Every finding on record at Stellar Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of the medical record, review of the Self-Reported Incident, review of the facility's investigation, review of facility policy, review of staff education, review of facility plan of correction documentation, and interview, the facility failed to ensure licensed nursing staff appropriately wasted narcotic medications and failed to ensure legible and appropriate documentation related to narcotic administration and wasting. This affected five residents (#7, #10, #12, #18, and #20) of seven reviewed for abuse. Findings Include:Review of the Self-Reported incident (SRI) created 06/05/26 at 1:35 P.M. revealed during an in-house audit of narcotic records on 06/01/26 it was noted LPN #200 had not followed protocol for narcotic documentation for Residents #7, #10, #12, #18, and #20. LPN #200 had admitted during an interview that she was not following protocol by not wasting medications appropriately and scribbling out on the narcotic count sheets. LPN #200 stated she was either busy or tired. Medical records were reviewed, narcotic sheets and medication administration records were audited, and residents involved were assessed for pain. There was no evidence of the residents not receiving their medication or unrelieved pain. The facility reported the documentation issue to the Ohio Board of Nursing and the police. The Ohio Board of Nursing indicated there was suspicion for diversion, so the facility filed an SRI. The SRI was unsubstantiated. LPN #200 was terminated for not following protocol. Further review of the investigation revealed when LPN #200 was asked why she was not following policy and procedure she repeatedly stated she was either busy, tired, or had been helping the aides on the floor. She admitted to all of the above policy violations, and when the Administrator stated there was a blatant disregard for policy her response was I know!. She admitted everything except the diversion. She stated her residents received their medications and the residents were not reporting they did not receive their medications. Considering her admission to multiple violations of the facility's narcotic policy and procedure, she was terminated on 06/03/26 at the end of the interview. Review of the Notice of Disciplinary Action dated 06/01/26 revealed LPN #200 was suspended pending investigation.Review of the Notice of Disciplinary Action dated 06/03/26 revealed LPN #200 was terminated for not following narcotic administration and destruction policy and procedures, no witnesses or documentation on the MARS, administering and signing out more medication than orders allowed without physician's notification, and multiple documentation revisions making the narcotic log difficult to understand. Review of the letter to the Sheriff's office from the Administrator dated 06/08/26 revealed as a result of a state survey, the team was looking into pain management records. On 06/01/26, it came to the facility's attention the narcotic administration, narcotic wasting, and documentation revealed Licensed Practical Nurse (LPN) #200 failed to follow facility policy in many ways. Upon review of the findings, LPN #200 was suspended on 06/01/26 pending further investigation. On 06/03/26, LPN #200 was interviewed in person by the Administrator and Director of Nursing (DON). During this interview LPN #200 was specifically questioned about the following concerns:-Not wasting narcotics with another witnessing nurse. -Administering or signing out more than the ordered amount of pills in a 24-hour period. -Only documenting as needed (PRN) medications in the narcotic log and not documenting in the resident's electronic health record (EHR). -The significantly increased frequency of being the only nurse who administered PRN medications when other nurses were not. -The frequent documentation of the resident coughing, spitting, or dropped as reasons to pull another pill with no witness of wasting these medications. -Scribbling out and frequent documented corrections on the narcotic logs making them illegible or confusing to follow. On 06/22/26 at 10:50 A.M. an interview with the Administrator revealed the facility did not file an SRI with the State agency for the potential misappropriation of narcotics for Resident #7, #10, #12, #18, and #20 because at first, they were just treating it as a documentation procedure concern, however after speaking to the Ohio Board of Nursing on 06/04/26 she stated they recommended filing an SRI and notifying the police. The Administrator confirmed LPN #200 frequently documented coughing, spitting, or dropped as reasons to pull another pill with no witness of wasting these medications, only documenting PRN medications in the narcotic log and not documenting in the resident's EHR, and the scribbling out/illegible notations on the log were not appropriate procedures for a nurse who was handling narcotics. Review of the undated facility policy titled Controlled Substance (Narcotic) Administration and Documentation revealed the wasting procedure stated to waste an unused portion of the medication with a licensed witness immediately after removal/prep, the waste must be performed with a licensed witness, and it must be recorded in the controlled substance log indicating the amount wasted, date and time, your signature, and the witness signature. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/23 revealed resident had the right to be free from abuse, neglect exploitation, and misappropriation of property. This included but was not limited to, freedom from corporal punishment, involuntary seclusion and any physician or chemical restraint that was not required to treat the resident's medical symptoms. It was the facility's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who reported such incidents and allegations were free from retaliation or reprisal for reporting the incident. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. In cases where a crime was suspected, the Administrator would report the same to local law enforcement in accordance with Facility's Crime Reporting policy. If any form of abuse was alleged or Serious Bodily Injury was identified related to any other reportable incident, the Administrator or his/her designee would notify ODH immediately, but not later than two hours after the allegation is made or the serious bodily injury identified. All other allegations involving Neglect, Exploitation, Mistreatment, Misappropriation of resident property and Injuries of Unknown Source would be reported to ODH immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. The following medical records were included in the SRI related to the improper documentation and wasting of narcotics: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic pain, insomnia, osteoporosis and hypertension. Review of the May 2026 physician's orders revealed Resident #10 had an order for hydrocodone/acetaminophen (Schedule 2 controlled substance) 5/326 milligrams (mg) one tablet twice daily for chronic pain dated 03/08/26. Review of the Individual Patient Controlled Substance Administration Record for hydrocodone/acetaminophen 5/325 mg revealed Resident #10 was administered hydrocodone/acetaminophen 5/325 mg on the following occasions:-On 05/01/26, one tablet was administered to Resident #10 at 9:00 P.M. then another tablet at 9:10 P.M. by LPN #200. There was a handwritten note in the margin indicating the resident was coughing. No witness to the wasted narcotic was noted on the record. -On 05/15/26, one tablet was administered to Resident #10 at 9:00 P.M. and then another tablet at 9:20 P.M. There was a handwritten note in the margin indicating the resident spit the tablet out. No witness to the wasted narcotic was noted on the record. -On 05/18/26 one tablet was administered to Resident #10 at 9:00 P.M. and then another tablet at 9:10 P.M. by LPN #200. -On 05/19/26, one tablet was administered to Resident #10 at 9:00 P.M. and then another tablet at 9:15 P.M. by LPN #200. There was a handwritten note in the margin indicating the resident was coughing. No witness to the wasted narcotic was noted on the record. -On 05/22/26, one tablet was administered to Resident #10 at 9:10 P.M. and then another tablet at 9:30 P.M. by LPN #200. There was a handwritten note in the margin, however it was errored out and not legible. -On 05/23/26, one tablet was administered to Resident #10 at 9:00 P.M. and then another tablet at 9:00 P.M. by LPN #200. There was a handwritten note in the margin indicating the resident was coughing. No witness to the wasted narcotic was noted on the record. -On 05/25/26, one tablet was administered to Resident #10 at 9:00 P.M. and then another tablet at 9:00 P.M. by LPN #200. -On 05/30/26, one tablet was administered to Resident #10 at 9:00 P.M. and then another tablet at 9:05 P.M. by LPN #200. There was a handwritten note in the margin indicating the tablet was dropped. No witness to the wasted narcotic was noted on the record. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included left side hemiplegia, pneumonia, major depressive disorder, convulsions, right knee contracture, chronic obstructive pulmonary disease, protein calorie malnutrition, cerebral infarction, hypertension, spinal stenosis, gastroparesis, skin transplant, angina, anxiety disorder, repeated falls, hearing loss, insomnia, and hypothyroidism. Review of the April 2026 physician's orders revealed Resident #12 had an order for clonazepam (Schedule 4 controlled substance) 0.5 mg twice daily for anxiety dated 02/02/26. Review of the Individual Patient Controlled Substance Administration Record for clonazepam 0.5 mg revealed one tablet of clonazepam 0.5 mg was administrated to Resident #12 on 04/27/26 at 9:10 P.M. then another tablet at 9:15 P.M. by LPN #200. There was a handwritten note in the margin indicating the tablet was dropped. No witness to the wasted narcotic was noted on the record. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included necrotizing fasciitis, chronic obstructive pulmonary disease, respiratory failure, migraines, depression and insomnia. Review of the May 2026 physician's orders revealed Resident #7 had an order for tramadol (Schedule 4 opioid) 50 mg one tablet 30 minutes prior to dressing change dated 01/11/26. Review of the Individual Patient Controlled Substance Administration Record for tramadol 50 mg revealed one tablet of tramadol 50 mg was administered to Resident #7 on 05/30/26 at 2:00 A.M. then another tablet at 2:10 A.M. by LPN #200. There was a handwritten note in the margin indicating the tablet was dropped. No witness to the wasted narcotic was noted on the record. 4. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, hypertension, hypothyroidism, chronic pain, restless leg syndrome, tremors, chronic kidney disease, skin cancer, anxiety disorder, and colitis. Review of the May 2026 physician's orders revealed Resident #20 had an order for tramadol 50 mg one tablet three times daily dated 03/19/26. Review of the Individual Patient Controlled Substance Administration Record for tramadol 50 mg revealed one tablet of tramadol 50 mg was administered to Resident #20 on the following occasions:-On 05/23/26 at 5:00 A.M. then another tablet at 5:00 A.M. by LPN #200. No witness to the wasted narcotic was noted on the record.-On 05/24/26 at 7:00 P.M. then another tablet at 7:00 P.M. by LPN #200. No witness to the wasted narcotic was noted on the record. 5. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included sepsis, diabetes, pain, major depressive disorder, peripheral vascular disease, transient ischemic attack, cerebral infarction, spinal cord injury, generalized anxiety disorder, chronic ulcer of the right foot, hydronephrosis, brain cancer, and quadriplegia. Review of the April 2026 physician's orders revealed Resident #18 had an order for hydrocodone/acetaminophen 5/326 mg one tablet via peg tube every six hours as needed (PRN) for pain dated 04/22/26. Review of the Individual Patient Controlled Substance Administration Record for the PRN hydrocodone/acetaminophen 5/326 mg revealed Resident #18 was administered one tablet of hydrocodone/acetaminophen 5/326 mg on 04/25/26 at 6:00 P.M., on 04/26/26 at 12:00 A.M., 6:00 A.M., and 6:15 P.M., on 04/17/26 at 12:00 A.M., 6:00 A.M., and 6:00 P.M., on 04/28/26 at 12:00 A.M., 6:00 A.M., and 6:10 P.M., on 04/29/26 at 12:00 A.M., 6:00 A.M., and 6:00 P.M., on 05/01/26 at 4:45 P.M. and 10:30 P.M., on 05/02/26 at 5:00 A.M and at 6:00 P.M., on 05/03/26 at 12:00 A.M., 6:00 A.M., and 6:00 P.M., on 05/04/26 at 12:00 A.M., 6:00 A.M., and 6:00 P.M., on 05/05/26 at 12:00 A.M, 6:00 A.M., and 6:00 P.M., on 05/06/26 at 12:00 A.M., 6:00 A.M., and 6:00 P.M., on 05/23/26 at 6:00 P.M., on 05/24/26 at 12:00 A.M., 6:00 A.M., and 6:00 P.M., on 05/25/26 at 12:00 A.M., 12:00 A.M. (same time), 6:00 A.M., and 6:00 P.M., on 05/26/26 at 12:00 A.M. and 6:00 A.M., and on 05/27/26 at 12:00 A.M. and 6:00 A.M., on 05/28/26 at 8:00 P.M., on 05/29/26 at 6:30 P.M., on 05/30/36 at 12:00 A.M., 6:00 A.M., and 6:30 P.M., on 05/31/26 at 12:10 A.M., 6:00 A.M. (there was a note indicating this tablet was wasted) and 6:20 P.M. and on 06/01/26 at 12:00 A.M., 6:00 A.M., (there was a note indicating this tablet was spilled) and 6:05 P.M. LPN #200 was the only nurse who administered this medication three times daily every day and none of these doses were documented on the Medication Administration Records (MARS). The deficient practice was corrected on 06/09/26 when the facility implemented the following corrective actions: -On 06/03/26, LPN #200 was terminated for not following narcotic administration and destruction policy and procedures, related to no witnesses or documentation on the MARS, administering and signing out more medication than orders allowed without physician's notification, and multiple documentation revisions making the narcotic log difficult to understand. -On 06/05/26 an initial SRI report was completed and submitted by the Administrator for the residents involved and was pending. -On 06/08/26 the DON and Regional Director of Clinical Services (RDCS) #400 completed audits of narcotic records and all involved residents who were identified on the initial SRI. There was no evidence LPN #200 did not administer medications to the residents and there were no concerns with pain control. The facility was in an ongoing Quality Assurance and Performance Improvement (QAPI)/plan of correction (POC) to monitor for pain which would identify if any residents had unrelieved pain and was currently in compliance with pain management requirements. No other needs for SRIs related to diversion were identified. -On 06/08/26 the DON completed individual pain assessments on the residents involved. All residents in the facility had daily pain monitoring in the medical records. There were no concerns identified. -On 06/08/26 the DON educated all facility staff and agency nurses on appropriate documentation of narcotics including how to waste medications when necessary, how to document on the MAR, the controlled substance record, and pain monitoring. -On 06/08/26 a Root Cause Analysis was completed by the Corporate Risk Management Coordinator (CRMC) #500, RDCS #400, the Administrator, Regional Director of Operations (RDO) #600 and the Director of Nursing. The team was initially concerned with the documentation of LPN #200 and had not considered drug diversion at the time until a report was made to the Ohio Board of Nursing. LPN #200 had issues with documentation, and it was not identified as meeting the suspicion requirements until it was reported to the Ohio Board of Nursing and they suggested a report to the Ohio Department of Health. The lack of evidence of drug diversion versus just improper documentation was the cause and the facility did not recognize this was a potential SRI. It stated there was a lack of understanding of the reporting requirements and what constituted suspicion when looking at narcotic discrepancies. -On 06/09/26 the CRMC #600 educated the Administrator and DON on when to report for suspicion of diversion. -The DON and/or RDCS #400 would complete weekly audits of the narcotic records for four weeks. The results of those would be forwarded to the CRMC #500 to determine if there were any evidence or suspicions of narcotic diversion and the need to file an SRI. The results of the audits would also be forwarded to the QAPI committee after the fours weeks to determine further actions. The facility would additionally monitor for unrelieved pain according to the ongoing QAPI/POC.

Based on record review, hospital record review, facility policy review and interview, the facility failed to timely identify a decline in condition and obtain medical intervention for Resident #26 following an injury sustained because of a fall. This affected one (Resident #26) of four residents reviewed for skin conditions.Actual harm occurred on 04/04/26 when Resident #26 complained of pain and had a decline in the ability to transfer. There was no thorough assessment completed to ensure the resident was provided timely and necessary treatment/medical intervention because of this change in condition. On 03/27/26 Resident #26 had sustained an unwitnessed fall. Between 04/04/26 and 04/08/26 the facility failed to complete a comprehensive nursing assessment or physician notification related to the resident's pain and decline in functional status that was identified during this time. On 04/08/26 the resident's family requested an x-ray due to the resident's complaint of pain and decline in functional status. On 04/09/26 the diagnostic test identified a fracture to the left femur neck occurring as result of the fall. The resident was subsequently transferred to the hospital and underwent surgical repair of her left hip fracture on 04/11/26. Findings include: Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including weakness and hypertension. Review of a care plan dated 12/19/25 revealed Resident #26 was at risk for or had an activity of daily living self-performance deficit related to fractures of the thoracic vertebra (healed). The goal was for her functional ability to improve throughout the review period. Interventions included but were not limited to being able to transfer from sit to stand with supervision, resident was able to perform chair to bed transfers with supervision, and resident was able to transfer to the toilet with supervision. Review of a care plan dated 12/20/25 revealed Resident #26 was at risk for falls related to having a history of falls, unsteady gait, weakness, and getting on her knees typically at bedside to pray. The goal was to not sustain a serious injury from falls through the review date. Interventions included but were not limited to bedside table within reach, call light within reach, floor mat to resident's left side of bed, obtain and monitor lab work as ordered and report abnormalities to provider, offer to assist resident to kneeling position to pray in the morning and evening time, place bed in lowest position when not providing care, place walker next to resident's bed as a visual cue, and therapy to evaluate and treat as ordered and as needed. Resident #26 did not have a plan of care related to pain. Review of the Minimum Data Set (MDS) assessment completed 02/01/26 revealed Resident #26 had mildly impaired cognition, required substantial assistance with bed mobility, required moderate assistance with transfers, was frequently incontinent of bladder, occasionally incontinent of bowel, and had occasional pain. Review of a provider note dated 03/27/26 at 5:03 A.M. by Nurse Practitioner #500 revealed Resident #26 had a fall with no injuries and no signs of trauma. (This was not an in-person assessment by the NP). Review of the unwitnessed fall report dated 03/27/26 at 5:59 A.M., completed on 04/09/26, revealed a statement was received from Licensed Practical Nurse (LPN) #151 once a fracture was identified. An aide (unidentified) said the resident was on the floor. Upon entering the resident's room, the resident was on the floor next to her bed and the aide was with her. The resident stated she went to get up out of bed and it was at the lowest level and couldn't push because her legs were not strong enough and slid onto the floor. She said she did not lose consciousness and had no pain or complaints. She said she didn't hit her head. Neuro checks were initiated. Vital signs were within normal limits. Assisted resident to edge of bed and told her she would have neuro checks for the rest of tonight and tomorrow. The resident was asked if she wanted to go to the hospital and she said no, she was fine and would refuse to go anyway. Started neuro paperwork. No environmental factors. Predisposing factors were a fall within the last 30 days. Review of the record revealed no nursing progress notes related to the fall or documentation of an assessment related to the resident's range of motion (ROM) post-fall. There was no documentation post fall through 04/04/26. Review of a nursing note dated 04/04/26 at 1:40 P.M. authored by LPN #144 revealed she was called to Resident #26's room by staff. The resident had four skin tears to the right lower leg and a skin tear to the left upper arm. Wounds were cleansed with in-house wound cleanser, patted dry, and oil emulsion dressings were applied. The physician was notified and family was updated. Resident #26 had a physician order dated 04/04/2026 to cleanse the skin tear to the left upper arm with in house wound cleanser, pat dry, apply oil emulsion dressing and cover with dry dressing every 48 hours and to cleanse the skin tears to the right lower leg with in house wound cleanser, pat dry, apply oil emulsion dressing and cover with a dry dressing every 48 hours. Review of the Medication Administration Record for April 2026 revealed the resident received Tylenol 325 mg two tablets on 04/04/26 at 1:48 P.M. for a pain rated an eight (on a pain scale of 1-10 with one being minimal pain and 10 being the worst pain the resident ever felt) and on 04/06/26 at 6:00 A.M. for a pain rating of 5. There was no further assessment of the resident's pain, including location, description, non-pharmacologic interventions attempted, etc. Follow-up indicated the Tylenol was effective. Review of a nursing note dated 04/06/26 at 5:56 A.M. authored by Registered Nurse (RN) #110 revealed Resident #26 was wet three times this shift, she was put in her chair and was a two person assist as she almost slid to the floor. The aide working was able to pick Resident #26 up and physically place her in bed. Resident #26 had little to no ability to transfer herself and was in a lot of pain and if barely touched, she would moan out in pain. Resident #26 received Tylenol twice this shift and refused to have dressings changed. The dressings were dry and intact and resident stated she just hurt too bad. There was no documentation the physician was notified of Resident #26's condition change related to pain and/or the resident's inability to assist with transfers. Review of a nursing note dated 04/08/26 at 10:59 P.M. by RN #110 revealed the on-call provider was notified of the resident's complaints of pain. Resident #26 had bruising on various places across her body and had skin tears to both upper extremities and right lower extremity. Resident #26 was very sore to the touch and moaned out in pain with the lightest touch. Her biggest complaint of pain seemed to be in the left lower extremity. Resident #26's daughter was at the facility and requested an x-ray and whatever else staff thought she needed after examination. Upon examination, the resident's left leg was more swollen than her right leg. The left leg was warm to the touch. An ultrasound was requested to rule out a deep vein thrombosis and was given the following orders: x-ray of the left hip and knee to rule out fracture and doppler for left lower extremity to rule out deep vein thrombosis. When putting resident to bed, she was unable to stand/pivot transfer as she was able to previously per aides who know her well. Once in bed, the resident also complained of pain to her bottom and upon assessment, she had an open area which had increased in size to 10 centimeters (cm) by two cm which was about three times larger than it was two nights prior. The area was also reported to the on-call provider and received an order to clean the wound with wound cleanser daily, apply hydrocolloid/foam dressing per facility procedure, maintain clean, dry and moisturized skin. Monitor for increased drainage, redness and depth, reassess wound weekly or per policy, and notify provider if area worsens or signs of infection appear. Give Tylenol 1000 milligrams (mg) every eight hours as needed for pain. Resident' #26's daughter was notified of new orders; All Stat was called and orders given and stated they would arrive 04/09/26 to complete x-rays and doppler. Review of the MAR for April 2026 revealed Resident #26 had an order for Tylenol 500 mg give two tablets by mouth every eight hours as needed for pain. She received a dose on 04/08/26 at 10:24 P.M. for a pain rating of five and on 04/09/26 at 10:31 A.M. for a pain rating of seven. The location of the resident's pain was not identified on the MAR or progress notes. Review of an x-ray dated 04/09/26 revealed there was a mildly reduced femoroacetabular joint space with small marginal osteophyte concerning for mild osteoarthritis, osteopenic changes in the visualized bones, and acute fracture of the neck of the left femur. Review of a nursing note dated 04/09/26 at 2:57 P.M. by LPN #144 revealed Resident #26 was sent to the hospital via squad for an acute left femur neck fracture for surgery consult per physician orders. Family was updated. Review of the facility investigation related to the fracture revealed the following statements:Review of a statement by LPN #143 dated 04/07/26 revealed she worked with Resident #26 on 04/07/26 and resident did state to be careful of her left leg during a transfer to her wheelchair and was worried about the swelling in it. The leg had been swollen on and off to which the physician was aware. (There was no documentation in the medical record on 04/07/26 regarding the resident's status on 04/07/26 including notification to the physician). Review of a statement dated 04/09/26 by Certified Nursing Aide (CNA) #145 revealed on 04/02/26 she worked with Resident #26 with no concerns. She was off on 04/03/26 and came back to work on 04/04/26 when she got report from an agency aide who expressed no concerns. CNA #145 stated she went to get resident up and the resident complained of pain in her left knee. CNA #145 and the nurse, LPN #144, got the resident into her wheelchair and took her to the bathroom. When her pajamas were removed, the resident was sitting down on the toilet and was noted to have four new skin tears down her right leg which had band-aids on them and had discolored areas. LPN #144 checked the chart and found no information regarding the skin issues. LPN #144 left to go get supplies to care for the wounds and after waiting, CNA #145 looked out into the hallway and the housekeeper stated LPN #144 went downstairs to pass medications on the assisted living unit and would be right back. CNA #145 reported the whole time (while on the toilet), the resident was crying in pain about her knee and hip hurting. CNA #145 took off the pajama top to get the resident cleaned up while waiting, then put a blanket over her to stay warm and found an additional skin tear with another band-aid on it to her left upper arm. After waiting about 20 minutes with the resident crying in pain (CNA was unable to stand the resident by herself), she asked housekeeping to contact the nurse for help. The resident's daughter had come in and heard the resident crying and asked, what the hell happened, to which she was instructed to ask the nurse. The resident was assisted back to her room and placed in her recliner. Review of a statement dated 04/09/26 at 5:00 P.M. by LPN #144 revealed she came to work at 6:00 A.M. on 03/27/26 and was supposed to be oriented on memory care and assisted living units but the nurse orienting her was late. She received report from the nightshift nurse for memory care and he stated Resident #26 had fallen at 4:00 A.M., everyone was notified, and neurochecks had been initiated. After finishing report on memory care, they went down to the assisted living unit for report there and the other dayshift nurse had arrived and stated LPN #144 had an assignment change. Dayshift nurse (LPN #120) asked if the carts were counted and if report was completed, and if anything was going on upstairs. LPN #144 stated she told LPN #120 Resident #26 had fallen at 4:00 A.M. then she went to her assigned hall on the skilled unit. Review of a statement by CNA #127 for 04/03/26 revealed while bathing Resident #26, due to friction of the washcloth and soaking in the tub, the resident's skin reopened from old skin tears on her leg. Review of a statement by LPN #143 revealed on 04/04/26, skin tears were already on Resident #26, they were just bleeding a little so band-aids were applied and she didn't know she needed to do an incident on old areas. There was no additional documentation about the skin tears or how/when they occurred in the resident's medical record. Review of an email dated 04/09/26 at 5:05 P.M. from RN #106 to the Administrator revealed she had collected the following statements related to Resident #26's injury: On 04/08/26 at 11:20 A.M. CNA #145 worked 04/02 and 04/04: She had been rubbing and complaining of that left knee for about a week now. I worked with you, RN #106, on last Thursday and there was nothing on her legs, no bruising, nothing. I came to work early Saturday morning and changed her like always, nothing on her butt. When I got her up that morning to dress her, Oh my RN #106 she had band-aids down her right leg, a band-aid on her left shoulder, bruising on her left knee, a skin tear on her right forearm. That's when LPN #144 sent you the pictures of the band-aids on her leg. On 04/08/26 at 12:00 P.M. RN #166 worked 04/03 dayshift: I helped the aide change her blue jumpsuit, but I did not notice any discoloration on her knee or leg. I did notice the band-aids to her leg. CNA #145 said the next day that she had all of those areas and I wondered if maybe she had fallen but nobody knew anything. On 04/08/26 at 3:00 P.M. LPN #173 worked 04/03 nightshift: I helped the aide, CNA #185, put her to bed and change her. I did not see anything on her. I heard staff talking and thought they said she had fallen, but I am not sure. On 04/09/26 at 9:57 A.M. CNA #163 worked 03/28 nightshift: Resident #26 did not fall the night I worked. I was not told by LPN #151 the night I worked that she had fallen the night prior. On 04/08/26 at 1:30 P.M. LPN #120 worked 03/27 dayshift: I was not aware of any fall on memory care. He told me that everyone upstairs was fine. I did not see any neuro check sheet or any fall papers on the desk. I counted with LPN #144 because she was pulled downstairs to orient. Undated; LPN #144, worked 03/27/26 dayshift: Heard LPN #151 say the resident fell at 4:00 A.M. and everything was taken care of and everyone was notified. I think he started a neuro sheet. The oncoming nurse was LPN #120 and LPN #144 was pulled downstairs to orient and was not sure what LPN #151 told LPN #120. On 04/09/26 at 2:54 P.M. LPN #151: I know I filled out the papers and documented the fall in the chart. I don't know, they came up missing. I got ahold of on-call too. She was found sitting by her bed in her room by the aide. I grabbed her vitals, she denied hitting her head, her bed was in low position. I helped her get back in bed and she said her mind was not real good because she can't remember things. RN #106 worked 04/02/26 dayshift: Resident was acting per her usual. She had no areas on her legs, no discoloration to her left knee/leg during my shift. She had sat in her recliner and was in her wheelchair in the lobby with the other residents. No complaints of pain and CNA #145 was able to transfer her to the toilet with no issues. Review of a hospital record dated 04/11/26 revealed Resident #26 presented on 04/09/26 with left hip pain since a fall on 03/27/26, she had been unable to bear weight on the leg, and she was admitted for left femoral neck fracture. She had a known deep vein thrombosis (DVT) in her left lower extremity from January 2026 and was on Eliquis. She was admitted and orthopedics was consulted and a left hip bipolar hemiarthroplasty was completed on 04/11/26. Resident #26 had post-operative hypoxic and hypercarbic respiratory failure and required a BiPap post-operatively for several hours and was able to eventually wean off the BiPap. She also had post-operative acute on chronic anemia and had two units of blood on 04/12/26 with improvement in hemoglobin. During an interview on 04/22/26 at 10:21 A.M., Resident #26's daughter stated she came to visit the resident on 04/04/26 and the aide had her in the shower room on the commode. Resident #26's daughter revealed her mom was naked, freezing, and screaming, oh, help me, help me. The daughter said the resident was in major pain. It took the nurse a while to come to the shower room and the daughter asked if the resident could be put back in her wheelchair and when she was, the pain eased some. The resident leaned to her side when in her chair because of hip pain. The resident's daughter also stated she requested an x-ray for the resident due to her complaints of pain and she had a broken hip and went to the hospital. Lastly, the resident's daughter shared the surgeon in the hospital said the resident's hip was broken for about two weeks prior to her surgery. During an interview on 04/22/26 at 3:24 P.M., Regional Nurse #191 confirmed the MAR for March 2026 revealed Resident #26 had not taken any as needed Tylenol, but on the MAR for April 2026, she received a dose of Tylenol 325 mg two tablets on 04/04/26 for a pain of eight, on 04/06/26 for a pain of five, then received Tylenol 500 mg two tablets on 04/08/26 for pain of five, and 04/09/26 for pain of seven. Regional Nurse #191 confirmed no x-ray was ordered until 04/08/26 which resulted in a delay in the resident's care because a new onset of resident pain was not addressed timely. She stated she would try to find out why there was a delay. However, no additional information was provided during the survey related to the delay in care or notification with the resident's complaints of pain in conjunction with the resident's functional decline. During an interview on 04/23/26 at 10:47 A.M. with CNA #142 revealed she worked with Resident #26 on 03/31/26 and she was complaining about her leg and hip hurting, she was having a hard time moving in bed. The CNA stated the complaints of pain were reported to the nurse but she could not recall which nurse. During an interview on 04/23/26 at 3:25 P.M. with CNA #145 confirmed the incidents in her statement regarding 04/04/26 were accurate and she provided the same information during the interview. During an interview on 04/23/26 at 2:02 P.M. with RN #110 revealed she worked agency and was not in the facility a whole lot. RN #110 stated Resident #26's family stopped her and asked her to assess the resident upon the start of her shift so she completed an assessment (on 04/08/26). The resident was complaining of pain and favoring one leg so she called the on-call providers and received orders for a doppler to rule out deep vein thrombosis and an x-ray to check for fracture. RN #110 stated the resident did have a fracture and was sent out. RN #110 stated no one knew what had happened but she was having quite a lot of pain, then during the investigation they found out an agency nurse (identified as LPN #151) did not know how to complete a change in condition (fall). The RN stated when she and the aide tried to assist her to bed, she couldn't stand (this was documented in the 04/06/26 progress note). The aides stated normally she could, but an aide lifted her into bed. Resident #26 was moaning with any movement and when barely touched. She was complaining of pain to the inside of her leg but couldn't rate it due to dementia. Resident #26 also had some swelling around her hip. An interview on 04/24/26 at 10:53 A.M. with Physician #501 revealed he completed Resident #26's hip surgery. He stated the injury did not look fresh because as you continue to go with an unaddressed fracture, the bone fragments rub together and grind down a bit so it wasn't a crisp break like a new fracture would be. Physician #501 estimated the fracture happened one to three weeks prior to surgery. Review of a policy titled Change in a Resident's Condition dated 08/2023 revealed the facility shall notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. The nurse will notify the resident's physician when there has been a change in condition. Unless otherwise instructed by the resident, the nurse will notify their representative. Except in medical emergencies, notifications will be made timely of a change occurring in the resident's medical/mental health condition or status and regardless of the resident's current mental of physical condition, the nursing supervisor will inform the resident of any changes in their medical care or nursing treatments. The nursing supervisor will record in the resident's medical record information related to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Numbers 2960434 and 2806419.

Based on record review and interview, the facility failed to ensure the food license was renewed timely. This had the potential to affect 31 of 31 residents residing in the facility. The facility census was 31.Findings include: Review of an email from the Administrator to Corporate Accounts Payable dated 02/12/26 revealed the Administrator sent the appropriate food license application to the corporate office and requested payment be sent to the local health department to renew the building's food service license.Review of a Food Service Operation License revealed it was issued on 03/06/26 and would expire 03/01/27.Review of an additional food license application revealed it was completed on 03/11/26 and had a late fee of $110.00 applied to the renewal fee. (The initial renewal application fee was not paid).Interview on 04/20/26 at 9:29 A.M. with the local health department revealed the facility went without a license for three days. The original license expired on 03/02/26 and the new license was issued on 03/06/26. The facility did have to pay a late fee.Interview on 04/21/26 at 1:57 P.M. with Dietary Manager #104 revealed he had not been aware the food license was something he had to take care of because he thought the company completed it. He confirmed the license had expired for a few days.This deficiency represents non-compliance investigated under Complaint Number 2963559 and 2806419.

Based on record review, interview, policy review, and job description review,the facility failed to ensure professional standards of nursing care were provided when nursing staff did not verify and maintain a valid medical practitioner's order for the resident's clinical record prior to administering a controlled psychotropic medication. Although the dispensing pharmacy had a prescription for the medication, the facility did not have the order available or documented within the resident's medical record and medication administration record at the time of administration of the medication. This affected one resident (Resident #11) of four residents reviewed for medications. The census was 31. Review of Resident #11's medical record revealed an admission date of 08/09/23 and a re-admission date of 03/23/26 with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, other schizophrenia, acquired absence of right leg above the knee, acquired absence of left leg above the knee, anxiety disorder and major depressive disorder.Review of Resident #11's physician's orders revealed an order for clonazepam 0.5 milligrams (mg) twice a day as needed with a start date of 09/22/25 and an end date of 12/20/25. This was the only clonazepam order in the medical record.Review of Resident #11's controlled drug sheets for the medication clonazepam 0.5mg revealed the medication was documented on the sheet as given on 01/02/26 at 8:00 P.M., 01/03/26 at 8:00 P.M., 01/04/26 at 8:30 P.M., 01/05/26 at 8:00 P.M., 01/06/26 at 8:00 P.M., 01/09/26 at 8:00 P.M., 01/11/26 at 9:00 P.M., 01/12/26 at 9:00 P.M., 01/15/26 at 9:00 P.M., 01/16/26 at 9:00 P.M., 01/18/26 at 8:30 P.M., 01/19/26 at 8:35 P.M., 01/20/26 at 8:00 P.M., 01/21/26 at 8:00 P.M., 01/23/26 at 8:00 P.M., 01/24/26 at 9:00 P.M., 01/25/26 at 9:00 P.M., 01/26/26 at 9:00 P.M., 01/27/26 at 5:00 A.M., 01/29/26 at 6:00 P.M., 01/30/26 at 5:00 A.M., 03/06/26 at 9:00 P.M., 03/07/26 at 9:00 P.M., 03/08/26 at 9:00 P.M., 03/09/26 at 9:00 P.M., 03/10/26 at 9:00 P.M., 03/13/26 at 9:00 P.M., 03/17/26 at 1:40 A.M., 03/18/26 at 9:00 P.M., 03/28/26 at 9:00 P.M., 03/30/26 at 9:00 P.M., 03/31/26 at 9:00 P.M., 04/03/26 at 9:30 P.M., 04/05/26 at 9:00 P.M. and 04/06/26 at 9:10 P.M. There were no corresponding Medication Administration Record (MAR) entries documenting administration of the medication. Further review of the Narcotic Log revealed there were no doses of the medication documented as administered for the month of February 2026.Review of Resident #11's progress notes on 01/02/26 at 8:00 P.M., 01/03/26 at 8:00 P.M., 01/04/26 at 8:30 P.M., 01/05/26 at 8:00 P.M., 01/06/26 at 8:00 P.M., 01/09/26 at 8:00 P.M., 01/11/26 at 9:00 P.M., 01/12/26 at 9:00 P.M., 01/15/26 at 9:00 P.M., 01/16/26 at 9:00 P.M., 01/18/26 at 8:30 P.M., 01/19/26 at 8:35 P.M., 01/20/26 at 8:00 P.M., 01/21/26 at 8:00 P.M., 01/23/26 at 8:00 P.M., 01/24/26 at 9:00 P.M., 01/25/26 at 9:00 P.M., 01/26/26 at 9:00 P.M., 01/27/26 at5:00 A.M., 01/29/26 at 6:00 P.M., 01/30/26 at 5:00 A.M., 03/06/26 at 9:00 P.M., 03/07/26 at 9:00 P.M., 03/08/26 at 9:00 P.M., 03/09/26 at 9:00 P.M., 03/10/26 at 9:00 P.M., 03/13/26 at 9:00 P.M., 03/17/26 at 1:40 A.M., 03/18/26 at 9:00 P.M., 03/28/26 at 9:00 P.M., 03/30/26 at 9:00 P.M., 03/31/26 at 9:00 P.M., 04/03/26 at 9:30 P.M., 04/05/26 at 9:00 P.M. and 04/06/26 at 9:10 P.M. revealed no documentation the resident had requested the medication or had complaints of anxiety.There was no documentation in the progress notes that the resident received clonazepam during the month of February 2026.Review of Resident #11's behavior monitoring on the treatment administration record on 01/02/26 at 8:00 P.M., 01/03/26 at 8:00 P.M., 01/04/26 at 8:30 P.M., 01/05/26 at 8:00 P.M., 01/06/26 at 8:00 P.M., 01/09/26 at 8:00 P.M., 01/11/26 at 9:00 P.M., 01/12/26 at 9:00 P.M., 01/15/26 at 9:00 P.M., 01/16/26 at 9:00 P.M., 01/18/26 at 8:30 P.M., 01/19/26 at 8:35 P.M., 01/20/26 at 8:00 P.M., 01/21/26 at 8:00 P.M., 01/23/26 at 8:00 P.M., 01/24/26 at 9:00 P.M., 01/25/26 at 9:00 P.M., 01/26/26 at 9:00 P.M., 01/27/26 at 5:00 A.M., 01/29/26 at 6:00 P.M., 01/30/26 at 5:00 A.M., 03/06/26 at 9:00 P.M., 03/07/26 at 9:00 P.M., 03/08/26 at 9:00 P.M., 03/09/26 at 9:00 P.M., 03/10/26 at 9:00 P.M., 03/13/26 at 9:00 P.M., 03/17/26 at 1:40 A.M., 03/18/26 at 9:00 P.M., 03/28/26 at 9:00 P.M., 03/30/26 at 9:00 P.M., 03/31/26 at 9:00 P.M., 04/03/26 at 9:30 P.M., 04/05/26 at 9:00 P.M. and 04/06/26 at 9:10 P.M. revealed no behaviors were recorded for the resident on those dates.Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed but review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment. Further review of Resident #18's 03/27/26 admission MDS revealed the resident was dependent on staff for toileting hygiene showering/bathing, transfers, and bed mobility, received antipsychotic and antianxiety medications.Review of Resident #11's progress notes revealed a note dated 04/08/26 at 9:01 A.M. written by the Director of Nursing (DON) that read Discussed with pharmacy and ViaQuest nurse practitioner, order was active with an active script the entire time of administration, however, was not active on the EMAR.In an interview on 04/21/26 at 8:32 A.M. the DON stated the progress note dated 04/08/26 at 9:01 A.M. was related to Resident #11's clonazepam medication. The resident's medication was renewed in December of 2025 by the ViaQuest nurse practitioner (NP); however the nurse who received the verbal order did not enter the order for the clonazepam in the medical record or make an entry on the MAR to indicate the administration instructions for the medication. The DON verified this administration, without an active order in the medical record, occurred from 01/02/26 through 04/06/26. The DON verified the pharmacy had a prescription for the medication from ViaQuest. In an interview on 04/22/26 at 12:09 P.M. Registered Nurse (RN) #148 stated she did not recall giving the medication or the medication not being on the MAR. She normally worked upstairs (the facility had a first floor and second floor which both housed residents) however she did know the resident had clonazepam ordered for a long time but did not know if it was scheduled or as needed. The RN said if it was as needed she would look for an order before giving the medication and would assess for symptoms such as anxiety, yelling out, and behaviors that were normal for him such as raising and lowering the head of his bed and saying he was unable to locate the bed control. Review of the Narcotic Control Log provided revealed RN #148 did document doses of the medication for Resident #11.In an interview on 05/13/26 at 10:00 A.M. the DON stated she was made aware of the clonazepam 0.5 mg being given without being on the MAR, on one of the first days that she was working as the DON, when RN # 174 asked her to destroy the medication because there was not an order for it, the DON noted that it had been given recently and investigated to find out why. Her expectation was that the nursing staff would question any medication that was not on the MAR before administering the medication.In an interview on 05/13/26 at 10:10 A.M. RN #174 stated if a medication in the medication cart is not on the MAR and no current order can be seen in the electronic healthcare record (EHR) she would check the completed and discontinued orders to see if it was recently discontinued. If it is not needed for the resident any longer it should be removed from the cart and placed in the return to pharmacy bag. If it is a controlled medication and cannot be returned it remains in the cart and is counted until the DON and another nurse have to destroy the medication. If there is not a place to sign the medication off on the MAR she would not give it. RN #174 further stated there have been instances where the NP has sent a script to the pharmacy and not updated the facility that she/he has extended the order and pharmacy sends the medication and there is not an order. They then have to talk with the pharmacy and the NP to get the correct order in the EHR so that the order is on the MAR. RN #174 stated she always made sure to follow five rights of medication administration the right resident, the right route, the right dose, the right medication and the right time.In an interview on 05/13/26 at 10:25 AM LPN #144 stated if a medication is in the medication cart but not on the MAR and no order for it is in the EHR she would call the doctor and get the order if the resident needs the medication but would not give any medication that is not on the MAR. She stated she would follow the five rights of medication administration the right resident, the right route, the right dose, the right medication and the right time. Review of the policy titled Physician Orders Policy and Procedure, dated 05/09/24, reviewed 08/2025 revealed the nurse receiving the order would enter it into the electronic healthcare record as soon as practicable.Review of the Facility Assessment, revised 05/14/26, revealed the facility would provide administration of medications that residents needby route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. and would provide assessment/management of polypharmacy.Review of the Registered Nurse (RN) job description, undated, revealed the RN, when working a shift, would receive and transcribe physician's orders to resident chart, Medication Administration Record (MAR), treatment record and care plan as required, would prepare and administer medications as ordered by the physician and would follow all controlled drug policy and procedures as requiredReview of the Licensed Practical Nurse (LPN) job description, undated, revealed the LPN, when working a shift, would receive and transcribe physician's orders to resident chart, Medication Administration Record (MAR), treatment record and care plan as required, would prepare and administer medications as ordered by the physician and would follow all controlled drug policy and procedures as required. Review of the policy titled Administering Medications, revised 12/2012, revealed medication must be administered in accordance with the orders. Further review of the policy revealed the individual administering the medication was to record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed.This deficiency represents non-compliance investigated under Master Complaint Number 2992141.

Based on record review, interview, observations, and policy review, the facility failed to ensure residents did not exit the facility unsupervised, had elopement assessments completed as appropriate and fall interventions were in place. This affected three residents (Resident #5, #26 and #32) of three residents reviewed for accidents. The census was 31. Findings include: 1.Record review revealed Resident #32 admitted to the facility on [DATE] with diagnoses including dementia and diabetes.Review of a Minimum Data Set (MDS) Assessment completed on 02/01/26 revealed Resident #32 had severely impaired cognition, wandered one to three days during the assessment period, and was able to walk 150 feet with supervision or touching assistance.Review of a care plan dated 02/25/26 revealed Resident #32 resided on a secured unit. The goal was to wander safely within her environment. Interventions included but were not limited to administer medications as ordered, ask resident to discuss how they feel about placement, elopement assessments as ordered and as needed, and redirection as needed.Review of a provider note dated 03/17/26 by Certified Nurse Practitioner (CNP) #502 revealed Resident #32 would be moving out of the memory care unit to make room for another resident who needed the bed.Review of assessments revealed there was no elopement assessment completed prior to moving off the secured unit but the resident was at risk for elopement.Review of a nursing note dated 03/19/26 at 1:20 P.M. by Registered Nurse (RN) #174 revealed she noticed staff running down the hallway, when further investigating, realized that resident had wheeled herself to the front door of the building, left her wheelchair at the front door and walked outside the facility and into the roadway. Staff rushed to her and assisted her back to safety in the building. Assessment was performed to check for injury and obtain information about the incident. Vital signs were within normal limits. There were no injuries noted and all supervisors, family and the provider were notified of the incident. Wander guard immediately placed to resident's right ankle and checked for functioning. Staff were alerted to monitor resident closely. Resident continued to wander around the facility and exit seek. Redirection was somewhat effective. Resident was currently resting in her chair with a call light in reach.Review of a nursing note dated 03/19/26 by RN #174 revealed Resident #32 was displaying exit seeking behaviors around the front door, wander guard was in place to the right ankle, supervisor, provider and representative were aware of behaviors.Review of an order dated 03/19/26 revealed Resident #32 had a wander guard placed on her right ankle, check placement and function every shift.Review of a provider note dated 03/19/26 by Medical Director (MD) #503 revealed Resident #32 was being seen for a regulatory visit and she could not recall a recent incident in which she left her wheelchair at the front door and was observed running down the street. Resident #32 then denied any intention to elope stating she valued her life.Review of a nursing note dated 03/20/26 at 2:49 P.M. by RN #413 revealed Resident #32 was being moved back to the memory care unit related to exit seeking behaviors and her spouse was aware. Interview on 04/20/26 at 12:51 P.M. with RN #174 revealed she had been at the nurses' station and was able to see staff running down the halls due to camera monitors at the desk. Stated she did not actually see where resident had made it to, but it was reported she was walking down the road and someone on a motorcycle had stopped her and someone else had called the facility to tell staff.Interview on 04/21/26 at 9:06 A.M. with Certified Nursing Assistant (CNA) #107 revealed Resident #32 moved off the secure unit to accommodate another resident. Resident #32 had been wandering and confused. CNA #107 stated she was in a room with other staff caring for a resident and when she exited the room, a visitor walked in and stated a woman was walking out in the road, and CNA #107 and two other staff sprinted out the door. CNA #107 stopped at the door to grab the wheelchair while the other staff ran ahead. CNA #107 stated she almost made it to the next road to the left but a guy on a motorcycle had stopped in the road and distracted her until we could get there. Interview on 04/21/26 at 9:42 A.M. with CNA #125 revealed she was upstairs and received a phone call which stated a resident was out in the road walking down the street. The nurse, Licensed Practical Nurse (LPN) #120 took off running down the stairs while CNA #125 stayed with the residents on memory care.Interview on 04/21/26 at 9:47 A.M. with CNA #116 revealed Resident #32 had been exit seeking earlier on 03/19/26 and was redirected twice, which was reported to RN #174. No interventions were implemented. CNA #116 stated she was with CNA #107 in a room providing care and when she came out someone had told them a resident was down the road. CNA #116 stated she took off running and resident was not too far down the road, on the right ride. There was a man on a motorcycle who stopped and was talking to the resident. CNA #116 stated she was concerned because there was no interventions in place during the adjustment period after moving off the secure unit. CNA #116 stated residents with dementia get confused with a change in environment and their routine and a move off the unit could have triggered that.Interview on 04/21/26 at 10:12 A.M. with Administrator confirmed there was not an investigation. Administrator stated Resident #32 had lived on the secured unit and they moved her off the unit because she was not having behaviors. Administrator confirmed the secured unit was for memory care, not a behavioral unit. Administrator stated a change in environment for someone with dementia could cause more confusion but she did not feel resident was more confused. Administrator also confirmed a wander guard and elopement assessment was not completed prior to the resident moving off the secured unit.2.Record review revealed Resident #5 admitted to the facility on [DATE] with diagnoses including dementia and depression.Review of an MDS completed 02/15/26 revealed Resident #5's cognition was moderately impaired and she had no behaviors.Review of the census line revealed Resident #5 moved from the memory care unit on 03/20/26 to the first floor.Review of assessments revealed an elopement assessment was not completed until 04/03/26.Interview on 04/23/26 at 1:05 P.M. with Administrator confirmed Resident #5 did not have an elopement assessment completed prior to moving off the secured memory care unit. 3.Observational tour completed on 04/24/26 at 12:19 P.M. with Maintenance Director (MD) #140 revealed while walking with a wander guard in hand, surveyor was able to walk through the front entrance of the assisted living facility three times without the door locking or alarming. The facility was connected to the AL and residents were able to access the AL through open double doors from the nursing home dining room to the AL facility. MD #140 confirmed findings.4.Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including anxiety disorder and weakness.Review of a care plan dated 12/20/25 and revised on 03/16/26 revealed Resident #26 was at risk for falls related to having history of falls, unsteady gait, weakness, resident gets on her knees typically at bedside to pray. The goal was to not sustain serious injury from falls through review date. Interventions included but were not limited to floor mat to left of bed.Observation on 04/21/26 at 9:45 A.M. revealed Resident #26's fall mat was not to the left of her bed, but was against the wall with a laundry basket on it.Interview on 04/21/26 at 11:37 A.M. with CNA #102 confirmed the floor mat was not in place. This deficiency represents non-compliance investigated under Master Complaint Number 2992141 and Complaint Number 2960434.

Based on record review, interview and policy review, the facility failed to ensure weights were obtained as ordered. This affected one (#26) of one resident reviewed for edema. The facility census was 31.Findings include: Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including weakness and hypertension.Review of a care plan dated 12/19/25 revealed Resident #26 had altered cardiovascular status related to hypertension, congestive heart failure (CHF), and myocardial infarction. The goal was to be free from signs and symptoms of complications related to cardiac problems through the review date. Interventions included but were not limited to give cardiac medications as ordered, monitor for edema and note extent/report to provider, and weight monitoring as ordered and as needed.Review of a Minimum Data Set, dated [DATE] revealed Resident #26 had mildly impaired cognition, had no behaviors, had a diagnosis of CHF, and had a weight gain while not on a physician prescribed weight-gain regimen.Review of orders revealed an order dated 03/24/26 to weigh Resident #26 daily starting on 03/25/26, if the weight gain is three pounds or more, call the provider. After seven days, weigh Resident #26 daily or follow physician's order and call physician if weight gain of three or more pounds in one day or five or more pounds in one week for CHF.Review of weights revealed Resident #26 was weighed on 03/26/26 and was 97 pounds (lbs).Review of weights revealed Resident #26 weighed 97.6 pounds on 04/02/26.Review of a nursing note dated 04/06/26 at 4:18 A.M. by Registered Nurse (RN) #110 revealed Resident #26 refused to be weighed.Review of a nursing note dated 04/07/26 at 4:19 A.M. by RN #148 revealed Resident #26 refused to be weighed.Review of a nursing note dated 04/08/26 at 4:01 A.M. by RN #110 revealed resident #26 refused to be weighed and stated she preferred dayshift. Review of the medical record revealed Resident #26 discharged to the hospital on [DATE] and returned to the facility on [DATE] for a left displaced femoral neck fracture.Review of weights revealed Resident #26 weighed 113.6 lbs on 04/14/26.Review of weights revealed Resident #26 weighed 113.8 lbs on 04/18/26.Review of weights revealed Resident #26 weighed 99.2 lbs on 04/19/26.Review of weights revealed Resident #26 weighed 116.4 lbs on 04/20/26.Review of weights revealed Resident #26 weighed 117.8 lbs on 04/22/26.There was no additional information in the medical record related to Resident #26's daily weights or refusals.Interview on 04/23/26 at 10:15 A.M. with Director of Nursing confirmed missing daily weights for 03/25/26, 03/27/26-04/01/26, 04/03/26-04/05/26, 04/15/26-04/17/26, and 04/21/26 and lack of notification to physician related to weight fluctuations or refusals to be weighed.Review of a policy titled Weight Management Program and Weight Gain/Loss Policy dated 08/2024 revealed all resident will have their weight and nutritional status monitored and addressed as indicated. All residents will be weighed monthly and as ordered. Their weights will be reviewed by the dietician and nursing management monthly and as needed. This deficiency represents non-compliance investigated under Complaint Number 2960434.

Based on interview, record review and policy review the facility failed to ensure residents did not receive psychotropic medications without an active order in the medical record. This affected one resident (Resident #11) of four residents reviewed for medication use. The facility census was 31.Findings include: Review of Resident #11's medical record revealed an admission date of 08/09/23 and a re-admission date of 03/23/26 with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, other schizophrenia, acquired absence of right leg above the knee, acquired absence of left leg above the knee, anxiety disorder and major depressive disorder.Review of Resident #11's physician's orders revealed an order for clonazepam 0.5 milligrams (mg) twice a day as needed with a start date of 09/22/25 and an end date of 12/20/25. This was the only clonazepam order in the medical record.Review of Resident #11's controlled drug sheets for the medication clonazepam 0.5mg revealed the medication was documented on the sheet as given on 01/02/26 at 8:00 P.M., 01/03/26 at 8:00 P.M., 01/04/26 at 8:30 P.M., 01/05/26 at 8:00 P.M., 01/06/26 at 8:00 P.M., 01/09/26 at 8:00 P.M., 01/11/26 at 9:00 P.M., 01/12/26 at 9:00 P.M., 01/15/26 at 9:00 P.M., 01/16/26 at 9:00 P.M., 01/18/26 at 8:30 P.M., 01/19/26 at 8:35 P.M., 01/20/26 at 8:00 P.M., 01/21/26 at 8:00 P.M., 01/23/26 at 8:00 P.M., 01/24/26 at 9:00 P.M., 01/25/26 at 9:00 P.M., 01/26/26 at 9:00 P.M., 01/27/26 at 5:00 A.M., 01/29/26 at 6:00 P.M., 01/30/26 at 5:00 A.M., 03/06/26 at 9:00 P.M., 03/07/26 at 9:00 P.M., 03/08/26 at 9:00 P.M., 03/09/26 at 9:00 P.M., 03/10/26 at 9:00 P.M., 03/13/26 at 9:00 P.M., 03/17/26 at 1:40 A.M., 03/18/26 at 9:00 P.M., 03/28/26 at 9:00 P.M., 03/30/26 at 9:00 P.M., 03/31/26 at 9:00 P.M., 04/03/26 at 9:30 P.M., 04/05/26 at 9:00 P.M. and 04/06/26 at 9:10 P.M. There were no corresponding Medication Administration Record (MAR) entries documenting administration of the medication. Further review of the Narcotic Log revealed there were no doses of the medication documented as administered for the month of February 2026.Review of Resident #11's progress notes on 01/02/26 at 8:00 P.M., 01/03/26 at 8:00 P.M., 01/04/26 at 8:30 P.M., 01/05/26 at 8:00 P.M., 01/06/26 at 8:00 P.M., 01/09/26 at 8:00 P.M., 01/11/26 at 9:00 P.M., 01/12/26 at 9:00 P.M., 01/15/26 at 9:00 P.M., 01/16/26 at 9:00 P.M., 01/18/26 at 8:30 P.M., 01/19/26 at 8:35 P.M., 01/20/26 at 8:00 P.M., 01/21/26 at 8:00 P.M., 01/23/26 at 8:00 P.M., 01/24/26 at 9:00 P.M., 01/25/26 at 9:00 P.M., 01/26/26 at 9:00 P.M., 01/27/26 at5:00 A.M., 01/29/26 at 6:00 P.M., 01/30/26 at 5:00 A.M., 03/06/26 at 9:00 P.M., 03/07/26 at 9:00 P.M., 03/08/26 at 9:00 P.M., 03/09/26 at 9:00 P.M., 03/10/26 at 9:00 P.M., 03/13/26 at 9:00 P.M., 03/17/26 at 1:40 A.M., 03/18/26 at 9:00 P.M., 03/28/26 at 9:00 P.M., 03/30/26 at 9:00 P.M., 03/31/26 at 9:00 P.M., 04/03/26 at 9:30 P.M., 04/05/26 at 9:00 P.M. and 04/06/26 at 9:10 P.M. revealed no documentation the resident had requested the medication or had complaints of anxiety.There was no documentation in the progress notes that the resident received clonazepam during the month of February 2026.Review of Resident #11's behavior monitoring on the treatment administration record on 01/02/26 at 8:00 P.M., 01/03/26 at 8:00 P.M., 01/04/26 at 8:30 P.M., 01/05/26 at 8:00 P.M., 01/06/26 at 8:00 P.M., 01/09/26 at 8:00 P.M., 01/11/26 at 9:00 P.M., 01/12/26 at 9:00 P.M., 01/15/26 at 9:00 P.M., 01/16/26 at 9:00 P.M., 01/18/26 at 8:30 P.M., 01/19/26 at 8:35 P.M., 01/20/26 at 8:00 P.M., 01/21/26 at 8:00 P.M., 01/23/26 at 8:00 P.M., 01/24/26 at 9:00 P.M., 01/25/26 at 9:00 P.M., 01/26/26 at 9:00 P.M., 01/27/26 at 5:00 A.M., 01/29/26 at 6:00 P.M., 01/30/26 at 5:00 A.M., 03/06/26 at 9:00 P.M., 03/07/26 at 9:00 P.M., 03/08/26 at 9:00 P.M., 03/09/26 at 9:00 P.M., 03/10/26 at 9:00 P.M., 03/13/26 at 9:00 P.M., 03/17/26 at 1:40 A.M., 03/18/26 at 9:00 P.M., 03/28/26 at 9:00 P.M., 03/30/26 at 9:00 P.M., 03/31/26 at 9:00 P.M., 04/03/26 at 9:30 P.M., 04/05/26 at 9:00 P.M. and 04/06/26 at 9:10 P.M. revealed no behaviors were recorded for the resident on those dates.Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed but review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment. Further review of Resident #18's 03/27/26 admission MDS revealed the resident was dependent on staff for toileting hygiene showering/bathing, transfers, and bed mobility, received antipsychotic and antianxiety medications.Review of Resident #11's progress notes revealed a note dated 04/08/26 at 9:01 A.M. written by the Director of Nursing (DON) that read Discussed with pharmacy and ViaQuest nurse practitioner, order was active with an active script the entire time of administration, however, was not active on the EMAR.In an interview on 04/21/26 at 8:32 A.M. the DON stated the progress note dated 04/08/26 at 9:01 A.M. was related to Resident #11's clonazepam medication. The resident's medication was renewed in December of 2025 by the ViaQuest nurse practitioner (NP); however the nurse who received the verbal order did not enter the order for the clonazepam in the medical record or make an entry on the MAR to indicate the administration instructions for the medication. The DON verified this administration, without an active order in the medical record, occurred from 01/02/26 through 04/06/26. The DON verified the pharmacy had a prescription for the medication from ViaQuest. In an interview on 04/22/26 at 12:09 P.M. Registered Nurse (RN) #148 stated she did not recall giving the medication or the medication not being on the MAR. She normally worked upstairs (the facility had a first floor and second floor which both housed residents) however she did know the resident had clonazepam ordered for a long time but did not know if it was scheduled or as needed. The RN said if it was as needed she would look for an order before giving the medication and would assess for symptoms such as anxiety, yelling out, and behaviors that were normal for him such as raising and lowering the head of his bed and saying he was unable to locate the bed control. Review of the Narcotic Control Log provided revealed RN #148 did document doses of the medication for Resident #11.In an interview on 04/22/26 at 1:40 P.M. ViaQuest (psychiatric services) Certified Nurse Practitioner (CNP) #200 confirmed she remembered Resident #11's clonazepam 0.5 mg one tablet twice daily as needed prescription had ended and the facility called her to get it reordered because the resident was restless and anxious, yelling out and the former Director of Nursing (DON) was who called her to get the order. CNP #200 stated that she sent a new prescription to the pharmacy for clonazepam 0.5 mg one tablet twice daily as needed after she received the call. The CNP stated she would provide verbal orders via phone if she wasn't in the facility to write the order herself. In an interview on 05/13/26 at 10:00 A.M. the DON stated she was made aware of the clonazepam 0.5 mg being given without being on the MAR, on one of the first days that she was working as the DON, when RN # 174 asked her to destroy the medication because there was not an order for it. The DON noted that it had been given recently and investigated to find out why. Her expectation was that the nursing staff would question any medication that was not on the MAR before administering the medication.Attempts were made to reach LPN #117 via phone during the onsite survey regarding her administration of the clonazepam 0.5 mg as needed when it was not on the MAR. No return calls were provided.Review of the policy titled Administering Medications, revised 12/2012, revealed medication must be administered in accordance with the orders. Further review of the policy revealed the individual administering the medication was to record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed.This deficiency represents non-compliance investigated under Master Complaint Number 2992141.

Based on record review, review of pharmacy receipts, Pyxis spread sheet review, policy review, and interview, the facility failed to ensure residents were free of significant medication errors when medications were not administered per physician orders. This affected one resident (#26) of three residents reviewed for anticoagulant medications. The facility census was 31.Findings include: Medical record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including weakness and hypertension.Review of a care plan dated 01/15/26 revealed Resident #26 was at increased risk of adverse reactions related to taking anticoagulant (blood thinning) medications. The goal was to experience no adverse reactions to the medication regimen throughout the review date. Interventions included but were not limited to administering medications as ordered, monitor skin for increased bruising and abnormalities, and obtain/monitor lab/diagnostic work as ordered and report any abnormalities to the medical provider.Review of orders revealed Resident #26 had an order in place dated 01/09/26 for Eliquis oral tablet 5 milligrams (mg) give two tablets (for total of 10 mg) by mouth two times a day for blood clots until 01/14/26. Beginning on 01/15/26, the order decreased to Eliquis 5 mg give one tablet twice a day. Further review of the physician orders revealed no discontinue date for the Eliquis.Review of a pharmacy receipt revealed the facility received a 80 count of Eliquis 5 mg tablets on 01/09/26 from their contracted pharmacy for Resident #26.Review of the medication administration record (MAR) for January 2026 revealed Resident #26 received Eliquis two tablets by mouth twice daily as ordered from 01/09/26 starting at 8:00 P.M. through 01/14/26, with one refusal on 01/12/26 at 8:00 A.M. Resident #26 would have taken 20 of the tablets during the timeframe leaving 60 tablets.Further review of the MAR for January 2026 revealed Resident #26 received the medication as ordered. Out of the 60 tablets left, Resident #26 would have taken 34 of the tablets during this timeframe leaving 26 tablets.Review of the MAR for February 2026 revealed Resident #26 received medication as ordered except on 02/18/26 (see nurses note with no corresponding note) and 02/20/26 with no information. However, when totaled out, the 26 remaining tablets would have been used by 02/13/26. Review of the nurse progress notes revealed no entry in the notes for 02/18/26 regarding the Eliquis administration.Further review of the progress notes revealed no mention of the Eliquis being out of stock, needing re-ordered or issues with the Eliquis medication administration.No additional Eliquis was ordered in the month of February 2026.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had mildly impaired cognition and received anticoagulant medication.Review of the MAR for 03/09/26 indicated no disruption in Eliquis administration, however Eliquis was not ordered until 03/09/26 and the resident received a 60-count supply of Eliquis 5 mg tablets with that order.Review of the Pyxis (back-up medication storage) Orange Kit Product Location Key revealed six tablets of 2.5 mg Eliquis in stock. Review of a spreadsheet from 01/01/26 through 03/09/26 revealed Resident #26 did not receive any Eliquis from the Pyxis.Interview on 04/22/26 at 8:05 A.M. with the Administrator revealed a review of the amount of Eliquis received from the pharmacy on 01/09/26 (90 tablets) and a comparison of the orders with the MAR and the next re-order date for the Eliquis on 03/09/26. In review, the Eliquis should have been re-ordered before 02/13/26 as this would have been the date the resident had no additional tablets for administration. The Administrator declined to answer if the resident received the Eliquis per order. The Administrator did confirm Resident #26 did not receive Eliquis doses from the Pyxis system.A follow-up interview on 04/22/26 at 1:33 P.M. with the Administrator revealed she had no additional information regarding the resident's Eliquis including additional re-orders or how the resident would have had enough doses to be administered if the pharmacy did not deliver more Eliquis between 02/18/26 and 03/08/26. The Administrator, who was also a Registered Nurse (RN), indicated she believed missing that many doses of Eliquis (02/18/26 until delivered on 03/09/26) would be considered a significant medication error.Interview on 04/21/26 at 2:25 P.M. with Pharmacist #550 revealed potentially missing doses of Eliquis could lead to a blood clot which is what they were trying to prevent with the medication. The pharmacist verified there was no Eliquis sent to the facility after 02/18/26 and was not re-ordered until 03/09/26.Review of a policy titled Administering Medications dated 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required timeframe. This deficiency represents non-compliance investigated under Master Complaint Number 2992141.

Based on medical record review, pharmacy receipt review, interview and policy review the facility failed to ensure medication administration was accurately documented in the medical record for Resident #26. This affected one resident (Resident #26) of three residents reviewed for anticoagulant medication. The facility census was 31. Findings include:Medical record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including weakness and hypertension.Review of orders revealed Resident #26 had an order in place dated 01/09/26 for Eliquis oral tablet 5 milligrams (mg) give two tablets (for total of 10 mg) by mouth two times a day for blood clots until 01/14/26. Beginning on 01/15/26, the order decreased to Eliquis 5 mg give one tablet twice a day. Further review of the physician orders revealed no discontinue date for the Eliquis.Review of a pharmacy receipt revealed the facility received an 80 count of Eliquis 5 mg tablets on 01/09/26 from their contracted pharmacy for Resident #26.Review of the medication administration record (MAR) for January 2026 revealed Resident #26 received Eliquis two tablets by mouth twice daily as ordered from 01/09/26 starting at 8:00 P.M. through 01/14/26, with one refusal on 01/12/26 at 8:00 A.M. Resident #26 would have taken 20 of the tablets during the timeframe leaving 60 tablets.Further review of the MAR for January 2026 revealed Resident #26 received the medication as ordered. Out of the 60 tablets left, Resident #26 would have taken 34 of the tablets during this timeframe leaving 26 tablets.Review of the MAR for February 2026 revealed Resident #26 received medication as ordered except on 02/18/26 (see nurses note with no corresponding note) and 02/20/26 with no information. However, when totaled out, the 26 remaining tablets would have been used by 02/13/26. Review of the nurse progress notes revealed no entry in the notes for 02/18/26 regarding the Eliquis administration.Further review of the progress notes revealed no mention of the Eliquis being out of stock, needing re-ordered or issues with the Eliquis medication administration.No additional Eliquis was ordered in the month of February 2026.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had mildly impaired cognition and received anticoagulant medication.Review of the MAR from 02/13/26 through 03/09/26 indicated no disruption in Eliquis administration, however Eliquis was not ordered until 03/09/26 and the resident received a 60-count supply of Eliquis 5 mg tablets with that order.Interview on 04/22/26 at 1:33 P.M. with Administrator revealed she had no additional information on Eliquis and if given correctly, Resident #26 would've run out on 02/13/26 and more was not ordered until 03/09/26. Administrator confirmed if Resident #26 ran out of medication on 02/13/26, the medication administration record for 02/2026 and 03/2026 was filled out inaccurately because resident could not have received her medication and the MARs indicated she did receive the medication.Review of a policy titled Charting and Documentation dated 08/2024 revealed services provided to the resident, progress toward goals, or any changes in the resident's medical, physical, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective, complete, and accurate.This deficiency represents non-compliance investigated under Master Complaint Number 2992141.

Based on observation and interview the facility failed to ensure the daily posted nursing staff information was current. This had the potential to affect all 31 residents residing in the facility. The census was 31.Findings include: On 04/20/26 at 9:40 A.M. during the initial tour an observation revealed the required daily nurse staff posting was dated 04/18/26. No other posting of the daily nurse staffing was observed during the tour.In an interview on 04/20/26 at 9:45 A.M. Activities Director #103 confirmed the observed posting was dated 04/18/26 and was not current.This is an incidental finding discovered during the course of the complaint investigation.

Based on observation, interview, and record review the facility failed to ensure foods were stored under sanitary conditions. This had the potential to affect all residents residing in the facility. The census was 36. Findings include:Observation on 01/20/26 at 8:38 A.M. during the initial tour of the facility kitchen revealed a walk-in white refrigerator. Upon entry to the refrigerator a foul odor was noted. Upon inspection under the shelf in the right corner a rotten apple, an old onion, open cheese slice, and an unidentifiable rotted item.Interview and observation on 01/20/26 at 8:48 A.M. with the Dietary Manager confirmed a foul odor was noted in the white walk in refrigerator and items including a rotten apple, an old onion, open cheese slice, and an unidentifiable rotted item were seen under the shelf in the right corner of the refrigerator.Review of undated facility policy titled Food Storage revealed food will be stored in an area that is clean, dry, and free from contaminants. All refrigerator units should be kept clean and in good working condition at all times.

The facility failed to ensure residents, who had resided in the facility for over a year, were offered the opportunity to be vaccinated with the updated Covid-19 vaccine for the 2025- 2026 respiratory season. This affected four residents (Resident #4, #5, #33, and #36) of five residents reviewed for vaccinations. Findings include: 1. Review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), morbid obesity, adult-onset diabetes mellitus, nicotine dependence, and hypertension. Review of Resident #4's Vaccination Consent Form dated 11/12/25 revealed the resident was offered several different vaccines at that time to include Influenza, Pneumococcal, Shingles, Respiratory Syncytial Virus (RSV), and Hepatitis B. There was a place on the form to add other vaccines that were offered but that box was left blank and no additional vaccines had been added to the form as having been offered. There was no evidence of the resident being offered the updated Covid-19 vaccine for the 2025-2026 respiratory season. Findings were verified by the interim Director of Nursing (DON). 2. Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, hypertension, and hyperlipidemia (high cholesterol). Review of Resident #5's vaccination consent forms dated 02/15/25 revealed the resident was offered the Influenza vaccine and the Pneumococcal vaccine on 02/15/25. He consented to receive the Influenza vaccine and received it on 02/15/25. He received the updated Influenza vaccine for the 2025-2026 respiratory illness season on 11/07/25. He was also offered the Pneumococcal vaccine, but refused it when offered on 02/15/25. There was no documented evidence of the resident having been offered the updated Covid-19 vaccine for 2025- 2026. Findings were verified with the interim DON. 3. Review of Resident #33's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, hypertension, adult-onset diabetes mellitus, hypercholesterolemia (high cholesterol), and bronchitis. Review of Resident #33's vaccination consent forms dated 11/03/25 revealed the resident was offered the Influenza vaccine and the Pneumococcal vaccine on 11/03/25. She declined both the Influenza and the Pneumococcal vaccines when offered. There was no evidence of the resident having been offered the updated Covid-19 vaccine for 2025- 2026 respiratory illness season. Findings were verified with the interim DON. 4. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, morbid obesity, congestive heart failure, hypertension, and unspecified dementia. Review of Resident #36's Vaccination Consent Form dated 11/12/25 revealed the resident was offered several different vaccines at that time to include Influenza, Pneumococcal, Shingles, Respiratory Syncytial Virus (RSV), and Hepatitis B. There was a place on the form to add other vaccines that were offered but that box was left blank and no additional vaccines had been added to the form as having been offered. There was no evidence of the resident being offered the updated Covid-19 vaccine for the 2025-2026 respiratory season. Findings were verified by the interim DON. On 01/27/26 at 1:05 P.M., an interview with the interim DON revealed they did not have any evidence of an updated Covid-19 vaccine being offered and/ or provided to the above residents for the 2025-2026 respiratory illness season. They were offering Covid-19 vaccines to residents upon their admission to the facility and had the documentation for that. The DON was having trouble locating the consent forms for Covid-19 vaccines being offered to residents that have been residing in the facility for over a year. She assured that they were offering and providing to those residents if requested, but could not find documented evidence to support such. Review of the facility's Covid-19 Vaccination policy (updated in August 2024) revealed the facility would offer the Covid-19 vaccine when available and in accordance with it's policy on Covid-19 vaccination for residents. The rest of the policy was directed towards vaccinating staff with the Covid-19 vaccines.

Based on medical record review, policy review, and staff interview the facility failed to document advance directives for a resident. This affected one resident (#2) of eighteen residents reviewed for advanced directives. The facility census was 36.Findings include:Review of the medical record for Resident #2 revealed admission to the facility on [DATE] for diagnoses including a stroke with left side paralysis, atrial fibrillation (irregular heartbeat), bilateral above the knee amputations, high blood pressure, anxiety and depression, schizophrenia (mental disorder with delusion thoughts and/or hallucinations), diabetes, and congestive heart failure.Further review of the medical record for Resident #2 revealed no current order for code status. Review of discontinued orders revealed an order to discontinue full-code status on 10/27/25. Interview on 01/21/26 at 10:40 A.M. with licensed practical nurse (LPN) #38 revealed that Resident #2's code status should be listed under the orders screen in the electronic medical record (EMR). LPN #38 reviewed the current orders and verified there was no current code status order. LPN #38 then checked Resident #2's additional paper chart and showed a green paper on the front of chart with FULL CODE written largely. LPN #38 reported that the paper charts were being phased out and new admissions did not have paper charts. LPN #38 reviewed the EMR for Resident #36 and found a discontinued order for full code status written on 10/27/25 when the resident was transferred to the hospital. LPN #38 reported that Resident #2's code status order must not have been updated after his hospital stay and return to the facility in October 2025.Interview on 01/21/26 at 10:45 A.M. with certified nurse aide (CNA) #22 revealed that resident's code status could be found in the Kardex section in the EMR. CNA #22 reviewed the Kardex for Resident #2 and could not find a code status listed. CNA #22 was unaware of the code status being listed in the paper chart. Review of the facility Advanced Directives Policy dated 08/2021 and last reviewed 08/2025 revealed, Resident wishes will be communicated to the staff via the care plan and (identify facility protocol for communication of advance directives either in written or oral format) and to the resident physician.

Based on review of beneficiary liability notices and staff interview, the facility failed to ensure residents and/ or their representatives signed the liability notices provided acknowledging their skilled services were ending for coverage under Medicare (MCR) Part A services. This affected two residents (#2 and #36) of three residents reviewed for liability notices. Findings include:1.) Review of Resident #2's liability notices revealed the resident's last covered day for MCR Part A services was on 09/05/25. Notice of non-coverage was documented on a Centers for Medicare and Medicaid Services (CMS) form 10123, titled Notice of MCR Non-Coverage (NOMNC) and was dated for 08/25/25. The form included a place for the residents or their representatives to sign acknowledgement of receiving that notice, but was only signed by two facility employees (Admissions Director #49 and MDS Coordinator #47), and not the resident or their representative. There was no documented evidence on the NOMNC of the resident or their representative having been notified their skilled service was ending or that the resident would no longer be covered under MCR Part A services. Resident #2 remained in the facility following their skilled service ending and was also provided a CMS form 10055, titled Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN). That form was also dated 08/25/25 and further specified the skilled service ending included physical therapy and occupational therapy. The form included three options to choose from specifying whether the resident wanted to appeal the decision and continue to receive the skilled service, or if they were opting out of continuing to receive those skilled services with the understanding they would not responsible for paying and could not appeal to see if MCR would pay for the services. Option #3 was marked as having been selected opting out of wanting to continue to receive those skilled services. The form also had a place for the resident or their representative to sign acknowledgement of receiving that notice. Again, Admissions Director #49 and MDS Coordinator #47 were the only ones who signed the SNF ABN, and there was not a signature from the resident or their representative acknowledging receiving that notice. 2.) Review of Resident #36's liability notices revealed the resident's last covered day for MCR Part A services was on 08/27/25. Notice of non-coverage was documented on CMS form 10123 (NOMNC) and was dated for 08/15/25. The form included a place for the residents or their representatives to sign acknowledgement of receiving that notice, but was only signed by two facility employees (Admissions Director #49 and MDS Coordinator #47), and not the resident or their representative. There was no documented evidence on the NOMNC of the resident or their representative having been notified their skilled service was ending, or that the resident would no longer be covered under MCR Part A services. Resident #36 remained in the facility following their skilled service ending and was also provided a CMS form 10055 (SNF ABN). That form was also dated 08/15/25 and further specified the skilled service ending included physical therapy and occupational therapy. The form included three options to choose from specifying whether the resident wanted to appeal the decision and continue to receive the skilled service, or if they were opting out of continuing to receive those skilled services with the understanding they would not responsible for paying and could not appeal to see if MCR would pay for the services. Option #3 was marked as having been selected opting out of wanting to continue to receive those skilled services. The form also had a place for the resident or their representative to sign acknowledgement of receiving that notice. Again, Admissions Director #49 and MDS Coordinator #47 were the only ones who signed the SNF ABN, and there was not a signature from the resident or their representative acknowledging they received that notice. On 01/26/26 at 8:45 A.M., the facility's Administrator acknowledged the liability notices provided to Resident #2 and #36 were not signed by the residents or their representatives showing evidence they had been notified their skilled services were ending and would no longer be covered under MCR Part A services. The Administrator indicated that Resident #2 was not physically able to sign the forms and Resident #36's daughter was allegedly notified via phone. The Administrator confirmed Resident #2's cognition was moderately impaired and his representative should have signed acknowledgement of receiving the notification that his skilled services were ending. She further acknowledged there was no documentation on the liability notices for Resident #36 or in her electronic medical record to support her representative was notified when her skilled services and coverage under MCR Part A services ended on 08/27/25.

Based on record review, observation, interview, and policy review, the facility failed to ensure residents with the diagnosis of dementia did not receive an anti-psychotic medication without an adequate indication for use. This affected two residents (#5 and #33) of five residents reviewed for unnecessary medications. Findings include:1.) Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included unspecified dementia (moderate) with agitation and depression. Review of Resident #5's acknowledgement/ consent for psychoactive medications dated 02/15/25 revealed the resident's representative signed consent for the use of the Seroquel that had previously been indicated to be used for dementia with behavioral disturbances on a prior acknowledgement/ consent dated 03/30/24. The target behaviors it was previously used for included anxiety and agitation. The more recent acknowledgement/ consent form did not include a diagnosis or condition that warranted the use or any new specific target behaviors it was being used for. The form signed by the resident's representative indicated they understood that non-drug approaches would continue to be utilized to reduce target behaviors, routine dosage reduction attempts would be made unless the reduction was clinically contraindicated, and also understood that the physician and interdisciplinary team (IDT) would review the order routinely for the continued need of the medication intervention. Review of Resident #5's active physician's orders revealed the resident had an order to receive Seroquel (an atypical anti-psychotic medication used in the treatment of schizophrenia, bipolar disorder, and as an add-on treatment for major depressive disorder) 50 milligrams (mg) with directions to receive one tablet by mouth twice a day related to unspecified dementia with agitation. The current order had been in place since 03/11/25. Review of Resident #5's pharmacy recommendation for an irregularity that was identified as a result of the monthly medication regimen review completed on 08/17/25 revealed the facility's contracted pharmacist recommended the physician evaluate the need for continued use of the Seroquel per the guidelines for psychotropic drug therapy. The recommendation indicated that the Centers for Medicare and Medicaid Services (CMS) had an increased focus on the use of psychotropic medications in long-term care. State and Federal surveyors would be scrutinizing their use as a result. The pharmacist asked the prescriber to review the resident's medication regimen and to indicate their professional opinion on further use of the medication listed above. The prescriber (a psychiatric nurse practitioner) agreed with the recommendation indicating that a dose reduction would be attempted and to see the new order provided below. The prescriber's response was to decrease the Seroquel to 25 mg po every day and give Seroquel 50 mg po every night at bedtime, if the resident's daughter/ family would agree. The response indicated that the family had refused the last gradual dose reduction (GDR) recommendation. Review of a nurse's progress note dated 09/29/25 at 10:47 A.M. revealed the nurse had talked with Resident #5's sister/ Power of Attorney (POA) that day and she did not want the resident's Seroquel changed in any way. She did not want the dose to be reduced or discontinued. The note indicated that the POA was very adamant about that and he (the resident) was to stay on the current dose. Review of a psychiatric note from Certified Nurse Practitioner (CNP) #200 dated 11/05/25 revealed she had seen Resident #5 on that date for a follow up evaluation for a psychiatric medication management visit to address symptoms related to anxiety and dementia. She indicated his mood had been fine and he denied any depression and anxiety. He was noted to have some confusion, which was at his baseline. He denied any intent to harm himself or others and also denied having any delusions. She noted his psychiatric history of dementia and alcohol abuse. A mental status exam at the time of the visit revealed his general appearance was within normal limits (WNL) as he was appropriately dressed and groomed for the occasion. His mood and affect was WNL and he was euthymic (a normal, stable mood state that was neither manic nor depressive) and congruent. She indicated on her assessment that the resident did not display any signs of psychosis or a disturbance of his perception. Her medical decision making indicated his anxiety was a stable, chronic condition. His chart indicated a possible history of an anxiety diagnosis and he was found to be irritable and distracted during the assessment. He was being managed on Lexapro (an anti-depressant) to manage that problem. His dementia was also indicated to be a chronic illness where he had been diagnosed prior to the start of service with the CNP's psychiatric company. He demonstrated memory loss and poor cognition and was being managed on Donepezil (medication used in the treatment of dementia). She listed his medications, which included Seroquel 50 mg twice a day for dementia with behaviors. She did not recommend any medication adjustments that that time and wanted to continue the current regimen. She would follow up with the resident in four to eight weeks unless acute issues or concerns presented. Her note referenced, per the nurse, the resident had a failed GDR of Seroquel in the past and had increased behaviors yelling out, agitation, irritability, and difficulty to redirect. The note did not specify when that failed GDR attempt allegedly occurred or if it had been attempted while residing in the nursing home side of the building. He was a resident of the assisted living facility prior to 02/15/25 that was connected to the nursing home. There was nothing in the resident's order history for the use of the Seroquel to indicate any dosage reduction attempts had been tried since he was admitted to the nursing facility on 02/15/25. Review of Resident #5's medication administration record (MAR) for January 2026 revealed the resident was receiving Seroquel 50 mg twice a day as ordered for unspecified dementia with agitation. The Seroquel was scheduled to be given every morning at 9:00 A.M. and every night at 9:00 P.M. Review of Resident #5's active care plans revealed he had a care plan in placed for an impaired cognition as evidenced by deficits in memory, judgement, decision making that was related to dementia. The only behavior the resident was indicated to have in his active care plans was him being known to crawl on the floor. Observations of Resident #5 throughout the course of the investigation with on-site visits 01/20/26- 01/22/26 and again on 01/27/26 revealed the resident was not observed to display any behaviors. He was mostly observed lying in bed or up in his recliner with his eyes closed and no behaviors being displayed. On 01/22/26 at 2:55 P.M., an interview with Certified Nursing Assistant (CNA #34) revealed she was a part- time CNA, but was somewhat familiar with Resident #5. She had been assigned to work his hall and has had interactions with him. She denied that he had much in the way of behaviors other than being known to yell out hey, hey, hey. She would respond to his calling out and some of the times he needed something, while other times he didn't. She stated she would usually just talk to him and it would help distract him. It would be effective for a while and then he may start yelling out again. She denied she had known him to display any aggressive behaviors towards staff or other residents on the days she was there. His behaviors was more in the afternoon/ evening time, when they occurred. On 01/22/26 at 3:11 P.M., an interview with CNP #200 via phone revealed dementia with agitation was not an appropriate diagnosis for the use of Seroquel. She acknowledged Resident #5 had been on Seroquel 50 mg twice a day (BID) since his admission to the nursing facility on 02/15/25. She identified three diagnoses that were appropriate for the use of anti-psychotics in nursing facilities to include Huntington's Chorea, Tourette Syndrome, and schizophrenia. She reported they have been trying to work with the resident's sister/ POA, who did not want his Seroquel discontinued. She reported she attempted to reduce his Seroquel when he was residing on the assisted living side, but his POA declined those attempts as well. The POA had been reluctant to allow them to make any changes to the medication. She was asked how she handled families that were resistant to allow psychotropic medication changes to be able to adhere to the regulations on GDR's. She stated in the end, they took a combined approach. The family had a big play in what medications a resident received. She indicated the family typically knew the resident's history better than the facility did. She again stated she attempted to write an order twice to reduce the dosage of the Seroquel and the POA refused. She agreed families should be able to give input on medications a resident received, but it was ultimately up to the prescriber to order the medication at the proper dose to treat a resident's condition. She was not able to indicate if the facility had tried any behavior management, changes in his environment, or person-centered approaches to manage behaviors in place of using an anti-psychotic for management of his dementia with agitation. She stated that would be more the facility's Director of Nursing that would have to answer that. On 01/22/26 at 3:55 P.M., an interview with Regional Nurse #90 confirmed the resident did not have an adequate indication for use of the Seroquel as dementia with agitation was not an appropriate diagnosis. She further confirmed there had not been any GDR attempts with the resident's Seroquel, since the resident had been admitted to the facility on [DATE]. She thought they had attempted in the past, but acknowledged the psych CNP indicated she gave the order twice to reduce his dose when still on the assisted living unit, which was not followed through with due to the POA's refusal for any medication changes to be made. She acknowledged the prescriber was the one that ultimately decided what medications should be used for a resident and at what dose to manage medical diagnoses. The family could give input, but should not be determining the need for a particular medication or at what dose it should be given. Review of the facility's policy for Psychotropic Medication Use updated August 2025 revealed psychotropic medications may be considered for residents with dementia, but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Psychotropic medications would be prescribed at the lowest possible dosage for the shortest period of time and were subject to gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue those drugs. Residents may receive psychotropic medications when necessary to treat specific conditions for which they were indicated and effective. Psychotropic medications should generally be used for the following conditions/ diagnoses as documented in the medical record, consistent with the definition in the Diagnostic and Statistical Manual of Mental Disorders: Schizophrenia, Schizo-affective disorder, Schizophreniform disorder, delusional disorder, mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression), psychosis in the absence of dementia, medical illnesses with psychotic symptoms and/ or treatment- related psychosis or mania, Tourette's Disorder, Huntington Disease, hiccups, nauseas and vomiting associated with cancer or chemotherapy, and any other diagnosis deemed necessary by the physician/ nurse practitioner. Diagnoses alone did not warrant the use of psychotropic medications. In addition to the above criteria, antipsychotic medications may be considered if the following conditions were also met: the behavioral symptoms present a danger to the residents or others, and the symptoms were identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia, or grandiosity, or behavior interventions have been attempted and included in the plan of care, except in an emergency. Psychotropic medications would not be used if the only symptoms were one of the following to include restlessness, impaired memory, mild anxiety, fidgeting, nervousness, or uncooperativeness. 2. Review of Resident #33's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (moderate) with mood disturbance. Review of Resident #33's monthly physician's orders revealed the resident was receiving Seroquel (an antipsychotic) 25 mg po three times a day (TID) for depressive disorder. She was also receiving 50 mg po every night at bedtime for agitation. Both order had been in place since her admission to the facility on [DATE]. She also received Sertraline HCL (Zoloft) 100 mg po once daily for depression. Review of Resident #33's psychiatric notes revealed she had been seen by the psychiatric nurse practitioner twice since her admission. Visits were made on 11/19/25 and again on 01/13/26 for an initial and follow up psychiatric evaluation for medication management and mental health services respectively. Her diagnoses included unspecified dementia (moderate) with mood disturbance and depression. Her initial visit on 11/19/25 indicated she had no suicidal or homicidal ideations, delusions, or hallucinations. Her follow up visit on 01/13/26 indicated she was redirectable and had no reports of aggression. Both visits she was not indicated to have psychosis or a disturbance in perception. The first visit on 11/19/25, the CNP indicated the resident was receiving Seroquel TID for dementia and there was no plan for a medication adjustment at that time, as the CNP would talk with the resident's family to see if they were agreeable to a GDR with the Seroquel. The last visit on 01/13/26, the CNP indicated the resident was receiving Seroquel 25 mg four times a day and her plan was to recommend a GDR of the Seroquel to 25 mg three times a day. She attempted to contact the resident's daughter but received no answer. Staff were made aware of the need to follow up with the resident's daughter, and if she was in agreement, to please reduce the Seroquel to 25 mg TID. Review of Resident #33's MAR's for January 2026 revealed the resident continued to receive Seroquel 25 mg TID for depressive disorder. The latest order originated on 01/14/26. Review of Resident #33's care plans revealed she had an active care plan in place for impaired cognition as evidenced by deficits in memory, judgement, and decision making related to dementia. She also had care plans for an attention to delirium or confusional episodes and insomnia related to dementia. No other behavior related care plans were noted. Review of Resident #33's progress notes revealed she had a electronic medication administration (eMAR) note dated 01/14/26 at 6:48 P.M. that indicated the system identified a black box warning pertaining to the use of Seroquel 25 mg where the resident was receiving one tablet three times a day for depressive disorder. The black box warning indicated there was an increased risk of death in elderly patients with dementia- related psychosis. Studies show those patients, when treated with an atypical antipsychotic had a 1.6 to 1.7 times higher risk of death compared to others taking a placebo, often due to cardiovascular events or infections like pneumonia. Seroquel was not approved for treating dementia- related psychosis. There was also an increased risk of suffering a stroke. Observations of Resident #33 during the course of the investigation with on-site visits between 01/20/26 and 01/22/26 and again on 01/27/26 revealed no evidence of the resident displaying any behaviors. She was observed to be out of her room and sitting in common areas around other residents pleasant and smiling. On occasion she was observed to be sleeping while in a chair or on the sofa by the nurses' station. She did not have any negative or aggressive interactions with staff or other residents. On 01/21/26 at 1:43 P.M., an interview with Registered Nurse (RN) #47 revealed the facility could not find an adequate indication for use for the Resident #33's use of Seroquel. She stated the only diagnosis they had was dementia with behaviors. On 01/21/26 at 2:00 P.M., an interview with Regional Nurse #90 revealed they (facility staff) had identified Resident #33 did not have an appropriate diagnosis for the use of Seroquel and they were having the psychiatric CNP address that. They would be tapering the resident's Seroquel down with plans to discontinue it, since she did not have an appropriate diagnoses to support the use. She provided a copy of the CNP #200's psychiatric note for 01/13/26 for supportive documentation as evidence of such. That visit note only indicated they planned to do a GDR for the resident's Seroquel, if it was okay with the resident's daughter. It did not indicate it was their intent to taper the medication until it could be discontinued, since she did not have an adequate indication for use. On 01/21/26 at 3:40 P.M. an interview with the director of nursing (DON) revealed the facility's hope was to eventually get the resident off the Seroquel, but her daughter may not be in agreement. She reported when Resident #33 first came, the daughter had showed them videos she had of the resident's agitative behaviors. She reported the daughter was totally against any medication changes being made with the resident's Seroquel, when she first came in, but they were able to get her to agree to a dosage reduction attempt a little while after. The DON was informed they needed an adequate indication for use for the Seroquel and dementia with behaviors was not an adequate indication for use. She was also informed, although the family can give input on medications received, they could not insist that a medication be given, if there was not a medical indication for use. It was ultimately the responsibility of the prescriber to justify the use and to order it at the lowest dose necessary to manage the resident's condition. On 01/22/26 at 9:10 A.M., an interview with CNA #74 revealed every now and then Resident #33 would want some alone time. She would want to go to her room and sit by herself for some quiet time. The resident could get overstimulated at times, and that was usually later in the afternoon. They would notice her being up more and walking around like she was getting anxious/ restless and looking for things. If she was taken to her room and sat on her sofa or at the table in her room and provided with a magazine or had the TV turned on, she would calm down. She denied the resident had any other behaviors. She denied the resident showed any agitation towards staff or other residents. On 01/22/26 at 3:11 P.M., an interview with CNP #200 via phone revealed Resident #33 did not have an adequate diagnosis for the use of Seroquel. She confirmed with a mood disturbance was not typically an adequate indication for use. She stated they were working on a GDR for the resident's Seroquel and it was her ultimate goal to get the resident off that medication. The resident's daughter had indicated that the resident had been aggressive in the past. She was not sure where they would end up with the GDR's, so she did not write the order to slowly taper it until it could be discontinued, nor did she document it was her intent to take the resident off of the medication due to not having an appropriate diagnosis for it's use. They generally did not know a resident's history if the resident was already on the medication when they came in. She stated they wanted to ensure the resident was safe and other residents were kept safe as well. She was not able to state if any behavior management, environmental changes, or other person-centered interventions had been attempted in place of the Seroquel that was being used. She stated the DON would have more information about what modifications had been made.

Based on record review and staff interview, the facility failed to ensure a resident and/ or their representative was provided a transfer notice in writing and a bed hold notice at the time of a transfer to the hospital. This affected one resident (#1) of three residents reviewed for hospitalizations. Findings include:Review of Resident #1's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a stroke, acute respiratory failure, and pneumonitis due to the inhalation of food and vomit into his lungs. Review of Resident #1's progress notes revealed a nurse's note dated 09/11/25 at 9:40 A.M. that indicated the nurse went into the resident's room to administer his medications and was unable to arouse the resident. He did not respond to tactile stimuli and remained unresponsive. The facility's Director of Nursing (DON) was notified and it was decided to send the resident to the emergency room. He was transported to the emergency room via squad at 10:05 A.M. The facility was asked to provide a copy of the transfer notice and the bed hold notice that was provided to the resident and/ or their representative at or around the time of the transfer. They provided a copy of a bed hold notice that had been provided and electronically signed by Resident #1 on 09/10/25, when his admission paperwork was completed with him. There was no evidence of a transfer notice being provided to the resident and/ or to his representative upon his transfer to the hospital on [DATE]. There was also no documented evidence of a bed hold notice having been provided to the resident or his representative at the time of the transfer giving him the option to hold a bed, if he chose to do so. On 01/26/26 at 2:38 P.M., the facility's Administrator confirmed they did not have evidence of a transfer notice being provided to the resident and/ or the resident's representative at the time of the resident's transfer to the hospital on [DATE]. She reported the resident's representative was notified of the need to transfer him to the hospital, as was indicated in a progress note, but denied the transfer notice was provided in writing as required. She further confirmed there was no evidence of a bed hold notice having been provided to the resident or his representative at the time of his transfer giving him the right to hold a bed, while out of the facility. She reported the employee responsible for providing the bed hold notices was unaware that all residents should be provided a bed hold notice despite their payer status. She indicated they had only been providing bed hold notices to residents who had Medicaid as their payer status and the resident was under private insurance.

Based on interviews and record review the facility failed to ensure accuracy of minimum data set (MDS) assessments for residents. This affected two residents (#3, #33) of 18 residents reviewed for accuracy of assessments. The census was 36. Findings include:1.Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, cardiac pacemaker, type two diabetes, hypertension, and gastro esophageal reflux disease. Review of Resident #3 orders revealed an order to admit the resident to hospice active 11/20/24. Review of Resident #3 care plan completed 09/10/25 revealed the resident is receiving hospice services. Initiated on 09/10/25. Goals, include the resident needs, will be met with comfort and dignity through end-of-life services. interventions include coordinating care with hospice. Review of Resident #3 annual minimum data set (MDS) completed on 01/01/26 revealed a brief interview for mental status (BIMS) score of 04 indicating cognitive impairment. Review of Resident #3 MDS revealed no documentation of Resident #3 receiving hospice care and services or of Resident #3 having a life expectancy of six months or less. Interview on 01/22/26 at 12:20 P.M. with Regional MDS #91 revealed Resident #3 MDS was inaccurately coded to reflect the resident's hospice status. Interview on 01/27/26 at 8:49 A.M. with facility admissions director revealed Resident #3 does receive hospice care and services. 2. Review of Resident #33's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (moderate) with mood disturbance and insomnia. Review of Resident #33's active physician's orders revealed she had the use of Melatonin (a supplement that replaces a hormone naturally produced by the pineal gland in the brain that regulates the sleep-wake cycle) 10 milligrams (mg) by mouth (po) every night at bedtime for insomnia. She had been on that medication since the order originated on 11/02/25. Review of Resident #33's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's medications received during the seven day assessment period included a hypnotic. The box was marked to indicate the resident was taking a hypnotic and had an indication for use. Review of Resident #33's medication administration record (MAR) for November 2025 revealed the resident was receiving Melatonin 10 mg po at bedtime for insomnia. The order originated on 11/02/25 and the resident received it nightly as ordered. There was no evidence of a hypnotic having been administered to the resident, as was indicated on the admission MDS assessment completed on 11/10/25. Review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual from October 2024 revealed it included coding tips for section (N.) of the MDS assessment, which documented medications received during the seven day assessment period. The coding tips instructed the assessor to code medications in Item N0415 according to the medication's therapeutic category and/ or pharmacological classification, not how it was used. They gave an example of a medication that may have been prescribed for use as a hypnotic, such as Oxazepam, but was classified as another pharmacological classification (anti-anxiety medication). On 01/21/26 at 1:25 P.M., an interview with MDS Nurse #47 confirmed Resident #33's admission MDS assessment dated [DATE] was not coded accurately. She acknowledged she coded in the MDS assessment that the resident had received a hypnotic medication, when she had only been given Melatonin for insomnia. She confirmed Melatonin was considered a supplement and not a hypnotic, based on it's pharmacological classification. She further confirmed medications should be classified based on their pharmacological classification and not for how it was used, as specified in the RAI manual.

Based on record review, interview, and policy review the facility failed to ensure residents received complete treatment for infections including antibiotic therapy and failed to ensure physician prescribed weight loss treatment was completed. This affected two residents (#3, #17) of 16 residents reviewed for quality of care. The census was 36. Findings include:1.Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, cardiac pacemaker, type two diabetes, hypertension, and gastro esophageal reflux disease. Review of Resident #3's annual minimum data set (MDS) completed on 01/01/26 revealed a brief interview for mental status (BIMS) score of 04. Review of Resident #3's orders revealed an order to clean left index finger around the nail bed with IHWC, pat dry, apply triple antibiotic ointment (TAO) and cover with band aid daily until resolved. Review of Resident #3's orders revealed an order for Doxycycline hyclate (antibiotic) tablet 100 milligrams (mg) give one tablet by mouth twice daily for infection for seven days starting 01/05/26 and ending 01/12/26. Review of Resident #3's January 2026 medication administration record (MAR) revealed Doxycycline hyclate 100 mg was not administered for both doses (8:00 A.M. and 9:00 P.M.) on 01/08/26 and for the morning (8:00 A.M.) dose on 01/09/26, for a total of three missed doses of the antibiotic. Review of Resident #3's progress notes revealed a progress note dated 01/08/26 at 2:59 P.M. stating Doxycycline hyclate tablet 100 mg give 1 tablet by mouth two times a day for infection for seven days, awaiting arrival from pharmacy. Review of Resident #3 progress notes revealed a note dated 01/09/26 at 9:23 A.M. revealing the resident's Doxycycline was unavailable. Unable to pull from emergency kit, Doxycycline was out of stock. Spoke with pharmacy who stated it would be out for delivery this day. Eventus aware. Review of Resident #3 progress notes revealed a note dated 01/09/26 at 10:59 A.M. revealed Doxycycline hyclate tablet 100 MG give one tablet by mouth two times a day for infection for seven days, awaiting delivery from pharmacy. E-kit was out of stock at this time. Review of Resident #3 record revealed no documentation of Resident #3 Doxycycline for finger infection being adjusted after doses were unavailable to ensure the full course of the antibiotic was received by the resident. The resident received 11 out of 14 doses of the antibiotic. Interview on 01/26/26 at 11:28 AM with Licensed Practical Nurse (LPN) #61 revealed they have been having issues with pharmacy. You may order something from pharmacy, and it doesn't come in for days. If an antibiotic is missing doses they can drop ship it from a local pharmacy, or pull from the emergency kit (E-kit). You can pull from the E-kit or call pharmacy to ensure they get full doses. If someone goes two days without their antibiotic then they are not receiving the full dose, unless its rescheduled/ extended. Interview on 01/27/26 at 1:30 P.M. with facility Director of Nursing and Assistant Director of Nursing confirmed Resident #3's Doxycycline was not rescheduled to make up for the missing doses for their finger infection. 2. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, chronic obstructive pulmonary disease, hyperlipidemia, insomnia, morbid obesity, and depression. Review of Resident #17's record revealed an order for Zepbound Subcutaneous Solution Auto-injector 10 milligram (MG) /0.5 milliliter (ML), (Tirzepatide for Weight Management), Inject 10 mg subcutaneously one time a day every Saturday for weight loss. Ordered on 12/27/25 and discontinued on 01/05/26. Review of Resident #17 progress notes revealed a progress note dated 01/03/26 at 9:28 A.M. stating Zepbound Subcutaneous Solution Auto-injector 10 milligram (MG) /0.5 milliliter (ML), Inject 10 mg subcutaneously one time a day every Saturday for weight loss. None available to give. Reordered from pharmacy. Review of Resident #17 record including progress notes, medication administration record, and treatment administration record revealed no documentation Resident #17 received their ordered dose of Zepbound for January (2026). Review of Resident #17's medication administration record revealed no documentation of Resident #17 receiving their prescribed dose of Zepbound 10 mg/ 0.5 ml for weight loss.

Based on observation, interview, record review, and policy review the facility failed to ensure catheter care was completed for Resident #17, urinary outputs were monitored as ordered for Resident #27, and Resident #36 completed their full course of prescribed antibiotics for a urinary tract infection (UTI). This affected three residents (#17, #27, #36) of four residents reviewed for urinary catheters and UTIs. The census was 36. Findings Include:1.Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, chronic obstructive pulmonary disease, hyperlipidemia, insomnia, morbid obesity, and depression. Review of Resident #17's minimum data set (MDS) completed on 12/26/25 revealed the resident had an indwelling urinary catheter. Review of Resident #17's orders revealed an order to maintain 16 French (F) with 10 milliliter (ML) balloon catheter in place, to be changed every 30 days as needed to maintain patency. Review of Resident #17 record revealed no documentation of catheter care being completed. Review of Resident #17's care plan completed 12/20/25 revealed the resident has an indwelling catheter and is at risk for complications such as but not limited to infection, sepsis, skin decline, self image declines, and wound intervention. Goals include the resident will show no signs and symptoms of complications related to catheter use through the review date. Interventions include monitor and document for pain and discomfort due to catheter. Monitor/ record/ and report signs and symptoms of UTI such as pain, burning, blood-tinged urine, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Position the catheter bag and tubing below the level of the bladder and away from entrance door. Review of Resident #17's record including orders, medication administration record, treatment administration record, orders, and tasks revealed no documentation of Resident #17 being provided indwelling urinary catheter care. Observation and interview on 01/20/26 at 12:59 P.M revealed Resident #17 had an indwelling urinary catheter in place. Sediment and dark color were observed in the indwelling urinary catheter tubing. Interview on 01/27/26 at 1:33 P.M. with facility Director of Nursing and Assistant Director of nursing confirmed there was no documentation in the resident's medical record of indwelling urinary catheter care being completed. 2. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, type two diabetes mellitus, obstructive and reflux uropathy, hyperlipidemia, hypertension, urinary retention, Alzheimer's diseases, dementia, chronic kidney disease. Review of Resident #27's minimum data set (MDS) revealed the resident had an indwelling urinary catheter. Review of the resident's care plan completed on 11/06/26 revealed the resident has an indwelling catheter related to at risk for complications such as infection, sepsis, skin decline, self-image, obstructive uropathy, BPH, and urine retention. The resident will show no signs or symptoms of complications related to catheter use. 18 French catheter 10 milliliter balloon change per order, document and monitor pain, monitor and report signs and symptoms of UTI: burning, blood, cloudy, no output, increase pulse/ temp/ no output, fever, chills, altered mental status, position catheter and tubing below bladder and away from entrance room door. Enhanced barrier precautions for catheter. Review of Resident #27's orders revealed an order placed on 11/06/25 to record indwelling urinary output every shift for monitoring. Notify provider if less than 400 milliliter (ML) per shift. Review of Resident #27's treatment administration record revealed no documentation of indwelling urinary catheter outputs on 12/01/25, 12/06/25, 12/11/25, 12/17/25, 12/21/25, and 12/24/25 and no documentation of physician notification for an output of less than 400 ml for the shift. Review of Resident #27's record revealed documentation on the treatment administration record on 12/14/25, 12/18/25, 01/01/26, and 01/13/26 had no documented output and was documented as see nurses notes. Review of Resident #27's progress notes revealed no documentation of a nurses notes on 12/14/25, 12/18/25, 01/01/26, and 01/13/26 related to Resident #27 indwelling urinary catheter output. Review of facility policy titled Catheter Care (reviewed 04/28/25) revealed for documentation, catheter care was given, should be documented in the resident's medical record. Notify the supervisor if the resident refuses the procedure, any problems or complaints made by the resident related to the procedure. Observation on 01/20/26 at 10:00 A.M. revealed Resident #27 had an indwelling urinary catheter with a privacy bag in place, above the floor and below the level of the bladder. Interview on 01/20/26 at 10:11 A.M. with Resident #27 revealed he does have an indwelling urinary catheter. Resident #27 stated it gets clogged a lot, he is unsure why, but they [the staff] do have to flush his indwelling urinary catheter due to it getting clogged a lot. Interview on 01/27/26 at 1:35 P.M. with facility Director of Nursing and Assistant Director of Nursing confirmed Resident #27 had an indwelling urinary catheter, upon review of the MAR/TAR there were missing dates of indwelling urinary catheter outputs and see nurses notes with no corresponding nurses note. 3. Review of the medical record for Resident #36 revealed admission to facility on 7/28/25 for diagnoses including Atrial Fibrillation (an irregular heartbeat), congestive heart failure, contractures (stiffing of the joints preventing them from bending) of the bilateral hands and knees, Rheumatoid Arthritis, dementia (impaired memory and cognition), and frequent urinary tract infections (UTI). Review of the Minimum Data Set (MDS) 3.0 quarterly assessment completed on 11/24/25 revealed Resident #36 required set up assistance and supervision with meals, was dependent in several areas including bathing, dressing, toileting, and utilized a specialized wheelchair to be pushed by staff. The MDS assessment also indicated Resident #36 was incontinent of urine and feces. Further review of the MDS assessment for Resident #36 revealed a brief interview for mental status (BIMS) score of 3/15 indicating significant cognitive impairment (poor memory and brain function affecting communication of needs). Review of the medical record for Resident #36 revealed an order written on 01/15/26 for Macrobid (antibiotic use to treat UTIs) 100 milligrams(mg) capsule by mouth twice a day x 5 days through 01/19/26 for a total of 10 doses. Review of the medication administration record (MAR) for January 2026 revealed Macrobid being administered by nursing staff once on 01/15/26 and twice each day on 1/16/26 through 1/19/26 for a total of nine doses. Observation and interview on 01/21/26 at 7:50 A.M. with licensed practical nurse (LPN) #38 during the medication pass for Resident #36 revealed a medication card of Macrobid containing two doses of medication. LPN #38 reviewed the order for the Macrobid and reported it was completed on 01/19/26 and did not administer the medication and placed the medication card in bottom drawer for disposal. LPN #38 reported that the two doses could be left over because depending on the time of day the medication is prescribed it may not be delivered timely and the medication would be taken from the facility emergency medication supply to ensure it was given. Interview on 01/22/26 at 1:04 P.M. with regional registered nurse (RNN) #90 revealed verification that the MAR for Resident #36 indicated the resident only received nine doses of the Macrobid and not the prescribed 10 doses. RNN #90 notified the provider for further orders.

Based on medical record review, resident observations, and staff interviews, the facility failed to provide adequate hydration for Resident #36. This affected one resident (#36) of two residents reviewed for hydration status. The facility census was 36.Findings include:Review of the medical record for Resident #36 revealed admission to the facility on 7/28/25 for diagnoses including Atrial Fibrillation (an irregular heartbeat), congestive heart failure, contractures (stiffing of the joints preventing them from bending) of the bilateral hands and knees, Rheumatoid Arthritis, and dementia (impaired memory and cognition). Review of the Minimum Data Set (MDS) 3.0 quarterly assessment completed on 11/24/25 revealed Resident #36 required set up assistance and supervision with meals, was dependent in several areas including bathing, dressing, toileting, and utilized a specialized wheelchair to be pushed by staff. Further review of the MDS assessment for Resident #36 revealed a brief interview for mental status (BIMS) score of 3/15 indicating significant cognitive impairment.Review of the medical provider's orders for Resident #36 revealed an order written on 11/16/25 at 6:00 P.M. to increase fluids; drink at least one large glass of water once every two hours; offer cranberry juice. Avoid drinks that irritate the bladder. Further review of Resident #36 provider orders revealed an order written on 05/02/25 to provide two-handled cups for every meal.Observation on 01/20/26 at 12:26 P.M. of Resident #36 revealed resident sitting in her wheelchair in the main hallway near the lounge with eyes closed and covered with a blanket. There were no staff continuously present in the immediate area. There were no fluids or two-handled cups present within reach of Resident #36.Observation on 01/20/26 at 3:00 P.M. of Resident #36 revealed her sitting in her wheelchair in the main hallway near the lounge with eyes closed and covered with a blanket. There were no staff continuously present in the immediate area. There were no fluids or two-handled cups present within reach of Resident #36.Observation on 01/21/26 at 7:50 A.M. revealed Resident #36 in bed eating breakfast. There was no divided plate or 2 handled cups present. Further observation revealed a nurse providing small 4-ounce (oz) plastic cup to Resident #36 to take her medications. Resident #36 hands were contractured and she used her index finger and thumb in pincer grasp to hold cup and drink all the water.Observation on 01/21/26 at 10:15 A.M. of Resident #36 revealed her sitting in her wheelchair in the main hallway near the lounge with eyes closed and covered with a blanket. There were no staff continuously present in the immediate area. There were no fluids or two-handled cups present within reach of Resident #36.Observation on 01/21/26 at 11:37 AM. of Resident #36 in the dining room eating noon meal. Observed a divided plate with onion rings and a sandwich wrap, and a bowl of soup. Further observation revealed a two-handled cup with a sip lid of coffee and another two-handled cup with straw with orange Kool-Aid. Resident #36 was slouched in wheelchair with eyes closed and bilateral hands contractured and resting on upper chest. A nurse approached and encouraged Resident #36 to eat meal. Resident #36 reported she was not hungry, but when the nurse attempted to feed her bites, she did eat and then would ask for a drink. Resident #36 drank 4 oz of the orange Kool-Aid then asked for more water and drank another 4 oz of water. The certified nurse aide (CNA) in the dining room reported to the nurse that Resident #36 had already consumed 2 glasses of orange Kool-Aid prior to the nurse sitting down to assist Resident #36.Observation on 01/21/26 at 12:26 P.M. of Resident #36 after the noon meal revealed her sitting in her wheelchair in the main hallway near the lounge with eyes closed and covered with a blanket. There were no staff continuously present in the immediate area. There were no fluids or two-handled cups present within reach of Resident #36.Observation on 01/21/26 at 1:30 P.M. of Resident #36 revealed her sitting in her wheelchair in the main hallway near the lounge with eyes closed and covered with a blanket. There were no staff continuously present in the immediate area. There were no fluids or two-handled cups present within reach of Resident #36.Observation on 01/22/26 at 8:25 A.M. revealed Resident #36 alone in bed eating breakfast. There was a divided plate present and no two-handled cups present. There was a 4 oz cup of orange juice with no lid, a one handled cup of coffee with no lid and a regular large 1 handled pitcher of water with a straw. Resident #36 requested assistance to take a drink. Observation on 01/22/26 at 10:15 A.M. of Resident #36 revealed her sitting in her wheelchair in the main hallway near the lounge covered with a blanket. There were no staff continuously present in the immediate area. As the surveyor walked by, Resident #36 asked for a drink of water. There were no fluids or two-handled cups present within reach of Resident #36. Surveyor notified certified nurses' aide (CNA) #77, who confirmed that there was no water available to Resident #36 and went to get the resident a drink of water.Observation on 01/22/26 at 1:18 P.M. revealed Resident #36 resting reclined in bed with bedside table over bed. Observed large one handled water pitcher with straw, one plastic cup with lemonade and straw and no handles, and a 1/2 eaten peanut butter and jelly sandwich. Resident #36 requested assistance with getting a drink. Two CNA's (CNA #77 and #71) verified she did not have any two-handled cups present. CNA # 77 verified that Resident #36 sometimes does not always get a two-handled cup with meals like this morning for breakfast she did not have one. CNA #77 further reported that Resident #36 can sometimes feed herself but sometimes needs assistance with feeding and drinking.

Based on record review, review of hospital records, facility policy review and interviews, the facility failed to develop and implement comprehensive and individualized suprapubic catheter (a tube inserted into the bladder through a small cut in the lower abdomen (just above the pubic bone) to drain urine for resident's who can't pass urine normally through the urethra) care/interventions to prevent complications resulting in an acute change in medical condition and hospitalization. This resulted in Immediate Jeopardy and Actual Harm on 09/21/25 when Resident #05 was transferred to a local hospital and then life-flighted to a higher acuity hospital and admitted to the intensive care unit for treatment of sepsis and acute kidney injury secondary to a urinary tract infection. Prior to the hospitalization, facility staff failed to ensure Resident #05's orders for suprapubic catheter care, monitoring, and catheter changes were completed as ordered, documentation of care was accurate, and staff were knowledgeable on how to provide necessary suprapubic catheter care. This affected one resident (#05) of two residents reviewed for indwelling catheter care. The facility census was 35. On 09/25/25 at 8:53 A.M. the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, Regional Director of Operations (RDO) #1011, and Regional Director of Clinical Operations (RDCO) #1022 were notified Immediate Jeopardy began on 09/21/25 when Resident #05 was transferred to the hospital and admitted to the intensive care unit for treatment of sepsis and acute kidney injury secondary to a urinary tract infection Hospital assessment revealed the resident was hypotensive (low blood pressure), had an elevated temperature of 103.6 degrees Fahrenheit (F), an elevated heart rate in the 120's (tachycardic), an elevated white blood cell count (WBC) of 24.4 (normal 4.5-11), an elevated Blood Urea Nitrogen (BUN) of 32, and an elevated creatinine level of 2.2. The resident required surgical procedure under anesthesia to place a ureteral stent, required intravenous (IV) antibiotics, continuous IV blood pressure medication that required femoral central venous catheter (CVC) placement and internal jugular (IJ) CVC placement. The resident remained hospitalized as of 09/25/25. The Immediate Jeopardy was removed on 09/25/25 when the facility implemented the following corrective actions: On 09/21/25 at 5:19 A.M. Resident #05 was transferred to the hospital and remained in the hospital at this time. On 09/22/25 at 2:06 P.M. an audit of all 34 current residents was completed by the DON for any residents with a suprapubic catheter. At this time, no other residents noted with a suprapubic catheter. Resident #09 was identified to have an order for an indwelling urinary catheter (Foley). Resident #09 was seen by the Nurse Practitioner on 09/24/25. On 09/25/25 at 9:30 A.M. an investigation was completed by the DON of why this error occurred (to Resident #05) in order to implement corrective actions. During the investigation it was noted Licensed Practical Nurse (LPN) #11, #69 and #84 did not read Resident #05's order completely (related to suprapubic catheter changes) before signing the order, so they did not follow the facility's current policy and procedures. On 09/25/25 at 10:00 A.M. RDCO #1022 reviewed facility policies including the Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures to ensure they were comprehensive, and no changes were needed prior to staff education which began on 09/25/25 at 10:00 A.M On 09/25/25 at 10:10 A.M. RDCO #1022 provided education to the DON on Physician Orders policy, Suprapubic Cath Care and Suprapubic Cath Replacement procedures. Beginning 09/25/25 10:15 A.M. and concluding on 09/25/25 at 5:50 P.M., education was provided in person or via phone to all 11 current licensed nurses (seven Licensed Practical Nurses and four Registered Nurses) by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The education included, following physician orders regarding catheters including catheter care (video was given on steps for suprapubic catheter replacement), along with the suprapubic catheter care and replacement procedure. In addition, staff were educated if they were unable to complete this task for the day as ordered, they were to report to the DON/ADON and they would assist on how to get the task completed. The DON followed up with the nurses after the education to ensure there were no unanswered questions related to the education. On 09/25/25 from 10:15 A.M. to 5:48 P.M., all current 17 Certified Nurses Assistants (CNAs) were educated by the DON on catheter care for Foley catheters using the facility Catheter Care policy. A video was provided on how to do catheter care. The CNA staff were educated if they were unable to complete this task as ordered for the day they were to report to the DON/ADON and they would assist in how to get the task completed. The DON followed up with CNAs after the education to ensure there were no unanswered questions related to the education. On 09/25/25 at 2:40 P.M. the Medical Director was notified by the DON of the Immediate Jeopardy (IJ) concern involving Resident #05. An Ad-hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with Medical Director, DON, Administrator, and RDCO #1022. The IJ was reviewed, the reason for the IJ, and the facility abatement plan. On 09/25/25 (no time identified) the Administrator provided contracted staffing agencies education related to catheter care. Education would be added for the staff to review prior to picking up a shift. The DON/designee would ensure agency staff reviewed education by contacting them once they had arrived at the facility and getting a verbal acknowledgement they have reviewed. Beginning 09/25/25 the facility implemented a plan for all new staff to be verbally educated on Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures, what to do if you do not know how to change a catheter, following physician orders by the DON/designee during new hire orientation. Beginning on 09/26/25 the DON/ADON would review physician orders daily and would ensure if there were any new suprapubic catheter orders that the care and changing orders were in place and being followed. The DON/ADON would review residents with suprapubic catheters and would review catheter orders to ensure they were accurately documented when completed by going in and checking if the care and or catheter had been changed per order.Although the Immediate Jeopardy was removed on 09/25/25, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Record review revealed Resident #05 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, hypertension, vitamin D deficiency, vitamin B deficiency, hyperlipidemia, gastro-esophageal reflux disease, neuromuscular bladder dysfunction, and benign prostatic hyperplasia. Review of the resident's medical record revealed a note from a hospital urology visit dated 02/19/25 that identified the resident was complaining of his indwelling urinary catheter (Foley) was leaking and causing skin breakdown around his scrotum. The resident was insistent that a suprapubic catheter be placed. The resident's power of attorney was contacted and agreed to the surgical procedure to place the suprapubic catheter.Record review revealed a physician order dated 03/25/25 by Medical Director (MD) #200 to perform suprapubic catheter care every shift and as needed. The resident also had an order on this date to anchor the catheter tubing and check placement every shift. Review of a hospital urology note dated 04/25/25 revealed the visit was for a follow up related to urinary incontinence. At the request of the resident, a suprapubic tube was inserted on 03/24/25. The resident presented today for first suprapubic tube exchange. Despite the tube, the resident was complaining of leakage around the tube through the penis. The resident was very bothered by the leakage. The plan was to continue with the suprapubic catheter. The note from the visit revealed future exchanges (changes of the catheter) could be done at the facility where the resident resided.Record review revealed a physician order dated 05/25/25 by Medical Director (MD) #200 to change suprapubic catheter every month with a 16 French 10 cubic centimeter (cc) balloon catheter, every month on the 25th. There was no documented evidence that a plan of care was developed and implemented for Resident #05's suprapubic catheter at the time the catheter was placed (03/2025). A plan of care was not developed until 09/14/25. Review of Resident #05's June 2025 Treatment Administration Record (TAR) revealed no documented evidence catheter care was completed on 06/05/25, 06/15/25, or on 06/16/25 for both day and night shift. Review of Resident #05's June TAR revealed no documentation of suprapubic catheter tubing and placement check being completed on 06/05/25, 06/15/25 and 06/16/25 on both day and night shift. Review of Resident #05's June 2025 TAR revealed on 06/25/25 the order to change the resident's suprapubic catheter every month with 16 French 10 cc balloon catheter, every month on the 25th, was documented as completed by Licensed Practical Nurse (LPN) #84. Review of Resident #05's July 2025 TAR revealed no documented evidence catheter care was completed on 07/03/25, 07/05/25, 07/06/25, 07/07/25, 07/09/25, 07/015/25, 07/16/25, 07/24/25, or 07/27/25. Review of Resident #05 July TAR revealed no documentation of suprapubic catheter tubing and placement check being completed on 07/03/25, 07/05/25, 07/06/25, 07/07/25, 07/09/25, 07/015/25, 07/16/25, 07/24/25, or 07/27/25.Review of Resident #05's July 2025 TAR revealed the order to change the resident's suprapubic catheter every month (on the 25th of each month) with 16 French 10 cc balloon catheter, was documented as completed by LPN #11.Review of Resident #05's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of 08 (out of 15) which reflected the resident exhibited moderate cognitive impairment. The assessment revealed the resident had no exhibited or displayed behaviors. Resident #05 had an indwelling catheter, a suprapubic catheter. The resident had bilateral upper and lower extremity range of motion (ROM) impairment, used a wheelchair, and was dependent on staff or required maximal assistance for activity of daily living (ADL) care and mobility. Review of Resident #05's August 2025 TAR revealed no documented evidence catheter care was completed on 08/06/25, 08/27/25, or on 08/30/25. Review of Resident #05's August TAR revealed no documentation of suprapubic catheter tubing and placement check being completed on 08/06/25, 08/27/25, or on 08/30/25.Review of Resident #05's August TAR revealed the order to change the resident's suprapubic catheter every month (on the 25th of each month) with 16 French 10 cc balloon catheter was documented as completed by LPN #69.Review of Resident #05's care plan initiated 09/14/25 revealed the resident had a suprapubic catheter related to neurogenic bladder. Goals included the resident would show no signs or symptoms of complications related to catheter use. Interventions included monitor and document for pain and discomfort due to catheter, monitor/ record/ report to medical provider for signs and symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. Record review of Resident #05's September (2025) TAR revealed no documented evidence catheter care was completed on 09/01/25, 09/17/25, or on 09/21/25. Review of Resident #05's August TAR revealed no documentation of suprapubic catheter tubing and placement check being completed on 09/01/25, 09/17/25, or on 09/21/25.The surveyor, with permission from Resident #05's power of attorney (POA), POA #400 reviewed POA #400's Facebook messenger messages dated 09/21/25 at 7:32 P.M. with LPN #84. POA #400 asked LPN #84 if they had changed Resident #05's suprapubic catheter any time since he has had it; LPN #84 stated No I haven't as a matter of fact I think the only time it was changed was when he went back for a checkup. There was never an order for it. Review of (POA) #400's Facebook messenger messages dated 09/21/25 at 7:30 P.M. with LPN #69 revealed POA #400 asked LPN #69 if they had changed Resident #05's suprapubic catheter any time since he has had it; LPN #69 responded on 09/22/25 at 8:14 A.M. and stated, I have not. Record review revealed no documentation Resident #05 refused catheter care including changing the suprapubic catheter. In addition, there was no documented evidence Resident #05's physician was notified the resident's suprapubic catheter had not been changed as ordered. Review of Resident #05's medical record revealed no documentation of urine appearance, or symptoms of UTI prior to Resident #05 being transferred to the hospital on [DATE]. In addition, there was no documentation of any urinary output monitoring or description of Resident #05's urine prior to the resident being transferred to the hospital on [DATE].Record review revealed a progress note dated 09/21/25 at 5:11 A.M. authored by LPN #3001 that indicated at approximately 4:58 A.M. Resident #05's call light was answered, and the resident was noted to be less responsive than baseline, vital signs were obtained which included a heart rate of 124 (tachycardic), respiratory rate of 22, oxygen saturation of 96%, blood pressure of 112/ 59, chest temperature 104.2 F, and temporal temperature 98.6 F. The resident was observed to have twitch-like movement of upper and lower extremities intermittently; skin was hot to the touch. Resident #05 was diaphoretic, the resident denied being able to see and was unable to follow finger. Resident #05 failed the National Institute of Health Stroke Scale (NIHSS) assessment. Resident #05 had no verbal complaints noted due to decreased responsiveness. Resident #05 was unable to communicate to explain what was wrong with him. 911 was called at approximately 5:00 A.M. and informed of the resident's change in condition and need for the resident to be evaluated. Resident #05's emergency contact, POA #400 was notified at approximately 5:02 A.M. that facility staff were sending the resident out to the emergency room. The ADON was on call and was called and informed at 5:05 AM. Emergency Medical Services (EMS) arrived at the facility at approximately 5:14 A.M. and was given a report on the resident. EMS stated they were taking the resident to the emergency room, emergency room was called and given report on the resident at 5:19 A.M. Review of a progress note dated 09/21/25 at 10:25 A.M. authored by LPN #84 revealed the hospital emergency room was contacted for an update on Resident #05. emergency room staff stated the resident had two obstructive kidney stones to his right kidney and one non obstructive kidney stone to his left kidney and would be transferring to another hospital. Review of a progress note dated 09/21/25 at 6:24 P.M. authored by LPN #4001 revealed Resident #05's POA #400 called to the facility to let them know that Resident #05 was life-flighted to another hospital.Review of a progress note authored by LPN #69 dated 09/23/25 at 11:29 A.M. revealed Resident #05 was still in the hospital at that time. Review of Resident #05's hospital record revealed a note authored by Physician #700 stating Resident #05 presented to the emergency department from the facility on 09/21/25 with a rectal temperature of 103.6 (Fahrenheit), grossly purulent urine from suprapubic catheter, abdominal tenderness and a high heart rate (tachycardic) in the 120's. Sepsis protocol was initiated and Resident #05 was started on intravenous (IV) fluids and antibiotics. Resident #05 was septic with a urinary tract infection (UTI), most likely source of sepsis and an associated acute kidney injury (AKI). Urine appeared grossly thick and purulent. Review of Resident #05's hospital record revealed the resident was noted to have an elevated lactic acid level/lactic acidosis. (Lactic acidosis is a high lactic acid level that can be caused from infections that make it hard for the body to get oxygen to cells. Lactic acidosis is usually a complication of other health conditions including kidney failure, infections, and sepsis. https://my.clevelandclinic.org/health/diseases/25066-lactic-acidosis) . Review of Resident #05's hospital record revealed the resident had an acute kidney injury as evidenced by an elevated blood urea nitrogen (BUN) and creatinine level. (BUN and creatinine can indicate how well the kidneys are functioning, elevated levels may indicate a problem with the kidneys https://my.clevelandclinic.org/health/diagnostics/17684-blood-urea-nitrogen-bun-test).Review of Resident #05's urinalysis performed on 09/21/25 revealed abnormal findings of many bacteria, yeast, and white blood cell count too numerous to count (TNTC). Review of Resident #05's hospital record revealed a urine culture received on 09/21/25 with results received on 09/22/25 that identified abnormal positive results of over 100,000 colony forming units per milliliter (CFU/mL).Review of Resident #05's blood lab work collected 09/21/25 revealed an elevated white blood cell (WBC) count of 24. 4 (White blood cells are part of your immune system responsible for protecting your body from infection a high white blood cell count indicates you may have an infection. https://my.clevelandclinic.org/health/body/21871-white-blood-cells). Review of Resident #05's hospital record revealed a urology operation note authored by Urologist #500 which noted Resident #05 had bilateral moderate swelling of the kidneys and ureter due to urine flow obstruction (hydroureteronephrosis), a 1.1 centimeter (cm) urethral calculus and possible urethral stricture on the left kidney. Resident #05 was septic likely caused by complicated UTI. Resident #05 was brought to the hospital from an outside facility on 09/21/25 presenting with altered mental status (AMS), and a fever. Work-up revealed a fever of 103 degrees Fahrenheit (F), tachycardia, and hypotension. Resident #5 had a suprapubic catheter in place which had not been exchanged since April of 2025. On 09/21/25 Resident #05 underwent surgical procedures under anesthesia where their suprapubic catheter was exchanged, and urethral stent placement was performed by Urologist #500. (Review of information provided by the Cleveland Clinic https://my.clevelandclinic.org/health/treatments/21795-urethral-stents revealed urethral stents placement is a surgical procedure used to hold your ureters open to allow (urine) to flow easily from your kidneys into your bladder).Review of Resident #05's hospital records dated 09/22/25 revealed a progress note by Medical Intensive Care Unit (MICU) Nurse Practitioner (NP) #800 indicating Resident #05 was admitted with concerns of septic shock, initially presenting to the first hospital on [DATE] from a Skilled Nursing Facility (SNF) due to altered mental status. The resident's urine and suprapubic catheter was purulent. Computed tomography scan (CT) showed right urethral calculus with possible left urethral stricture and the resident was life-flighted to another hospital for high acuity care and complicated UTI. Resident #05 underwent urgent bilateral double J-uteral stent and catheter exchange. Resident #05's blood pressure became low (hypotensive) and he was given two liters of fluid and remained hypotensive, so Levophed was started at 0.15 microgram per kilogram per minute (mcg/kg/min). (Levophed is used to increase and maintain blood pressure in limited, short term serious health situations such as septic shock, a life threatening condition resulting in extremely low blood pressure from an infection and in critical hypotension https://my.clevelandclinic.org/health/articles/22610-norepinephrine-noradrenaline). The hospital record also noted Resident #05 was given intravenous (IV) antibiotic Zosyn and Vancomycin. Resident #05 was also found to have excess fluid in the kidneys due to back-up of urine (hydronephrosis). Resident #05 continued to have purulent and sediment drainage from suprapubic catheter. Vasopressin and hydrocortisone were added for continued hypotension. (Vasopressin is a medication used to treat low blood pressure, infused into a vein and given in a hospital or clinic setting https://my.clevelandclinic.org/health/drugs/19734-vasopressin-adh-injection). Right femoral central venous catheter (CVC) was placed (a tube inserted into the groin leading to your vena cava, a large vein emptying into the heart. CVC are used to provide drugs, fluids, or blood for emergency treatment https://my.clevelandclinic.org/health/treatments/23927-central-venous-catheter). Review of information from https://my.clevelandclinic.org/health/treatments/25028-suprapubic-catheter revealed a suprapubic catheter is used to drain urine from your urinary bladder when you can not void (urinate) on your own. A suprapubic catheter accesses the bladder from a small cut (incision) in the lower part of your abdomen. Risks and possible complications of a suprapubic catheter include blockage preventing the catheter from draining, UTI's, and urine leakage around the catheter, and bladder stones. It's important to keep the area around your suprapubic catheter clean.Interview on 09/23/25 at 7:59 A.M. with LPN #69 revealed Resident #05 always had pain in his legs during his stay but felt it was nothing out of the ordinary. LPN #69 stated Resident #05's catheter and penis would leak (urine) at times due to position. LPN #69 denied ever changing Resident #05's suprapubic catheter (even though there was a physician order to do so) because the LPN stated staff had been told not change it unless there was an obstruction or something as changing it would increase the risk of infection. The LPN indicated staff only changed the urine collection catheter bag. Interview on 09/23/25 at 8:28 A.M. with anonymous staff member (ASM) #170 revealed CNA staff were responsible to perform catheter care. ASM #170 stated Resident #05's catheter had never been changed at all by any staff in the facility. ASM #170 stated Resident #05 knew it was supposed to be changed and was not being done. The ASM revealed Resident #05 would ask staff to change it but it still was not changed. ASM #170 stated during interview that he/she had witnessed nurses, who they did not want to name, tell Resident #05 there was no (physician) order to change his catheter. ASM #170 stated Resident #05's catheter was also not cleaned every shift as it should be, things were skipped and missed because staffing was so low they had to prioritize what they could get done and unfortunately things weren't getting done.Interview on 09/23/25 at 12:54 P.M with CNA #09 revealed the CNA was aware Resident #05 had a suprapubic catheter. CNA #09 stated care had been delayed or not completed due to lack of staff. CNA #09 stated Resident #05 was to receive catheter care every shift, but it was not completed because they did not have enough staff to get to all tasks of the shift. The CNA revealed they would inform the next shift of tasks not completed but it was unlikely the care would be completed. CNA #09 was unaware if the resident suprapubic catheter was being changed as ordered but verified catheter care was not being completed as ordered. Interview on 09/23/25 at 4:50 P.M. with LPN #11 revealed the LPN worked a shift one day at the facility on 07/25/25 during the day shift. During the interview, LPN #11 denied changing Resident #05's suprapubic catheter. Interview on 09/24/25 at 10:05 A.M. with Medical Director (MD) #200 revealed he was never notified of Resident #05's suprapubic catheter not being changed monthly per order. MD #200 stated when someone gets a catheter, or a suprapubic catheter placed they work together with urology to ensure the plan of care was appropriate and see if urology has any recommendation. If someone had a catheter that placed them at a higher risk of infection, having a catheter that had not been changed out in months would increase a person's risk of developing a urinary tract infection (UTI). Per MD #200 some symptoms of a UTI included fever, chills, burning sensation, and back pain. Depending on the medical condition and how severe the infection was, a UTI could lead to sepsis. Interview with the DON on 09/24/25 at 11:52 A.M. revealed Resident #05 had been seen on 06/17/25 by general surgery, who placed the suprapubic catheter but had not been seen by a urologist since. The DON stated Resident #05 had a urologist but the resident was not able to make the drive, that it was too far (for the resident to travel) so they were trying to find the resident a new urologist. The DON confirmed there was no documentation of Resident #05 refusing to see the urologist. Interview on 09/24/25 at 12:53 P.M. with Medical Intensive Care Unit Registered Nurse #21 revealed as of this time Resident #05 remained in intensive care for treatment. During Resident #05's stay he had required two intravenous blood pressure medications which were Levophed and Vasopressin. Resident #05 originally had a femoral intravenous catheter that was then replaced with an IJ CVC. The RN revealed the resident was being treated for sepsis (urosepsis) caused by a UTI. Interview with the DON on 09/24/25 at 1:14 P.M. revealed Resident #05's suprapubic catheter was placed on 03/25/25 by Physician Assistant (PA) #300 (who works for general surgery at a hospital). On 06/17/25 Resident #05 attended a follow up with PA #300 because the catheter was leaking. The DON revealed this was the last appointment he attended regarding the catheter and the facility was told by PA #300 they switched the catheter out, however they never received information confirming documentation it was changed out. Review of Resident #05's medical record including nursing notes revealed there was no record or nursing notes of the suprapubic catheter being placed during the visit on 03/25/25 or changed during a follow-up medical visit on 06/17/25. Interview with LPN #84 on 09/25/25 at 7:50 A.M. revealed the LPN had never personally changed Resident #05's suprapubic catheter. During the interview, the LPN denied having received training on how to do it and stated he/she wouldn't know how. To the LPNs knowledge the resident never had a physician order to change the catheter. Interview on 09/25/25 at 8:45 A.M. with the DON revealed she had spoken with LPN #84 and LPN #69 who revealed they had signed the catheter change as being completed because they thought it was just for the catheter bag (urinary collection bag) itself (not the actual catheter). The DON stated she believed there may have been confusion due to the facility not regularly changing indwelling Foley catheters due to the risk of infection.Interview on 09/25/25 at 1:54 P.M. with Medical Intensive Care Unit Physician #803 revealed Resident #05 was currently still under his care in the ICU. Physician #803 stated Resident #05's suprapubic catheter not being changed as ordered and catheter care not being completed as it should, led to the development of a UTI causing Resident #05 to become septic and in the condition he was in.Review of facility policy reviewed 04/28/25 titled Catheter Care revealed upon completion of catheter care document care was given. Notify the supervisor if the resident refused the procedure, any problems or complaints were made by the resident related to the procedure. Report other information in accordance with facility policy and standards of practice. This deficiency demonstrates non-compliance investigated under Master Complaint Number 2624018, Complaint Number 2618783, 1398689 and 1398688.

Based on closed and open medical record review, hospital record review, review of patient handout information from Medscape.com, emergency medical services (EMS) records, policy review and interviews the facility failed to provide comprehensive, resident centered care to adequately manage and prevent worsening of cardiac conditions for Resident #50. This resulted in Immediate Jeopardy and serious life-threatening harm/death for Resident #50, who was admitted to the facility on [DATE] with a history of chronic heart failure, cardiomyopathy, ventricular tachycardia (with an implanted defibrillator), atrial fibrillation, hypertension, and hypokalemia (low blood potassium level) when the resident did not receive the correct physician ordered dose of diuretics or antiarrhythmic medications for his cardiac conditions upon admission to the facility. The resident also did not receive comprehensive, individualized care for his extensive cardiac history including monitoring for fluid volume overload (intake and output), monitoring of weights and use of anti-embolism stockings, related to congestive heart failure. Despite the resident's known history of hypokalemia, no potassium supplement was ordered on admission to the facility. Potassium supplements were ordered once the facility identified the resident had a critical (low) potassium level; however, the resident experienced vomiting after meals. The physician and/or certified nurse practitioner (CNP) were not notified of the resident's declining condition. On [DATE] the resident was found unresponsive. Cardiopulmonary resuscitation was initiated, however unsuccessful, and the resident passed away. Per the coroner's report the resident's cause of death was cardiopulmonary failure due to coronary artery disease and cardiomyopathy in addition to the significant condition of hypertension. In addition, a concern that did not rise to Immediate Jeopardy occurred when facility failed to ensure Resident #14 was provided a comprehensive, resident centered status-post surgery treatment plan upon admission to the facility and failed to provide wound care as ordered. This affected two residents (#14 and #50) of three residents reviewed for appropriate care and services. The facility census was 37. On [DATE] at 4:48 P.M. the Business Office Manager, Social Service Designee #145, Regional Director of Operation #700, [NAME] President of Clinical Operation #701, and Registered Nurse (RN)/Regional Director of Clinical Operations #180 were notified Immediate Jeopardy began on [DATE] when the facility failed to ensure Resident #50's admission physician orders were clarified regarding discrepancies with the resident's diuretic medication, Torsemide and the resident's prescribed anti-arrhythmic medications, Amiodarone and Mexiletine, resulting in the medications not being administered and/or not being administered as ordered. Additionally, the resident did not receive comprehensive, individualized care for monitoring of known extensive cardiac history including obtaining resident weights and intake and output daily. The resident's family requested lab work due to diuretic use and a known history of hypokalemia which revealed a critically low potassium level of 2.9 (normal range 3XXX,d+[DATE].1 millimole per liter (mmol/L). Oral potassium supplementation was ordered, however the resident experienced vomiting after meals which had the potential to affect the effectiveness of the potassium medication. The facility failed to notify the resident's physician of medication discrepancies/errors, and the resident's decline in condition resulting in the resident's death after unsuccessful CPR. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:47 A.M. Resident #50 expired in the facility. On [DATE] at 6:21 P.M. RDCO/Registered Nurse (RN) #180 completed an audit of all 34 current resident's progress notes to ensure notification of a decline in resident condition was reported to the physician in the past 72 hours. Daily audits would begin on [DATE] and would be completed for the next three months by the Director of Nursing (DON) and/or designee for any change in condition and physician notification. On [DATE] at 6:45 P.M. RN #180 reviewed/audited the medical records for two additional residents (#55 and #56), who had expired since [DATE] to review the residents' care. Residents (#55 and #56) were receiving Hospice services and death were expected. Daily audits would begin on [DATE] and would be completed by the DON and/or designee for three months for any resident who experiences an unexpected death. On [DATE] RDCO/RN #180 reviewed the medical records for all new resident admissions since [DATE] who were still residing in the facility (Resident #6, #20, #54) to ensure orders were transcribed correctly from hospital discharge to facility admission. Daily audits would begin on [DATE] and would be completed by the DON and/or designee for new admission/readmissions daily for three months. RDCO #180 and/or designee would review Point Click Care (PCC) for any new or re-admissions for any medication error reports documented into the risk management in PCC by the DON/Assistant Director of Nursing (ADON) to ensure that an investigation of the error has been completed as needed. On [DATE] at 9:56 P.M. the Administrator notified Medical Director #501 of the Immediate Jeopardy situation. On [DATE] at 10:05 P.M RN #180 audited all current residents (#10, #30, #35 and #36) with a diagnosis of congestive heart failure (CHF) and discussed with Physician #501. The need for intake and output (I&O), weight orders, and anti-embolism stocking orders were discussed. Physician recommendations were ordered. Daily audits would begin on [DATE] and would continue for the next three months and would be completed by the DON and/or designee. Audits would include any new diagnoses of CHF for current residents or new admission with a diagnosis of CHF and would be discussed with the medical provider regarding the need for intake and output monitoring, weight orders, anti-embolism stockings and any other care needed related to the CHF diagnosis. Beginning [DATE] 10:03 P.M. and concluding on [DATE] at 11:29 A.M. education was provided in person or via phone to eleven licensed nurses (Licensed Practical Nurse #103, #127, #129, #140, #149, #168 and RN #113, #124, #206, #703 and Agency RN #709) by RN #180, Assistant Director of Nursing (ADON)#704, and the Administrator. The education included the new process of two nurses verifying new resident admission orders to ensure the orders were transcribed correctly from the hospital discharge to admission to the facility; newly diagnosed or new admissions with CHF would be discussed with the medical provider regarding care of the resident with CHF, and reviewed the change of condition policy, and notification of the physician/CNP of medication omission/discrepancies/errors and notification of decline in resident condition. RN #180 and #704 followed-up with the nurses after the education to ensure there were no unanswered questions related to the education. On [DATE] starting at 6:31 A.M. 14 of the facility 16 STNAs were educated in person and by via phone by ADON #704 and the Administrator on ted hose, change of condition, and I&0. Two STNAs (#711 and #712) would be educated prior to working their next scheduled shift. ADON #704 was educated on [DATE] at 5:30 P.M., by RDCO #180 that residents who had an unexpected death would have a chart audit completed to ensure no corrective action/education was needed and reviewing CNP/physician progress notes to ensure orders are implemented or if there are any questions to contact the provider. A new Medication Error policy and procedure created by VP of Clinical Services was reviewed by RDCO #180 and Medical Director #501 at 2:36 P.M. and would be implemented effective [DATE]. ADON #704 was educated on the new Medication Error Policy on [DATE] at 2:45 P.M. by RDCO #180. Any medication error needed to be investigated and any interventions implemented as indicated and if any med error occurs it was added to risk management. The DON/designee would review progress notes daily regarding resident and/or resident representative concerns and would address any concerns following the grievance process. The audits would begin on [DATE] and continue for three months. The contracted staffing agency was sent education by the Administrator on [DATE]. Education would be added to the site for our building for the staff to review prior to picking up a shift and there was a Nursing/Agency communication book at the nurse's station for them to review prior to the shift starting. The DON/designee would ensure Agency staff have reviewed education by contacting them once they have arrived at the facility and getting a verbal acknowledgement that they have reviewed. Starting [DATE] all new staff would be verbally educated and on the above education of what to do if a medication error occurs, what to do a patient has CHF, what to do if a family has concerns, what to do if there was a change in condition with a patient and the process of new admission orders by the DON/designee during new hire orientation. On [DATE] at 10:15 A.M. the previously identified 11 nurses were educated by Interim ADON #704 and RDCO#180 on Medication Error policy in person and via phone. Audit findings will be reviewed weekly by the QAPI Committee with further recommendations as needed for eight weeks. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: 1. Closed record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, cardiomyopathy, hypertension, ventricular tachycardia with an implanted cardiac defibrillator (a small battery-operated device implanted in the chest that detects dangerous, irregular heart rhythms), atrial fibrillation and hyperlipidemia (elevated cholesterol levels). Review of Resident #50's hospital discharge summary note dated [DATE] revealed the resident's chief complaint was vomiting and diarrhea. He was admitted in March of 2024 with heart failure, had weight gain in a few weeks post discharge and his Torsemide (diuretic medication) was increased to twice daily. The resident had heart failure with a reduced ejection fraction that was maintained on Torsemide and Metolazone (diuretics). The resident's blood pressure was ,d+[DATE] millimeters of mercury (mmHg) and ,d+[DATE] mmHg the day of discharge ([DATE]). He had no edema in the lower extremities and his potassium was 4.4 mmol/L (normal limits). The resident had a history of hypokalemia (low potassium). The resident's condition on discharge was noted to be improved. Further review of Resident #50's discharge summary revealed Torsemide 20 milligram (mg) twice daily was resumed, and patient tolerated well, the heart failure team was consulted for management of diuretics. The plan was to monitor closely as an outpatient and gradually resume his heart failure medication depending on his blood pressure and improvement of his diarrhea. The Torsemide was held today ([DATE]) since he was nothing by mouth (NPO). The resident had non-sustained ventricular tachycardia (abnormal beating of the ventricles that did not continue) with numerous episodes. Mexiletine dose increased to every eight hours post discharge, his potassium (laboratory) goal was greater than four (4.0) and Magnesium goal greater than two (2). Record review revealed the resident's hospital discharge medication list dated [DATE] did not include orders to continue the Torsemide twice daily as indicated in the hospital discharge summary note. However, the hospital discharge medication orders included to administer Amiodarone 300 milligrams (mg) daily and Mexiletine 150 mg every eight hours (antiarrhythmic medications). Review of Resident #50's facility general progress notes, authored by Registered Nurse (RN) #703, revealed on [DATE] male resident admitted to the skilled nursing home at 1:45 P.M. after a short acute care hospital stay. The resident was alert and oriented times three. The resident was a full code (advance directives) and he had a brief medical history including but not limited to paroxysmal atrial fibrillation, coronary artery disease, decreased ejection fraction of 20% (the heart was not pumping blood as strong as it normally would) and generalized weakness. Non-pitting edema noted to upper and lower extremities. The resident's lung fields were diminished at this time with a moist non-productive cough noted. The physician was made aware of the new admission, no orders were given other than to continue current regimen at this time until the resident could be seen by a provider. The resident weighed 123 pounds per mechanical lift. Record review revealed no evidence the resident's Torsemide was discussed or clarified with the physician at this time. Review of a skilled note, authored by RN #167 and dated [DATE] at 12:47 P.M., revealed the resident's blood pressure was ,d+[DATE] and pulse was 72 and regular. The resident had plus two pedal (feet) edema (an indentation in the skin that stays present for approximately two seconds and indicates there is fluid accumulation). No signs of shortness of breath or difficulty breathing. Lung sounds were clear. Review of general progress note authored by RN #167 dated [DATE] at 4:12 P.M. revealed the resident's power of attorney (POA) was in to visit and was concerned with resident's increased edema to his bilateral lower extremities. The note indicated the POA requested resident's the diuretic be restarted. Staff spoke to the doctor and a new order was received to give Torsemide 20 mg now and to re-start 20 mg daily. The note also indicated, will have the Certified Nurse Practitioner (CNP) come in and see resident for admission history and physical. Review of a dietary note, authored by Dietary Manager #706 and an addendum note added by Dietary Supervisor #705 dated [DATE], revealed the resident was on a cardiac diet and it was clarified with the facility for a no-added salt (diet). The resident's meal intakes were ,d+[DATE]%. The resident's body mass index was 19.9 (low/underweight) and his current body weight was 123 pounds on [DATE]. The note indicated the resident was at risk for weight fluctuations due to fluid shifts per hospital notes. Review of Resident #50's nutrition/hydration plan of care initiated on [DATE] revealed no evidence the resident was at risk related to CHF. Interventions included to monitor meal intakes, labs, tolerance to diet, weights per the facility policy, and to provide diet and snacks per order/preference. There was no evidence to monitor intake and output (I&O) for the resident. Review of the progress note dated [DATE] and authored by CNP #500 revealed the resident was a pleasant male with a past medical history consisting of, but not limited to, paroxysmal atrial fibrillation, chronic kidney disease, recurrent bowel obstructions, coronary artery disease, heart failure with reduced ejection fraction maintained on Torsemide and Metolazone (this medication was not ordered on admission to the nursing facility) cardiomyopathy, hypertension, and dyslipidemia. The resident had been admitted in [DATE] to the hospital for heart failure exacerbation and acute kidney injury. He had weight gain a few weeks ago post discharge so his Torsemide was increased to twice daily. The resident's heart rate was irregular, and lungs sounds were diminished. No edema noted. The plan was to monitor input and output, edema, and blood pressure. The note indicated continue Torsemide twice daily, potassium supplement (the medical record did not contain an order for potassium), and knee-high ted hose (anti-embolism/compression stockings). Review of an email confirmation, dated [DATE], revealed CNP #500 faxed Resident #50's progress note to the facility Medical Records Clerk #106 on [DATE]. Review of Resident/Family Education note authored by Agency Licensed Practical Nurse (LPN) #707 dated [DATE] revealed the Nurse Practitioner (NP) #500 saw the resident and new orders were received to apply ted hose (anti-embolism/compression stockings) daily for edema. Review of Resident #50's admission laboratory results, dated [DATE], revealed the resident's potassium level was 3.7 mmol/L (below the goal of 4.0). Record review revealed no evidence the facility developed and implemented a comprehensive and individualized plan of care for CHF/Cardiac. However, on [DATE] there was a plan of care initiated for risk of altered fluid balance and the only intervention was to evaluate skin turgor. Further review of Resident #50's plan of care revealed on [DATE] a risk for ineffective peripheral tissue perfusion was initiated. The intervention included to evaluate capillary refill and evaluate skin color, temperature, and characteristics. Review of Resident #50's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a poor appetite or overate ,d+[DATE] days. The assessment revealed the resident exhibited no behaviors including rejection of care. He was independent with prior function of everyday activities. The resident required setup or clean up assistance with eating and was dependent on staff for toileting. He had an ostomy (urostomy) and frequently incontinent with bowel. The assessment revealed the resident had CAD, heart failure, hypertension, hyperlipidemia, and malnutrition. Hyponatremia, hyperkalemia, vomiting, and shortness of breath were marked no. Weight loss/gain was marked no or unknown and the assessment noted the resident was on a therapeutic diet. The resident was on diuretics. The resident, family, significant other, legal guardian, or other legal authorized representative had not participated in the assessment or goal setting. The resident's overall goal was to be discharged to the community per family. Review of Resident/Family Education note, authored by LPN #140 and dated [DATE] at 8:00 A.M., revealed the family was in to visit and requested a lab draw to check the resident's potassium level due to the resident having a history of hypokalemia and he was on Torsemide. The physician agreed. The lab test was obtained, and the family took the specimen to the lab to drop it off. The note indicated, will await results. Review of Resident/Family Education note authored by LPN #140 and dated [DATE] at 11:17 A.M., revealed the lab called back with a critical potassium level of 2.9 (hypokalemic). The provider (Physician #501) was notified, and new orders were received for Potassium Chloride 20 milliequivalent (mEq) by mouth three times a day and recheck levels on Tuesday ([DATE]). The family was visiting and aware of the new order. Review of Resident/Family Education note, authored by LPN #140 and dated [DATE] at 6:03 P.M., revealed the resident had a small emesis this evening. It was green in color. There was no documented evidence CNP #500, or Physician #501 were notified of the resident's emesis. Review of the resident's paper and electronic medical record revealed no evidence the resident's oral intake or urinary output (I & O) were being monitored as stated in CNP #500's progress note dated [DATE]. Review of Resident #50's medication administration record (MAR) and treatment administration record (TAR), dated [DATE], revealed no evidence the potassium supplement (20 mEq) was administered until ordered on [DATE] even though the potassium supplement was first noted in CNP #500's progress note dated [DATE]. There was no further notation of the potassium supplement until [DATE] when the resident's family requested a potassium level be completed and the results were critically low, and potassium replacement was ordered in oral form. Review of Resident #50's medication administration records dated ,d+[DATE] revealed on [DATE] the resident only received 200 mg of Amiodarone (order from hospital was 300 mg daily) and he didn't receive any Amiodarone on [DATE]. The order was discontinued and re-written for 300 mg on [DATE]. The Mexiletine order was entered as twice daily from [DATE] to [DATE]. The resident received one dose on [DATE], one dose on the 20th due to the morning dose was not administered and two doses on the [DATE]. The order was for three times daily not twice daily from the hospital. The order was discontinued and re-written three times daily on [DATE]. Further review of Resident #50's MAR revealed no evidence the ted hose daily for CHF were applied per orders. In addition, review of the MAR revealed there was an order dated [DATE] to monitor for side effects of coronary artery disease (CAD) every shift such as chest pain with activity, heartburn, nausea, vomiting, shortness of breath, excessive sweating, dependent edema, alternation in color/warmth of extremities. The MAR revealed staff were to mark 0 if no signs or symptoms of side effects and + if signs and symptoms are present. If present, staff were to document and notify the physician. Review of the MAR revealed staff were handwriting initials on the MAR for monitoring instead of 0 or +. Further review of Resident #50's [DATE] TAR revealed the resident was to be weighed every Friday for monitoring until [DATE] then monthly. There was no evidence the resident was weighed on Friday [DATE] per order. Review of a skilled note dated [DATE] at 4:04 A.M. revealed the resident was assessed by RN #167. (Note- It was determined this date and time was inaccurate per interview with Registered Nurse (RN) #167 on [DATE] at 10:30 A.M. The RN reported the assessment was completed on [DATE] around 11:00 P.M. not on [DATE] at 4:04 A.M.). The residents blood pressure was ,d+[DATE], pulse 74 and regular, respiration was 18, oxygen saturation was 95% on room air, and documented he was alert to time, person, and place. The resident had ted hose ordered. Left and right pedal pulses were plus two and normal. No signs of difficulty breathing or shortness of breath. Denied indigestion, nausea, vomiting, diarrhea, constipation, or bowel incontinence. Skin warm and dry, color within normal limits, and turgor was normal. No changes in the pressure ulcer on the coccyx, right knee, or right ankle. The resident had impairment of range of motion of both upper and lower extremities. His gait was unsteady, and he had poor balance. No safety concerns noted. Review of Resident/Family Education note, authored by RN #206 and dated [DATE] at 5:00 A.M., revealed per State tested Nursing Assistant (STNA) #110, she had provided incontinence care to the resident around 3:00 A.M. The note indicated the resident was pleasant and carried on a conversation with the STNA throughout the care. When the nurse entered the resident's room to administer medication as ordered, the resident was non-responsive, and no vitals were found. The resident's code status was checked, and he was a full code. Cardiopulmonary resuscitation (CPR) was initiated and 911 was called. Paramedics arrived. assessed the resident and stopped CPR. The resident's time of death was noted to be 5:46 A.M. Review of emergency medical services (EMS) report dated [DATE] revealed at 5:03 A.M. a call was received from nursing home that Resident #50 had coded, and CPR was in progress. At 5:11 A.M. the squad arrived on the scene and went to Resident #50's room and CPR was being done by nursing home staff. The resident was in bed, but with a backboard under him. The EMS report indicated nursing home staff continued high quality CPR using bag valve mask (BVM) for ventilation. The EMS hooked the resident up to a four-lead showing asystole. The RN reported the resident was last seen at 3:00 A.M. and was fine. The nurse came in around 5:00 A.M. to administer medication and found the resident in this condition. Unknown down time. Due to the residents' condition and unknown down time, it was decided the resuscitation efforts would be futile. CPR was discontinued at this time. The cardiac arrest etiology was presumed cardiac. Coroner #710 arrived on scene, report given, and care transferred. Review of Resident #50's death certificate dated [DATE] revealed immediate cause of death was cardiopulmonary failure due to CAD and cardiomyopathy. Another significant condition was hypertension per Local Coroner #708. Record review revealed the facility did not complete an investigation into the resident's unexpected death and there was no documented evidence of any medication error reports being filed for the medication errors involving Resident #50. Review of the facility incident log for [DATE] revealed no documentation of the medication errors related to potassium, Amiodarone or Mexiletine for Resident #50. Review of Resident #50's medical record revealed no evidence the physician was notified of the medication errors related to the potassium, Amiodarone or Mexiletine. Interview on [DATE] at 4:28 P.M., with Family Member (FM)/Power of Attorney (POA) #502 revealed she was an RN and had voiced concerns on [DATE] to the facility regarding Resident #50's edema and difficulty breathing and requested the facility call the physician regarding restarting the resident's diuretics. The POA stated the diuretics had been stopped in the hospital due to the resident vomiting and having diarrhea. She stated she also asked daily for staff to call the provider back to get orders for a potassium supplement due to the resident having a history of hypokalemia while on diuretics. The POA voiced concerns the nurses would not address her requests related to starting a potassium supplement until [DATE] when a nurse finally agreed to call the provider to obtain orders. FM #502 stated she also requested a potassium level be obtained as well since the resident had been on a diuretic for five days. FM #502 reported a potassium level was done on [DATE] (which was within normal level but lower than the resident's goal determined by his recent hospitalization ) however the resident had only received one dose of the diuretic when that lab test was obtained. An additional lab test was obtained on [DATE], and the resident had a critical (low) potassium level. FM #502 reported the resident had vomiting, which she determined the nurses were not documenting all the vomiting episodes and she didn't believe the resident could keep the oral potassium down. During the interview, POA #502 shared the resident had passed away the following morning on [DATE] and stated family believed his death was a result of poor care by facility staff. Interview on [DATE] at 8:17 A.M., with CNP #500 revealed he had seen the resident on [DATE] for Physician #501 to review admission orders. The CNP reported he had ordered labs on [DATE], however the labs were routine admission lab orders. The CNP reported he had ordered a potassium supplement; however, he did not document or recall if he ordered 10 or 20 mEq of potassium. He stated when he visits the facility, he gives the nurses verbal orders, and the nurses enter the orders in the computer. He had also ordered ted hose to be applied. The CNP reported, in his professional opinion, if a resident had a potassium level of 2.9 (critical) he would have ordered potassium to be administered intravenously and hospitalization for monitoring but ultimately it would be up to the physician to treat. The CNP stated he was not aware or notified the resident had vomiting. The CNP reported he does his own visit dictation from his visits and emails the dictation note to Medical Records Clerk #106 usually the same day or the next day. Interview on [DATE] at 10:30 A.M., with RN #167 confirmed the skilled note dated [DATE] at 4:04 A.M. was not documented with the actual time and date the assessment was completed. The RN reported she had completed the skilled assessment on [DATE] around 11:00 P.M. The RN confirmed the resident was only weighed on admission and stated the resident should have been weighed on [DATE], however there was no documented evidence the weight was obtained. The RN reported staff had documented a weight on [DATE] after the resident had expired in error as well. The RN confirmed the provider was not notified the resident was vomiting due to the family voicing it was normal for the resident to vomit after eating. RN #167 reviewed the resident's May and [DATE] MAR/TAR with the surveyor and confirmed staff were not documenting vomiting or edema on the MAR/TAR as indicated per orders. The RN reported the nurse who received orders on [DATE] from the CNP was an agency nurse and there was no order for a potassium supplement documented in the medical record. The RN confirmed the CNP, and/or physician do not write orders when they see residents and only provide verbal orders for staff to enter. RN #167 confirmed all MAR/TARs were documented on paper and not electronically. Interview on [DATE] at 11:12 A.M., with Physician #501 revealed a resident with a diagnosis of CHF should be weighed daily or at least every other day. The physician confirmed he did not physically see Resident #50 during his brief stay. The physician reported he decided to administer oral potassium because he was unaware the resident had vomiting and thought he could tolerate the oral potassium. The physician reported if he had known the resident was vomiting, he would have sent him to the emergency room for potassium intravenously (IV) and fluids IV. He stated he really can't speak on the matter, it was very unfortunate, and he understood the family concerns however he couldn't really say if the resident's death occurred due to cardiac issues as that was hard to judge. Interview on [DATE] at 1:36 P.M., with RN #180 confirmed there was no documented evidence the facility was monitoring the resident's I&O during his stay. The RN confirmed staff were not documenting on the MAR/TAR the resident was having edema or vomiting as indicated with 0 or + and that signing their initials did not provide information regarding the monitoring. Interview on [DATE] at 9:50 A.M., with Registered Nurse (RN) #180 confirmed the admission orders for the Amiodarone and Mexiletine were not transcribed accurately on admission. RN #180 reported she could not find any evidence a medication error report was completed, or the physician was notified. An additional telephone interview on [DATE] at 8:00 A.M. with FM/POA #502 revealed she was not notified Resident #50's antiarrhythmic medication was not administered as ordered. The POA reported she had issues with Agency LPN #707 not addressing her concerns regarding the potassium supplement timely. The POA stated the LPN kept telling her the resident did not need potassium due to his potassium levels being normal. The POA reported she did request staff to adjust medication times around the resident's meals because he was having vomiting episodes, and she was afraid his medications were not absorbing/effective. The POA reported she would clean the vomit off the resident, however, would leave the bucket so the staff could assess the amount and color. The resident was scared to eat because he was afraid he would vomit. He would only eat 25% of his meals, if he ate anything at all. She stated she tried to bring him ice cream so he would at least get something on his stomach. The DON informed the POA the resident could not see a gastroenterologist while he was skilled (through Medicare) to try to determine what was causing the vomiting. The POA voiced concerns staff were not applying his ted hose or monitoring his intake and o [TRUNCATED]