1 of 18 residents received adequate supervision and assistance to prevent accidents. The specifics are detailed below: Per medical record review, Resident #236 fell on [DATE] at the facility, resulting in a sore shoulder. On 3/27/2018 Resident # 236 was scheduled to be transported to [MEDICAL TREATMENT] via the local bus service (RCT). Because of the pain in his/her shoulder, Resident # 236 declined to have the transport driver apply the shoulder seat belt. During the transport that day, an event occured in which the van stopped suddenly, causing the resident to lunge foward, hitting the dashboard, when s/he fell . The resident was evaluated at the hospital, diagnosed with [REDACTED]. The facility has a policy for use of their van but not for the use of the contracted services. There is no evidence to support how or who takes the resident from their room to the van, nor who is responsible to determine if the resident is secured safely for transport. Further, there is no evidence to support that the driver notified any facility staff that the resident refused the seatbelt prior to the transport. Per review of facility documents, the facility has a 1-sheet form that staff report deals with transportation needs of residents on an individual basis, when the facility van is not available. It deals with time frames for setting up appointments, but does not address protocols, in writing, for assuring safety requirements for residents. The drivers have lengthy training before they are allowed to transport folks, which the facility requested to be sent to them during the survey of 5/16/2018. The facility transportation policy is specific to the use of their own van, not the contracted service and indicates that the expectation is that a staff member accompanies the resident to the van and assists with getting him/ her safely into the facility van. It is not clear how this is handled with the contracted service. The DNS confirms, during interview on 5/16/2018 that there is no written policy that delineates how residents get to the van from their room or how they are secured in place when the contracted service is used for transport, nor if the driver is expected to notify the facility of any deviation from legal safety requirements.

Based on staff interviews, review of medical records, transportation policies and procedures and facility contracts between 5/14-16/2018, the facility failed to assure that contracted transportation services specify, in writing, the responsibilities of the transportation service versus the facility responsibility in maintaining resident safety. The specifics are detailed below: Per medical record review, Resident #236 fell on [DATE] at the facility, resulting in a sore shoulder. On 3/27/2018 Resident # 236 was scheduled to be transported to [MEDICAL TREATMENT] via the local bus service (RCT). Because of the pain in his/her shoulder, Resident # 236 declined to have the transport driver apply the shoulder seat belt. During the transport that day, an event occurred in which the van stopped suddenly, causing the resident to lunge forward, hitting the dashboard, when s/he fell . The resident was evaluated at the hospital, diagnosed with [REDACTED]. Per review of facility documents, the facility has a 1-sheet form that staff report deals with transportation needs of residents on an individual basis, when the facility van is not available. The form deals with time frames for setting up appointments, but does not address protocols, in writing, for assuring safety requirements for residents. The DNS (Director of Nursing Services) confirms, during interview on 5/16/2018 that the RCT drivers have lengthy training from the transportation company before they are allowed to transport folks. The facility did not have copies of the training until the surveyor requested that the facility provide evidence that they could assure safety issues were addressed. A copy of the power point presentation on safety issues was faxed by RCT to the facility that day. It covers use of shoulder and lap belts when transporting residents who are wheelchair bound. The facility transportation policy is specific to the use of their own van, not the contracted service and indicates that the expectation is that a staff member accompanies the resident to the van and assists with getting in. It is not clear how this is handled with the contracted service. The DNS confirms, during interview on 5/16/2018 that there is no written policy that delineates how residents get to the van from their room nor how they are secured in place when the contracted service is used for transport.

Based on staff interview and record review, the facility failed to ensure 1 applicable resident (Resident #1) was free from unnecessary drugs. Findings include: Per record review, Resident # 1 was administered the wrong drug on 11/2/17. A fax notice from facility nursing staff to the physician dated 11/4/17 stated that flu vaccine was drawn up in error instead of [MEDICATION NAME] solution and administered. (H/she) does have a flu vaccine allergy listed. Review of the Medication Administration Record [REDACTED]. A second fax to the physician on 11/4/17 indicated that Resident # 1 had developed a rash to abdomen and bilateral thighs, bilateral arms and back, hive-like and itching. At 1:10 PM on 1/3/18, the Center Nurse Executive (CEN) confirmed that on 11/2/17, Resident # 1 was administered Influenza vaccine on 11/2/17 instead of [MEDICATION NAME] solution despite having a documented allergy to flu vaccine.

Based on staff interview and record review, the facility failed to ensure that 1 applicable resident (Resident #1) was free from any significant medication errors. Findings include: Per record review, Resident # 1 was administered the wrong drug on 11/2/17 which caused the resident discomfort and/or jeopardized his/her health and safety. A fax notice from facility nursing staff to the physician dated 11/4/17 stated that flu vaccine was drawn up in error instead of [MEDICATION NAME] solution and administered. (H/she) does have a flu vaccine allergy listed. Review of the Medication Administration Record [REDACTED]. A second fax to the physician on 11/4/17 indicated that Resident # 1 had developed a rash to abdomen and bilateral thighs, bilateral arms and back, hive-like and itching. At 1:10 PM on 1/3/18, the Center Nurse Executive (CEN) confirmed that on 11/2/17, Resident # 1 was administered Influenza vaccine on 11/2/17 instead of [MEDICATION NAME] solution despite having a documented allergy to flu vaccine.

Based on record review and staff interviews, the facility failed to ensure that each resident, for 1 of 3 residents in the applicable sample (Resident #2), was free from abuse by another resident (Resident #1) who had an identified personal history which rendered him/her at risk for abusing other residents. Findings include: 1. Record review, Resident #2 was abused by Resident #1 on 4/10/15 at approximately 1:00 AM. Per record review, Resident #1 had a documented history as follows: On 10/21/14, Resident #1 attempted to kick another resident while entering the dining room. On 1/19/15 Resident #1 was discovered yelling at the current roommate and referring to him/her as crazy. On 1/23/15 through 1/27/15, Resident #1 had been placed on every 15 minute safety checks after becoming agitated with his/her roommate and stating "If you don't shut up I'll come and slap you". On 2/9/15, Resident #1 was recorded as upset at having a roommate and thinking the room was his/her own apartment. On 3/12/15 Resident #1 attempted to pull the roommate's TV cord from the wall, saying "(He/she) can't watch TV all night just because (he/she's) stupid". During an interview on 4/20/15 at 9:40 AM, the Assistant Director of Nursing Services (ADNS) confirmed that Resident #1 gets annoyed with people and has a written plan of care related to this. At 10:00 the nurse on duty also confirmed a known history of Resident #1 being annoyed with other residents. Per written documents and confirmed by the Director of Nursing Services (DNS) on 4/20/15 at 1:30 PM, during the night shift of 4/9-10/15 at approximately 1:00 AM, Resident #1 attacked Resident #2 in their shared room. The DNS confirmed that the Licensed Nursing Assistant (LNA) on duty heard yelling from the room shared by Residents #1 and #2, and noted the door was closed. When the LNA entered the room, Resident #1 was kneeling at the bedside of Resident #2. Resident #2 was lying in bed, positioned on the right side; examination revealed skin tears on the left arm, bruising to the face, and three bite marks on the abdomen.

Based on record review and staff interview, the facility failed to ensure that a resident with weight loss received the prescribed therapeutic diet for 1 of 23 residents in the stage 2 sample (Resident # 105). Findings include: Per record review on 618/14, Resident #105 had experienced a significant weight loss over the last few months. Documentation from 3/3/14 showed an increases in weight trend and good meal acceptance noted. The Registered Dietician (RD) was following him/her on a regular basis, as s/he was considered at nutritional risk, and s/he was on a weight gain and loss alternating pattern since admission in April 2013. On January 31, 2014 s/he weighed 105.6 lbs. By February 24, 2014 s/he had dropped to 101.8 lbs. after an illness, however started to regain the weight, was 102.4 lbs on March 22, and was stable until March 31, 2014 when s/he had dropped down to 100 lbs. again. S/he did begin to regain the weight in April/May and was stable, however not regaining enough and the RD recommended a supplement on May 26, 2014, which the doctor signed as an order on May 27, 2014. Per review of the Medication Administration Record [REDACTED]. high protein, high calorie shake three times per day as ordered for the next four days until June 1, 2014. Per review of the June 2014 MAR, there were no supplemental shakes given to the resident until noon on June 13th. Per interview on 6/18/14 at 10:30 AM, the Unit Manager and the nurse passing medications on that wing both confirmed that the MD order had not been transcribed to the June 2014 MAR indicated [REDACTED]. The MD was notified, and the resident resumed the shakes on June 13, 2014. Per review of the resident's weight documentation, s/he lost 9.5 lbs. between May 27 and June 7, 2014, and was down to 89.2 lbs. Per interview on 6/18/14 at 11:30 AM, the Registered Dietician confirmed that s/he was aware of the resident's recent weight loss since June 1, 2014 as they discuss him/her weekly in care meetings; however, s/he had not been told that the resident did not receive the supplemental shakes for 12 days, and that it was important information that should have been communicated to him/her.