Every finding on record at Village Health Care at The Glen

Based on record reviews and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident by having staff fail to follow physician orders for 1 (#1) of 1 sampled residents. The failed practice was evidenced by staff not implementing a physician's antibiotic order resulting in Resident #1 not receiving an antibiotic.Findings:Review of the undated facility policy entitled Verbal Orders revealed in part:Policy Statement: 1. Verbal orders shall only be given in an emergency or when the Attending Physician is not immediately available to write or sign the order.Policy Interpretation and Implementation:1. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.2. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf.4. The individual receiving the verbal order must write it on the physician's order sheet as v.o. (verbal order.5. The individual receiving the verbal order will: read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed; . Record the date and time of the order.Review of Resident #1's medical record revealed an admission date of 06/01/2026 and a discharge date of 07/09/2026. Diagnoses included, in part, dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, pressure ulcer of sacral region, unstageable, type 2 diabetes mellitus, and essential hypertension.Review of S3NP's (nurse practitioner) progress note dated 07/06/2026 for Resident #1 revealed, in part, WBC (white blood cell) count was elevated on recent lab, will order updated lab. WBC 17.5 on 07/07/2026 labs, gave verbal order for Rocephin 1 gram IM (intramuscular) qd (every day) for 3 days.Review of Resident #1's lab results dated 07/07/2026 confirmed a white blood cell count of 17.5 (critical high) with a normal reference range of 4.6-10.2.During an interview on 08/24/2026 at 2:15 p.m. S3NP confirmed, due to Resident #1's elevated white blood cell count, she gave a verbal order to S4LPN (licensed practical nurse) for Rocephin 1 gram IM qd for 3 days. Review of Resident #1's current physician orders and July 2026 MAR (medication administration record) failed to reveal an order for Rocephin 1 gram IM qd for 3 days.During an interview on 08/24/2026 at 1:30 p.m. S2DON (director of nursing) reported after review of Resident #1's medical record it was confirmed that S4LPN did not enter the verbal order for Rocephin and Resident #1 did not receive any doses of Rocephin.During an interview on 08/25/2026 11:10 a.m. S1Administrator confirmed, after review of Resident #1's medical record, S4LPN did not transcribe a verbal order from S3NP for an antibiotic.During an interview on 08/25/2026 at 3:20 p.m. S4LPN reported he failed to enter a verbal order from S3NP on 07/07/2026 for Rocephin 1 gram IM for 3 days for Resident #1. S4LPN confirmed he forgot to enter the order and he should have entered the order. During an interview on 08/27/2026 at 3:30 p.m. S2DON reported on 07/09/2026 she didn't think Resident #1 looked good and talked with S3NP. S3NP reported on 07/07/2026 she had given a verbal order to S4LPN for Rocephin due to Resident #1's elevated WBCs. S2DON checked the medical record and did not find an order for Rocephin. S2DON called S4LPN to ask about the verbal order and S4LPN said he had forgotten to put the order in and confirmed he had called S3NP on 07/07/2026 to report the elevated WBC and she gave him a verbal order for Rocephin. S2DON reported this to S3NP and S3NP rewrote an order for Rocephin on 07/09/2026. Resident #1 was sent out to the hospital on [DATE] so he never received the Rocephin originally ordered on 07/07/2026.

Based on record reviews and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status by failing to ensure weights were obtained monthly for 2 (#2, #9) of 3 (#2, #3, #9) residents reviewed for nutrition. Findings:Review of undated Policy titled Weighing and Measuring the Resident revealed:PurposeThe purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident.Preparation1. Review the resident's care plan to assess for any special needs of the resident.4. Weight is usually measured upon admission and monthly during the resident's stay. (Note: Weight is measured in pounds [16 ounces=1 pound]) .DocumentationThe following information should be recorded in the resident's medical record:1. The date and time the procedure was performed.3. The height and weight of the resident.6. If the resident refused the procedure, the reason (s) why and the intervention taken.Reporting1. Report significant weight loss/weight gain to the nurse supervisor.3. Notify the Nurse Supervisor if the resident refuses the procedure. Resident #2 Review of Resident #2's medical record revealed an admission date of 02/03/2025 with diagnoses that included, in part, other encephalopathy, Alzheimer's disease with early onset, moderate protein-calorie malnutrition, vitamin D deficiency, and hypomagnesemia. Review of Resident #2's physician orders revealed a 01/01/2026 order for Monthly weight unless specified otherwise. Special Instructions: Monthly weight on the 1st. Once a morning on the 1st of the month. Review of Resident #2's weights revealed the following weights, in part:06/22/2026 178.2 pounds04/09/2026 192 poundsFurther review of Resident #2's weights failed to reveal any weight was obtained between 04/09/2026 and 06/22/2026. During an interview on 06/22/2026 at 12:25 p.m. S2 DON (Director of Nursing) reported the staff had indicated Resident #2 would refuse weights and confirmed there was no documentation that Resident #2 had refused to be weighed since the 04/09/2026 weight. S2 DON further confirmed no weight had been obtained between 04/09/2026 and 06/22/2026 and should have been conducted monthly. Resident #9 Review of Resident #9's medical record revealed an admission date of 01/28/2026 with diagnoses that included, in part, mild protein-calorie malnutrition, Alzheimer's disease unspecified, major depressive disorder, generalized anxiety disorder, and iron deficiency. Review of Resident #9's weights revealed the following weights, in part:06/23/2026 95.2 pounds04/09/2026 103.1 poundsFurther review of Resident #9's weights failed to reveal any weight was obtained between 04/09/2026 and 06/23/2026. Review of Resident #9's Care Plan revealed Resident #9 was care planned for a potential for altered nutritional status with an approach that included monitor weight per facility protocol and report significant changes in weight to MD (Medical Doctor) and RD (Registered Dietician). During an interview on 06/22/2026 at 4:12 p.m. S2 DON confirmed there had not been a weight obtained since 04/09/2026 and Resident #9 should have been weighed monthly.

Based on record reviews and interviews, the facility failed to develop an individualized care plan for 3 (#11, #12, #70) of a total sample of 38 residents reviewed. The facility failed to develop a care plan for Resident #11's indwelling catheter, Resident #12's dementia and Resident #70's pressure ulcer. Findings: Resident #11 Review of resident #11's comprehensive plan care with S4 MDS (Minimum Data Set) Coordinator failed to reveal the facility develop a plan of care for resident #11's indwelling Foley catheter. Review of resident #11 's Physician's orders revealed an order dated 05/14/2026 for Indwelling Foley catheter 16 Fr (French) /10 ml (milliliters) change every month and as needed for occlusion, leaking, or dislodgment. Once a day on the 3rd of the month; 07:00 a.m. - 3:00 p.m. Review of resident #11's records revealed diagnoses that include benign prostatic hyperplasia without lower urinary tract symptoms, overactive bladder and Cervical disc disorder at C4-C5 level with myelopathy. Resident #12 Review of Resident #12's medical record revealed an admission date of 05/28/2026 with the following diagnoses, including in part: other Alzheimer's disease, dementia in other diseases classified elsewhere severe with psychotic disturbance, and cognitive communication deficit. Review of Resident #12's comprehensive care plan failed to reveal Resident #12 was care planned for Dementia. During an interview on 06/24/2026 at 8:39 a.m. S5 MDS Coordinator reviewed Resident #12's medical record and reported Resident #12 was living in a memory care facility prior to admission, had diagnoses that included Alzheimer's disease and non-Alzheimer's dementia and was not care planned for dementia and should have been. Resident #70 Review of Resident #70's medical record revealed an admit date of 03/11/2026 with the following diagnoses, including in part: type 2 diabetes mellitus without complications, overactive bladder, age-related physical debility, cognitive communication deficit and right heel pressure injury stage 3. Review of Resident #70's comprehensive care plan failed to reveal a problem and interventions for a right heel pressure injury stage 3. Review of Resident #70's physician's orders revealed an order dated 06/18/2026 for right heel: Monday, Wednesday, Friday and on shower days. Do not allow dressing to get wet, cleanse with wound cleanser, pat dry, apply betadine, and cover with dry dressing. During an interview on 06/24/2026 at 11:45 a.m. S4 MDS Coordinator acknowledged Resident #70 was not care planned for right heel pressure injury Stage 3 and should have been. S4 MDS Coordinator further acknowledged Resident #11 was not care planned for foley catheter and should have been.

Based on record review, observations and interview, the facility failed to ensure residents who required respiratory care received the care and services consistent with professional standards of practice for 1 (#4) of 3 (#4, #61, #80) residents reviewed for respiratory care. The facility failed to ensure Resident #4's oxygen tubing was changed weekly, nebulizer tubing was dated, and nebulizer mouthpiece was stored properly when not in use. Findings:Review of undated policy titled Departmental (Respiratory Therapy) - Prevention of Infection revealed:PurposeThe purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.Preparation1. Review the resident's care plan to assess for any special circumstances or precautions related to the resident.Infection Control Considerations Related to Oxygen Administration .7. Change the oxygen cannulae and tubing every seven (7) days, or as needed.8. Keep the oxygen cannulae and tubing used prn (as needed) in a plastic bag when not in use.Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol:7. Store the circuit in plastic bag, marked with date and resident's name, between uses.9. Discard the administration set-up every seven (7) days. Review of Resident #4's medical record revealed an admission date of 11/05/2020 with diagnoses that included, in part, senile degeneration of brain not elsewhere classified, chronic obstructive pulmonary disease unspecified (history of), chronic diastolic (congestive) heart failure, and unspecified asthma uncomplicated. Review of Resident #4's physician orders revealed the following orders, in part:-04/29/2026 Oxygen every week change oxygen tubing, water and clean filter Q (every) weekly on Saturday label and date. Once a day on Saturday.-06/20/2025 Change nebulizer tubing/mask, initial and date all pieces. Attach a Ziploc bag to for storage. Every week. Once a day on Saturday. Observation on 06/22/2026 at 8:37 a.m. revealed Resident #4 was asleep in bed with head of bed elevated, oxygen on via nasal cannula and oxygen tubing dated 05/23/2026. Further observation revealed nebulizer machine on Resident #4's nightstand beside bed with undated tubing attached and nebulizer mouthpiece lying unbagged on the nightstand. Observation on 06/22/2026 at 2:10 p.m. revealed Resident #4 dressed and seated in chair at bedside with oxygen on via nasal cannula and oxygen tubing dated 05/23/2026. Further observation revealed nebulizer machine on Resident #4's nightstand beside bed with undated tubing attached and nebulizer mouthpiece lying unbagged on the nightstand. During an interview on 06/22/2026 at 2:15 p.m. S6 ADON (Assistant Director of Nursing) observed Resident #4's oxygen tubing in use that was dated 05/23/2026, the undated nebulizer machine tubing, and the unbagged nebulizer mouthpiece lying directly on the nightstand and reported the tubing should have been changed each Saturday night by the night shift and nebulizer mouthpiece should have been bagged when not in use and was not.

Based on record review and interview the facility failed to ensure resident's medical records reflected the resident's advance directive wishes for 1 (#92) of 1 resident reviewed for advance directives. The facility failed to ensure resident #92's medical records were consistent with the resident's wishes. Findings:Review of resident #92's records revealed an admit date to this facility 05/05/2026.Review of resident #92's records revealed diagnoses that include unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified pain, muscle wasting and atrophy, not elsewhere classified, multiple sites, and unspecified heart failure.Review of resident #92's Physician Orders revealed an order dated 05/05/2026 for a Full Code.Review of resident #92's Face Sheet revealed the Advance Directive section indicated Full Code.Review of resident #92's records with S7 LPN (license practical nurse) revealed resident #92 as a Full Code.Review of the resident #92's records on 06/24/2026 at 2:30 p.m. with S3 ADON (assistant director of nursing) revealed the LaPOST (Louisiana Physician Orders for Scope of Treatment) signed and dated 01/27/2022 by the resident physician and personal health care representative indicated the resident was DNR (do not resuscitate) /Do Not Attempt Resuscitation (Allow Natural Death). During an interview on 06/24/2026 at 2:30 p.m. S3 ADON agreed resident #92 records should have indicated DNR status.

Based on record review and interview the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 1 (#46) of 1 (#46) resident reviewed for the completion of a 14 day discharge assessment. Findings: Review of Resident #46's medical record revealed Resident #46 was admitted on [DATE] and discharged on 02/20/2026. Review of MDS revealed a 02/20/2026 Discharge-Return Not Anticipated MDS with a status of production accepted. During an interview on 06/23/2026 at 12:43 p.m. S4 MDS Coordinator and S5 MDS Coordinator reported the 02/20/2026 Discharge MDS was transmitted and received by CMS on 06/19/2026. S4 MDS Coordinator and S5 MDS Coordinator further reported the 02/20/2026 discharge MDS should have been transmitted within 14 days of discharge and was not.

Based on record review, surveillance video review, observation, and interviews, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for Resident #1, who was cognitively impaired, on 01/09/2026 at approximately 7:58 a.m. when S4 CNA was observed on surveillance video physically abusing Resident #1. S4 CNA was observed to forcibly lift Resident #1 from a sitting to standing position three times by gripping Resident #1's left upper arm while yelling at Resident #1 Get up! resulting in multiple areas of bright purple purpura (bruising) to posterior left upper arm. S4 CNA further picked up Resident #1 by her underarms and S4 CNA dropped Resident #1 in wheelchair at the time of transfer. Because this type of inappropriate, unwanted physical abuse and being yelled at would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in Resident #1's position would have experienced severe psychosocial harm-dehumanization, and humiliation as a result of the physical abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings:Review of the facility's Resident Abuse & Neglect Prevention & Detection policy revised 11/2022 revealed in part:Definition: Abuse - Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.Physical Abuse - Hitting, slapping, pinching, and kicking. Controlling behavior through corporal punishment. Physical injury that results in substantial harm to the resident, or the genuine threat of substantial harm from physical injury to the resident, including an injury that is at variance with the history or explanation given. Failure to make a reasonable effort to prevent an action by another person that results in physical injury and substantial harm to the resident.Review of Resident #1's medical record revealed an admission date of 07/03/2025 to the facility's locked memory care unit. Further review of Resident #1's medical record revealed diagnoses including in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other lack of coordination, Alzheimer's disease, and muscle weakness. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 0, indicating severe impaired cognition. Resident #1 was dependent on staff for bed-to-chair transfer. Resident #1 had adequate ability to hear, with no difficulty in normal conversation.Review of Resident #1's comprehensive care plan revealed Resident #1 was a fall risk and had an approach dated 10/22/2025 use gait belt for all transfers. Assist to transfer using one staff for transfer.Review of Resident #1's progress notes revealed a late entry note on 01/12/2026 at 7:41 a.m. note dated for 01/09/2026 at 5:26 p.m. by S1 Administrator . noted during assessment one approximately nickel-sized irregular shaped area of bright purple purpura to [Resident #1's] lateral upper left arm proximal to antecubital space. Further review revealed a late entry note on 01/12/2026 7:50 a.m. for 01/11/2026 at 2:50 p.m. by S1 Administrator .resident has multiple areas of bright purple purpura to posterior left upper arm.Review of Resident #1's weekly skin review dated 01/11/2026 by S8 LPN 4 small reddish purple areas noted to back of left [upper arm] just above the elbow.During an interview on 03/10/2026 at 1:10 p.m. S1 Administrator reported the time of video was 01/09/2026 at 7:58 a.m. and S6Housekeeping was in the beginning of the video speaking with Resident #1, then S4 CNA enters the room.Review of the time stamped video with audio dated 01/09/2025 at 7:58 a.m. in part: 7:58:30 a.m. S4 CNA was observed entering Resident #1's room with linen under her left arm and proceeded to enter Resident #1's closet. Observation failed to reveal S4 CNA greeted/acknowledged Resident #1 upon entering the room. S6 Housekeeping was observed standing in front of Resident #1 blocking full view of Resident #1. Resident #1 appeared to be seated on the side of the bed. S6 Housekeeping and Resident #1 were observed to be in conversation (inaudible). 7:58:44 a.m. S6 Housekeeping was observed exiting Resident #1's room and Resident #1 came into full view of the camera. Resident #1 was sitting upright on the side of the bed wearing a nightshirt and brief and was observed smiling as S6 Housekeeper exited the room. Resident #1 laughed and stated to S6 Housekeeping I'll see you later. 7:58:50 a.m. Resident #1 was observed scratching her head and asked S4 CNA I can get something to eat anyway. Can't, I? Resident #1 looked to S4 CNA as she (S4 CNA) was walking out of the closet toward Resident #1 and S4 CNA failed to respond to Resident #1. 7:58:57 a.m. S4 CNA walked over to Resident #1 with linens, a brief and clothing under her left arm. S4 CNA blocked the view of Resident #1 and appeared to pull Resident #1 up by Resident #1's left arm by S4 CNA using her right arm. S4 CNA was observed lowering her right arm and Resident #1 remained in the bed. 7:59:01 a.m. S4 CNA yelled Get up and S4 CNA grabbed Resident #1's left upper arm and pulled Resident #1 forcefully in an upward motion. Resident #1 came into full view of the camera. Resident #1 stated Wait, and was observed to grimace. Resident #1 was unable to stand and propelled in a downward motion toward the floor as S4 CNA continued to hold onto Resident #1 by her left upper arm. Resident #1 asked S4 CNA to Wait. S4 CNA continued and pulled Resident #1 back into the bed by Resident #1's upper left arm. 07:59:06 a.m. S4 CNA called Resident #1 by her first name and yelled ____, get up!. S4 CNA pulled Resident #1 up by Resident #1's left upper arm and Resident #1 stated I know. I can. 07:59:11 a.m. S4 CNA continued to hold Resident #1 by the left upper arm and swung Resident #1 around back into bed when Resident #1 was unable to stand. 07:59:16 a.m. S4 CNA yelled at Resident #1 by her first name Get up, _____! Get up, ____!). Resident #1 was observed sitting in the bed with distressed facial gestures. S4 CNA dropped the linen and clothing onto the bed and walked away from Resident #1. 07:59:23 a.m. S4 CNA moved toward Resident #1's wheelchair, grabbed a pair of shoes from the wheelchair seat, and forcefully tossed the shoes on the ground. 07:59:26 a.m. S4 CNA unlocked Resident #1's wheelchair and began to move back toward Resident #1. 07:59:34 a.m. S4 CNA rammed Resident #1's wheelchair into the wooden footboard, shaking Resident #1's bed. 07:59:37 a.m. S4 CNA approached Resident #1 with wheelchair. Resident #1 recoiled and had a frightened look on her face. Resident #1 stated I can get up, if you don't mind. S4 CNA did not respond.07:59:40 a.m. S4 CNA placed unlocked wheelchair in front of Resident #1.07:59:41 a.m. S4 CNA leaned toward Resident #1 and lifted Resident #1 away from the bed by Resident #1's underarms. S4 CNA failed to use a gait belt. 07:59:43 a.m. S4 CNA dropped Resident #1 in the unlocked wheelchair, and an audible sound of impact was heard of Resident #1's buttocks against wheelchair.07:59:44 a.m. Resident #1 grimaced and stated Ow! 07:59:46 a.m. Resident #1 touched and rubbed her left arm with right hand, moaned, and appeared to express pain.07:59:48 a.m. S4 CNA gathered the linens, a brief and clothing off Resident #1's bed.07:59:54 a.m. S4 CNA began to pull Resident #1 backwards in the wheelchair.08:00:06 a.m. Resident #1 lifted her left arm away from her body08:00:06 S4 CNA pulled Resident #1 backwards in the wheelchair toward the bathroom and the wheelchair slammed against footboard08:00:07 a.m. Resident #1 pointed towards the door and stated Go out.08:00:14 a.m. Resident #1 placed her left hand on her forehead and expressed distressed facial gestures. Resident #1 appeared frightened. 08:00:20 a.m.S4 CNA rolled Resident #1 into the unlit bathroom in Resident #1's room.08:00:23 a.m. Resident #1 and S4 CNA are out of view of the camera. 08:00:26 a.m. Resident #1 asked Am I getting my bath in here?08:00:27 a.m. Lights turned on in the bathroom.08:00:28 a.m. Resident #1 stated Oh me! 08:00:30 a.m. video ended.An observation on 03/09/2026 at 8:27 a.m. Resident #1 was resting in bed with bed in lowest position and wheels locked. During an interview on 03/11/2026 at 12:25 p.m. S1 Administrator confirmed S4 CNA physically abused Resident #1 by yelling Get up! multiple times and grabbing, lifting, and twisting Resident #1's left arm in an attempt to transfer, unsafely and improperly. S1 Administrator further confirmed Resident #1 looked frightened during the event. During a telephone interview on 03/11/2026 at 2:42 p.m. S2 DON confirmed the video established Resident #1 received physical abuse from S4 CNA on 01/09/2026. During an interview on 03/12/2026 at 11:14 a.m. S1 Administrator reported a reasonable person subjected to the physical abuse and verbal aggression, which occurred on 01/09/2026 to Resident #1 from S4 CNA, would have experienced physical abuse and psychosocial harm.During an interview on 03/16/2026 at 3:45 p.m. S8 LPN confirmed a weekly skin review performed on 01/11/2026 for Resident #1 found 4 small reddish purple areas on the back of left upper arm just above the elbow looked like finger prints. During an interview on 03/16/2026 at 4:28 p.m. S2 DON reported Resident #1's weekly skin review on 01/11/2026 found 4 small reddish purple areas on the back of left upper arm just above the elbow could have been from S4 CNA's finger prints.During the survey, in-service records and QA monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice.Review of the facility's Plan of Correction-Physical Abuse Allegation [Resident #1] QA meeting revealed with a completion date of 01/22/2026: Intervention: 1. Address how corrective actions were accomplished for resident affected:01/09/2026 12:38 p.m. allegation received. Employee identified as S4 CNA. Employee placed on suspension pending investigation-removed from facility/removed from schedule. Clocked out 12:52 p.m.01/09/2026 Local Police Department notified of allegation; Responded 4:48 p.m.01/09/2026 Body audit for injuries conducted by S2 DON or Designee. (Completed 01/09/2026)01/09/2026 Abuse screen conducted by S10 Assistant Administrator. (Completed 01/09/2026)2. Describe how other residents with potential to be affected will be identified and what will be done for them: 01/09/2026 recent incidents reviewed for locked memory care unit.S2 DON and S1 Administrator identified other residents assigned to S4 CNA with the potential to be affected. S2 DON or designee to conduct body audit for signs of potential abuse of residents assigned to S4 CNA 01/09/2026 and daily for 72hrs. (Completed 01/12/2026) S10 Assistant Administrator to conduct abuse Screenings x1 with interviewable residents of locked memory care unit. (Completed 01/09/2026)Resident #1 reviewed for fall intervention - trial of discontinuing alarms - dismantled bed alarm. 01/09/2026. S2 DON reported Resident #1's family agreed with the plan.3. Measures that will be put in place or system changes that will be made to ensure practice will not recur:All Nursing employees - abuse training.Begin 01/09/2026. Employees who do not demonstrate competency to be retrained. (Completed 01/14/2026)Abuse policy reviewed - meets requirements.Continue abuse training on hire annually- monitored by S2 DON. (Ongoing)Angel rounds weekly x4 weeks - S2 DON or Designee S1 Administrator or designeeContinue safe transfer training on hire and monitored by S2 DONContinue gait belt training on hire (Ongoing).4. Indicate how the facility plans to monitor its performance to ensure solutions are sustained. Plan for ensuring corrective action is achieved and sustained. How corrective measures will be monitored. What QA program will be put in place (who, how, how often, what will be done if problems discovered?)Walking Angel rounds started on 01/09/2026, then weekly x4 Administrator/designee then monthly as part of QA. Any issues will be addressed as found. (X4 completed 01/30/2026 and ongoing monthly) Dementia education -S2 DON/S1 Administrator started education on 01/09/2026 for current memory care unit staff. Implement dementia education with all nursing staff within, 1st 90 days of here hire. Provide dementia education with all nursing staff. (Completed with locked memory care unit Staff 7am - 3pm staff, 01/22/2026) 5. Completion date: see each area for completion dateQA Committee meeting:01/09/2026: Summary of investigation video received and reviewed. S4 CNA used inappropriate transfer techniques, failed to communicate with resident during procedure, handled resident in a rough manner. Body audit summary, Resident #1: No new injury that can be attributed to incident. Existing old bruise left hand and wrist. Existing left x-ray wrist negative for fracture. Body audit summary other residents who received care by S4 CNA on 01/09/2026- no physical indicators of abuse.Abuse screenings/Interviews for all 23 Residents on locked memory care unit. Resident #1: denied abuse or mistreatment. No behavior observed to indicate withdrawal, fear, stress, tearfulness or agitation. Resident #1 calm, smiling, in common area, Conversational.Abuse interview dated 01/09/2026- 23 Residents on locked memory care unit. - 1 Resident stated he did not want to answer. 11 Residents were able to respond denied abuse or mistreatment. 23 Residents on locked memory care unit. 1- Did not want to answer 11 - Unable to respond/not interviewable11 - Report feeling safeStaff interview Summary on locked memory care unit - No Staff report witnessing abuse.01/14/2026 Employee (S4 CNA) terminated. S4 CNA did not use training provided to communicate or transfer. No injury. No mental anguish. - Implement gait belt training locked memory care unit CNAs- Implement transfer training refresher with nursing staffSchedule dementia education to begin 01/20/2026Signed by: S1 Administrator, S10 Assistant Administrator, S2 DONValidation of review of the facility's Plan of Correction-Physical Abuse Allegation [Resident #1] QA meeting revealed: 1. Address how corrective actions were accomplished for resident affected: Review of the facility's reported incident binder of Resident #1's reported incident revealed date of discovery on 01/09/2026 at 12:28 p.m. Review of the facility's timesheet for S4 CNA's time sheet revealed a clocked out time of 12:52 p.m. on 01/09/2026. Review of the facility's certified letter to S4 CNA confirming termination on 01/14/2026.Review of the facility's reported incident binder revealed a police report was filed on 01/09/2026 at 4:17 p.m.Review of Resident #1's skin audit on 01/09/2026 revealed no new skin areas noted. Review of the reported incident binder revealed Abuse interview dated 01/09/2026 for 23 Residents on locked memory unit completed.2. Describe how other residents with potential to be affected will be identified and what will be done for them: During a telephone interview on 03/11/2026 at 2:42 p.m. with S2 DON reported QA meeting on 01/09/2026 reviewed locked memory care unit for falls and incidents/events for any patterns, including abuse; no concerns noted. Confirmed by review of the facility's incident list for dates 10/01/2026 through 01/09/2026 revealed no concerns. Review of the facility's body audits for Residents S4 CNA cared for on 01/09/2026 were completed on 01/09/2026, 01/10/2026 and 01/11/2026. Review of the reported incident binder revealed abuse interview dated 01/09/2026 for 23 Residents on locked memory unit completed.Review of Resident #1's discontinued physician's orders revealed discontinued orders on 01/12/2026 and 01/14/2026 after Resident #1's chair and bed alarm trials. 3. Measures that will be put in place or system changes that will be made to ensure practice will not recur:Throughout survey dates 03/09/2026 through 03/16/2026 multiple staff were interviewed across all shifts including 8 CNAs and 5 LPNs to verify inservices on abuse were completed after 01/09/2026. Review of the facility's inservice dated 01/09/2026 with the topic abuse: reporting, recognizing, and reporting with facilitators S2 DON and S3 ADON revealed instructions complete each exam and turn in to S2 DON or S3 ADON. Take a copy of each packet. All CNA and Nursing staff signed log in sheet. Review of the exams revealed signed/dated by employee and verified by administrative staff; All nursing staff signatures on form. During an interview on 03/11/2026 at 12:25 p.m. S1 Administrator reported all staff inservices on abuse were completed on 01/22/2026. Review of S4 CNA, S5 CNA, and S11 CNA employee records revealed training of abuse on hire and updated annually. Review of safety rounds for dates, 01/09/2026, 01/16/2026, 01/23/2026, and 01/30/2026 revealed no concerns. Review of S4 CNA, S5 CNA, and S11 CNA employee records revealed training of gait belt training on hire. 4. Indicate how the facility plans to monitor its performance to ensure solutions are sustained. Plan for ensuring corrective action is achieved and sustained. How corrective measures will be monitored. What QA program will be put in place (who, how, how often, what will be done if problems discovered?)During an interview on 03/11/2026 at 12:25 p.m. with S1 Administrator reported QA meeting continued to discuss safety round findings.Review of S4 CNA, S5 CNA, and S11 CNA employee records revealed training of dementia on hire and updated annually.

Based on record review, observations, and interviews, the facility failed to ensure a resident's environment remained free of accident hazards by failing to ensure a resident's room floor maintained non-skid traction for 1 (Resident #3) of 3 residents reviewed for falls. Findings: Review of the facility's Falls and Fall Risk, Managing policy dated March 2018 revealed in part: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Policy Interpretation and Implementation:DefinitionAccording to the MDS, a fall is defined as:Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.Fall Risk Factors1. Environmental factors that contribute to the risk of falls include:a. wet floors;3. Medical factors that contribute to the risk of falls include:e. balance and gait disorders, etc. Resident #3 was admitted to the facility on [DATE] with diagnosis including in part, displaced mid-cervical fracture of left femur, subsequent encounter for closed fracture with routine healing, and unspecified dementia. Review of Resident #3's Significant Change MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 10, indicating moderately impaired cognition. Further review of Resident #3's Significant Change MDS Assessment revealed Resident #3 required partial assist by staff for transfers and walking at least 10 feet once standing.Review of Resident #3's comprehensive care plan revealed Resident #3 had a history of falling related to impaired balance and gait with a start date of 01/22/2026 and an intervention for staff to observe frequently and place in supervised area when out of bed. Review of Resident #3's medical record revealed Resident #3 had 2 falls on 01/21/26 and 1 fall on 01/29/2026, 02/21/2026 and 02/22/2026. Review of Resident #3's fall risk assessment dated [DATE] revealed Resident #3 was a high risk for falls. An observation on 03/09/2026 at 12:00 p.m. revealed Resident #3 asleep in a recliner chair in Resident #3's room. Further observation revealed Resident #3's entire floor from entry through the walkway to Resident's #3's recliner was dry, however, slippery, shiny and had little traction upon access. During an observation of Resident #3's floor with S5CNA on 03/09/2026 at 12:10 p.m., S5CNA acknowledged Resident #3's floor was dry and slippery throughout. During an interview on 03/09/2026 at 12:10 p.m., S5CNA reported Resident #3 could slip and fall. During an observation with S6Housekeeping of Resident #3's floor on 03/09/2026 at 12:15 p.m. S6Housekeeping acknowledged Resident #3's floor was shiny and slippery through the walkway and by the bed. During an interview on 03/09/2026 at 12:15 p.m., S6Housekeeping reported she had mopped Resident #3's floor this morning with facility's standard floor cleaning solution. During an observation on 03/09/2026 at 2:10 p.m. Resident #3's floor revealed a dry reflective shine along the walk pathway of Resident #'3 floor. Further observation revealed the area was slippery with little to no traction. Further observation revealed Resident #3 was standing up by the recliner next to the bed. During an interview on 03/09/2026 at 2:10 p.m. Resident #3 reported sometimes the floor is slippery and sometimes the floor feels like glue and my shoes get stuck. During an observation of Resident #3's floor with S7LPN on 03/09/2026 at 2:50 p.m., S7LPN acknowledged the flooring was slippery with little traction. During an interview on 03/09/2026 at 2:50 p.m. S7LPN reported Resident #3's slippery floor posed a fall risk. During an observation of Resident #3's room with S3ADON on 03/09/2026 at 3:10 p.m., S3ADON acknowledged Resident #3's floor was slick with little traction throughout the walking pathway into the room and around the bed. During an interview on 03/09/2026 at 3:10 p.m., S3ADON acknowledged Resident #3's floor was slippery and Resident #3 was at high risk for falls. During an observation of Resident #3's room with S1Administrator on 03/09/2026 at 3:45 p.m., S1Administrator acknowledged Resident #3's floor was shiny and slippery. During an interview on 03/09/2026 at 3:45 p.m., S1Administrator reported facility floors had never been waxed and were mopped with house cleaner. S1Administrator acknowledged the condition of Resident #3's floor was a fall hazard. During an interview on 03/09/2026 at 4:00 p.m., S9Housekeeping Supervisor reported she had examined Resident #3's room and confirmed Resident #3's floor was slippery. An observation on 03/10/2026 at 2:40 p.m. revealed Resident #3's floor had shiny reflective areas and a slippery surface throughout the room. During an interview on 3/10/2026 at 2:45 p.m., S1Administrator acknowledged Resident #3's floor was slippery and Resident #3 had a history of falls in Resident #3's room and bathroom.

Based on record review, observation, and interviews, the provider failed to develop and implement a comprehensive person centered care plan for each resident as evidenced by failing to implement care plan intervention for falls for 1 (#1) Resident out of 3 residents reviewed for falls.Findings: Review of Resident #1's medical record revealed an admission date of 07/03/2025 to the facility. Further review of Resident #1's medical record revealed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other lack of coordination, Alzheimer's disease, and muscle weakness.Review of Resident #1's comprehensive care plan revealed Resident #1 was a fall risk with approach dated 10/22/2025 fall mat to each side of bed when in bed.An observation on 03/09/2026 at 8:27 a.m. revealed Resident #1 was resting in bed with eyes closed. Further observation failed to reveal a fall mat in place to both sided of the bed.An observation on 03/09/2026 at 2:20 p.m. in Resident #1's room with S5 CNA failed to reveal fall mats in place in Resident #1's room.During an interview on 03/09/2026 at 2:20 p.m. S5 CNA confirmed Resident #1's room failed to have fall mats in place.During an interview on 03/09/2026 at 3:05 p.m. S3 ADON acknowledged Resident #1's care plan contained an intervention of a fall mat in place.An observation in Resident #1's room on 03/09/2026 at 3:10 p.m. with S3 ADON failed to reveal fall mats in place in Resident #1's room. S3 ADON confirmed Resident #1's room failed to have fall mats in place and should have.

Based on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medication had a Gradual Dose Review (GDR) attempted for 1 (#30) of 5 (#4, #5, #30, #51, #77) residents reviewed for unnecessary medications. Findings: Review of Resident #30's medical records revealed an admit date of 12/21/2021 with the following diagnoses, including in part: Alzheimer's disease with late onset, wandering in diseases classified elsewhere, depression unspecified, unspecified dementia moderate with mood disturbance, MDD (major depressive disorder) recurrent in partial remission, and generalized anxiety disorder. Review of Resident #30's Physician's Orders revealed an order dated 10/19/2023 for Trazadone 50mg (milligram) tablet by mouth at bedtime for MDD. Review of Resident #30's GDR dated 11/24/2024 failed to reveal Trazadone 50mg was reviewed for an attempted GDR and a rationale was provided for continuing psychoactive medication at current dose by the Physician/Nurse Practitioner. During an interview on 05/14/2025 at 2:15 p.m. S2 DON (Director of Nursing) acknowledged Resident #30's GDR for Trazadone 50mg reviewed for an attempted and a rationale was not provided for continuing psychoactive medication at current dose by the physician.

Based on record reviews and interviews the facility failed to develop and implement resident's comprehensive person-centered care plans by: 1. The facility failed to develop a care plan with a focus and appropriate approaches on bed rails/side rails for 2 (#9, #41) of 5 (#9, #30, #41, #52, #78) residents reviewed for restraints. 2. The facility failed to implement 1 (#24) of 3 (#19, #24, #90) residents reviewed for nutrition. The facility failed to ensure Resident #24 was weighed weekly as per the physician order. Findings: Resident #9 Review of Resident #9's May 2025 physician orders dated 09/17/2024 revealed 1/3 length assist rail up times one on left when in bed to facilitate bed mobility. Review of Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview on Mental Status) of 12 out of 15 indicating moderately impaired cognition. Review of Resident #9's care plan failed to reveal a care plan had been developed with a focus and appropriate approaches for use of bed rails/side rails. Observation on 05/12/2025 at 9:30 a.m. revealed Resident #9 in bed with 1/3 side rail raised to left side of the bed. During an interview on 05/12/2025 at 9:30 a.m. Resident #9 reported 1/3 side rail was used to assist with turning and repositioning while in bed. Resident #41 Review of Resident #41's MDS assessment dated [DATE] a BIMS of 14 out of 15 indicating intact cognition. Review of Resident #41's May 2025 physician orders dated 03/27/2025 revealed 1/3 length assist rail up times two on left when in bed to facilitate bed mobility Review of Resident #41's care plan failed to reveal a care plan had been developed with a focus and appropriate approaches for use of bed rails/side rails. Observation on 05/12/2025 at 9:00 a.m. revealed Resident #41 in bed with side rails raised to both sides of the bed. During an interview on 05/12/2025 at 9:00 a.m. Resident #41 reported side rails were used to assist with turning and repositioning while in bed. During an interview on 05/15/2025 at 9:00 a.m. S4 RN (Registered Nurse)/Director Quality and Compliance reviewed care plans for Resident 9 and Resident #41 and confirmed Resident # 9 and #41 did not have a focus on bed rails with appropriate approaches. During an interview on 05/15/2025 at 9:15 a.m. S1 Administrator reported Resident #9 and Resident #41's care plan did not have a focus on bed rails with appropriate approaches. Resident #24 Review of Resident #24's medical record revealed an admit date of 01/16/2023 with diagnoses that included, in part, hemiplegia following cerebral infarction affecting right dominate side, hemiplegia following cerebral infarction affecting left non-dominate side, gastrostomy status, dysphagia following cerebral infarction, other complications of gastrostomy, and gastroparesis. Review of Resident #24's May 2025 Physician Orders revealed an order dated 12/05/2024 for weekly weights on Wednesday via arm circumference: use conversion table and enter weight every week. Review of Resident #24's April 2025 and May 2025 MARs (Medication Administration Records) failed to reveal documentation of weekly weights as ordered. Review of Resident #24's EHR (Electronic Health Record) Weight Log failed to reveal documentation of weekly weights as ordered. During an interview on 05/13/2025 at 1:35 p.m. S6 LPN (Licensed Practical Nurse) reviewed Resident #24's April 2025 and May 2025 MARs and acknowledged there was no documentation of weekly weights as ordered. S6 LPN reviewed Resident #24's EHR Weight Log and acknowledged there was not documentation of weekly weights as ordered. S6 LPN reported she documented N/A (not applicable) in Resident #24 weight area when she documented because she just learned of the arm circumference conversion table yesterday. During an interview on 05/13/2025 at 2:45 p.m. S2 DON (Director of Nursing) reviewed Resident #24's record and reported weekly weights should be documented on Resident #24's MAR via arm circumference using the conversion table. S2 DON provided a copy of the conversion table utilized in converting arm circumference to pounds for weights. S2 DON reviewed Resident #24's April 2025 and May 2025 MARs and acknowledged there was no documentation of weekly weights as ordered.

Based on record reviews, observation and interviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#6) of 2 (#6, #24) residents reviewed for pressure ulcers. The facility failed to identify, assess, and treat pressure wounds for Resident #6. Findings: Review of Resident #6's medical records revealed an admit date of 10/02/2020 with the following diagnoses, including in part: moderate protein-calorie malnutrition, muscle wasting and atrophy multiple sites, Alzheimer's disease unspecified, neuromuscular dysfunction of bladder unspecified and cognitive communication deficit. Review of Resident #6's Comprehensive Care Plan revealed problems and approaches for: at increased risk for pressure ulcer - investigate causes of injury/bruise/skin tear, treatment as ordered .has fragile skin with history of prone to bruising and/or skin tear - assess new areas for size and injury .Further review failed to reveal current wounds on right foot and right heel with treatment and interventions noted. Review of Resident #6's Physician's Orders revealed an order dated 12/14/2022 for weekly skin assessment on Thursday. Review of Resident #6's Medication Administration Record/Treatment Administration Record failed to reveal skin assessments were completed weekly since January 2025. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated 05/09/2025 revealed a total score of 12 (if score is 18 or less, consider him/her high risk for pressure ulcer development). Review of Resident #6's Skin Evaluation Records revealed no assessments were completed since January 2025 indicating if skin was intact or not intact. Further review failed to reveal documentation of two black areas to right foot and right heel. Review of Resident #6's Skin Evaluation Form dated 05/14/2025 following S3 ADON (Assistant Director of Nursing) becoming aware of wounds revealed: Pressure injury to right bunion area, length 2cm (centimeter) x width 2cm, necrotic/eschar, no exudate, deep tissue injury. Pressure area to right outer heel, length 2cm x width 2.5cm, necrotic/eschar, no exudate. Review of Resident #6's ID (Interdisciplinary) Notes revealed the following entries: 05/08/2025 1230 - . black spots found on right foot .informed S7 NP (Nurse Practitioner) of right foot . 05/09/2025 0800 - .2 black areas noted on right foot. 1 near great toe and the other on the heel. Both blackened areas approx. ½ inch in diameter. No redness, edema or drainage noted Review of Resident #6's S7 NP Progress Notes failed to reveal documentation about wounds to right foot and right heel. During an interview on 05/14/2025 at 8:05 a.m. S6 LPN (Licensed Practical Nurse) reported she did not know Resident #6 had a wound on her right foot. During an interview on 05/14/2025 at 8:40 a.m. S3 ADON reported there were no wound assessments for Resident #6 because she had no wounds. S3 ADON further reported no one had notified her Resident #6 had wounds on her right foot and right heel. S3 ADON reported the nurses complete the weekly skin assessments. Observation on 05/14/2025 at 8:45 a.m. accompanied by S3 ADON revealed Resident #6's right foot with a half dollar sized blackened area surrounded by a 1/2 inch reddened area on the ball of the foot below the great toe. Further observation revealed a half dollar sized blackened area on the bottom right of the heel. During an interview on 05/14/2025 at 9:00 a.m. S7 NP reported she remembered being notified about Resident #6's wounds. During an interview on 05/14/2025 at 10:20 a.m. S3 ADON acknowledged the weekly skin assessments were not completed by the nurse since January 2025. S3 ADON further confirmed there should be documentation indicating if the skin was intact or not intact.

Based on record reviews and interviews, the facility failed to ensure equipment was in safe operating condition. The facility failed to perform glucometer control checks for 2 Households (X and Z) according to the facility's policy and procedures.This deficiency has the potential to effect 6 residents (#74, #43, #5, #31, #7, #41) residing in Household X and 3 residents (#14, #21, #346) residing in Household Z. Findings: Household X Review of Facility's Glucometer-Disinfecting and Quality Control Procedures Policy with an effective date of November 1, 2019 revealed: Policy and Purpose - To ensure proper disinfection and operation of glucometers in use by facility staff. Procedure: 3. At a minimum quality control checks on the glucometer will be performed daily. Results of quality control checks will be recorded on the glucometer log. Review of Facility's Blood Glucose Monitoring System Daily Quality Control Record for Household X failed to reveal glucometer controls were checked during the month of May 2025. During an interview on 05/14/2025 at 10:20 a.m. S8LPN (Licensed Practical Nurse) acknowledged the glucometer controls for Household X were not checked for the month of May 2025 and from April 19 through 22nd 2025. During an interview on 05/14/2025 at 2:30 p.m. S2 DON (Director of Nursing) acknowledged she was unable to produce documentation a Blood Glucose Monitoring System Daily Quality Control Record for Household X was completed for May 2025. Household Z Review of Facility's Blood Glucose Monitoring System Daily Quality Control Record for Household Z failed to reveal glucometer controls were checked from May 1 through 8th 2025. During an interview on 05/14/2025 at 3:25 p.m. S3 ADON (Assistant Director of Nursing) acknowledged the Blood Glucose Monitoring System Daily Quality Control Record for for Household Z failed to reveal glucometer controls were checked from May 1 through 8th 2025.

Based on record review, observations, and interviews the facility failed to provide respiratory care consistent with professional standards for 1 (#72) of 1 resident reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer mask and tubing were labeled, dated and stored properly when not in use, and failed to develop a care plan for respiratory treatments with appropriate approaches. Findings: Review of Facility's Policy on Administering Medications through a small volume (handheld) nebulizer with a revision date October 2010 revealed: Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Preparation: 2. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Steps in Procedure: 29. when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days, or according to facility protocol. Review of Resident #72's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 15 indicating cognition intact. Further review of Resident #72's MDS revealed the following active diagnoses but not limited to: debility, cardiorespiratory conditions, heart failure, hypertension, anxiety disorder, atherosclerotic heart disease, and bradycardia. Review of Resident #72's May 2025 Physician Orders dated 05/02/2025 revealed Albuterol sulfate 2.5 mg (milligram)/3 ml (milliliters) (0.083%) solution for nebulization; 1 vial inhalation every 4 hours as needed for wheezing if ineffective times two consecutive doses notify physician. Review of Resident #72's Care Plan failed to reveal a care plan for nebulizer treatments. Observation on 05/12/2025 at 9:30 a.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. Observation on 05/12/2025 at 4:06 p.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. Observation on 05/13/2025 at 8:40 a.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. Observation on 05/14/2025 at 8:45 a.m. revealed nebulizer and unlabeled/undated mask and tubing on Resident #72's bed side not stored in a plastic storage bag. During an interview on 05/14/2025 at 8:45 a.m. S8 LPN (Licensed Practical Nurse) reported Resident #72's nebulizer mask and tubing for the breathing treatments should have been labeled, dated and stored in a plastic bag and was not. During an interview on 5/14/2025 at 9:20 a.m. S2 DON (Director of Nursing) reported when resident's nebulizer mask and tubing was not in use the nebulizer mask and tubing should be labeled, dated and stored in a zip lock bag. During an interview on 05/14/2025 at 10:54 a.m. S1 Administrator reviewed Resident #72's care plan and confirmed Resident #72 was not care planned for nebulizer treatments.

Based on observations, record reviews, and interviews the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#30, #52, and #78) of 5 (#9, #30, #41, #52, and #78) residents reviewed for restraints. The facility failed to ensure: 1) Consent was obtained for the use of a gerichair with lap tray for Resident #30; 2) The facility failed to have documented evidence of monitoring of resident condition when lap trays were in use for Resident #30 and Resident #78; 3) Resident care plans were developed with problems and approaches related to the use of a gerichair with lap tray for Resident #30 and Resident #78 and; 4) Quarterly restraint assessments were conducted for the use of bed and chair alarms for Resident #52. Findings: Review of the facility's Physical Restraints policy dated reviewed/revised July 2024 revealed in part: Policy and Purpose: The facility is committed to maintaining a restraint-free environment. Physical restraints will only be used to treat a resident's medical symptoms and only after other alternatives have been tried unsuccessfully. In such circumstances that a physical restraint is indicated for treatment of medical symptoms, the facility will use the least restrictive alternative for the least amount of time necessary, and the on-going need for restraints will be documented. Restraints will never be used for discipline, staff convenience or solely for prevention of falls. Procedure: 1. Physical restraints are defined as any manual method or physical or mechanical device, equipment or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his or her body. 2. The definition of a restraint is based on the cognitive functional status of the resident and not the intent of the device. If the resident cannot intentionally remove the device in the same manner in which staff applied it given the resident's cognitive or physical condition, and this restricts his/her typical ability to change position or place, the device is considered a restraint. 8. Consent of the resident and/or resident representative is required . 10. Physical restraints should be used for the shortest duration indicated. Restraint use should be re-evaluated at least quarterly or upon significant change. Evaluations should address the medical symptoms, documentation of benefit versus risk to any physical or psychosocial impacts of restraint use present during the resident's evaluation, recommendations for least restrictive interventions, and recommendations for continuation of restraint use. Evaluations are to be completed by a licensed nurse. 14. Specific direct monitoring and supervision will be documented during the use of the restraint. Documentation will include (no inclusions were in the policy after this statement). 17. Position change alarms may be used initially as the least restrictive measure to reduce fall risk. 18. Use of alarm requires documentation of an identified medical symptom requiring treatment by a licensed nurse. 19. The goal of position change alarms may be, but are not limited to, determine the frequency of unassisted attempts to rise, determine a pattern of unassisted mobility placing a resident at risk, or alert staff of prolonged attempts to rise unassisted in the absence of safety awareness. Alarm use is intended to be short term until the least restrictive fall prevention measures can be identified. 20. Alarm use should be reassessed at minimum of quarterly. Alarm use should be reassessed immediately when resident meets potential criteria for alarm to be discontinued. 21. Position change alarms are any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clipped to a resident's clothing, self release seatbelt alarms, and infrared beam motion detectors . Further Review of the facility's Physical Restraints policy revealed additional policy titled Use of Restraints dated April 2017 (from ____, Inc.) which revealed in part: 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, gerichairs, and lap cushions and trays that the resident cannot remove. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative . 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. e. Restrained residents must be repositioned at least every two (2) hours on all shifts. 16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. 19. Documentation regarding the use of restraints shall include: f. observation, range of motion and repositioning flow sheets. During an interview on 05/14/2025 at 9:23 a.m. S1 Administrator reported the facility utilized _____, Inc. for nursing policies from Nursing Services Policy and Procedure Manual for Long-Term Care. S1 Administrator reported the facility's policy regarding restraints included both the Physical Restraints policy and the Use of Restraints Med-Pass Policy. S1 Administrator reported both components were the facility policy. Resident #30 Review of Resident #30's medical records revealed an admit date of 12/21/2021 with the following diagnoses, including in part: Alzheimer's disease with late onset, wandering in diseases classified elsewhere, unspecified dementia moderate with mood disturbance, weakness, unsteadiness on feet, and muscle weakness (generalized). Review of Resident #30's Physician's Orders revealed an order dated 11/07/2024 for gerichair with lap tray when out of bed; medical symptom (s) poor trunk support, impaired gait and balance, impulsive, cognitive deficit, lack of judgement, lap tray for activities and meal times. Review of Resident #30's Comprehensive Care Plan failed to reveal a problem and approach for gerichair with lap tray. Review of Resident #30's medical record failed to reveal a consent for lap tray. Review of Resident #30's medical record failed to reveal monitoring of lap tray use. Observation on 05/13/2025 at 2:15 p.m. revealed Resident #30 sitting upright in common area in a gerichair with lap tray in place. Further observation revealed lap tray with nothing on it. Observation on 05/14/2025 at 10:10 a.m. revealed Resident #30 sitting up in gerichair with lap tray in place in common area in front of tray. Further observation revealed lap tray with nothing on it. During an interview on 05/14/2025 at 1:10 p.m. S4 RN (Registered Nurse)/Director of Quality and Compliance reported the facility did not use restraints, no resident devices were classified as restraints. S4 RN/Director of Quality and Compliance reported if a resident has a lap tray with nothing on it, the lap tray should not be in place. S4 RN/Director of Quality and Compliance further reported a lap tray is placed on a gerichair for activities and meals only. Observation on 05/14/2025 at 1:20 p.m. revealed Resident #30 sitting up in gerichair with lap tray in place in common area. Further observation revealed lap tray with nothing on it. During an interview on 05/14/2025 at 1:50 p.m. S1 Administrator reported residents should not have lap trays on unless they are receiving meals or having activities. Administrator further reported if there is nothing on the lap tray, the tray should not be in place. During an interview on 05/14/2025 at 2:20 p.m. S6 LPN (Licensed Practical Nurse) reported Resident #30 had the lap tray on because she would jump up out of the chair. S6 LPN further reported the staff will remove the tray at certain times but there is no documentation of the monitoring of the lap tray. During an interview on 05/14/2025 at 3:30 p.m. S4 RN/Director of Quality and Compliance acknowledged Resident #30 did not have an informed consent for a lap tray and should have. Resident #52 Review of Resident #52's medical record revealed an admit date of 03/02/2022 with diagnoses that included in part congestive heart failure, chronic respiratory failure, idiopathic gout, paroxysmal atrial fibrillation, generalized muscle weakness, and unsteadiness on feet. Review of Resident #52's May 2025 Physician Orders included the following orders dated 09/03/2024: -Bed alarm when in bed every shift-staff to ensure it is on and working properly -Chair alarm when in recliner every shift-staff to ensure it is on and working properly Review of Resident #52's most recent MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #52 had a BIMS (Brief Interview for Mental Status) of 9 which indicated moderately impaired cognition. Further review of Resident #52's MDS revealed Resident #52 required one person extensive assistance with transfers. Review of Resident #52's medical record revealed documentation of a pre-restraining assessment dated [DATE] for use of bed and chair alarms. Further review of Resident #52's medical record failed to reveal further quarterly assessments for use of bed and chair alarms. Observation on 05/12/2025 at 9:25 a.m. revealed Resident #52 asleep in his bed with bed alarm noted to bed. Observation on 05/12/2025 at 3:09 p.m. revealed Resident #52 sitting in his wheelchair next to his bed with bed alarm noted to Resident #52 bed. During an interview on 05/14/2025 at 3:57 p.m. S4 RN/Director of Quality and Compliance reviewed Resident #52's record and acknowledged there was no documentation of further quarterly assessments for use of bed and chair alarms after the pre-restraining assessment dated [DATE]. Resident #78 Review of Resident #78's record revealed an admit date of 10/04/2024 with diagnoses including: Alzheimer's disease, dementia, cerebral infarction, generalized muscle weakness, repeated falls, other frontotemporal neurocognitive disorders, and epilepsy. Review of Resident #78's current physician orders revealed an order dated 01/17/2025 for a gerichair with lap tray when out of bed for impaired gait, impaired balance, impaired mobility, lack of coordination, impulsive poor judgement, and cognitive deficit. Review of Resident #78's most recently completed MDS assessment dated [DATE] revealed the resident's BIMS (Brief Interview for Mental Status) was not completed due the resident being rarely/never understood. Further review revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. Further review revealed the resident required extensive assistance with two-plus person physical assist for bed mobility, total dependence with one person assist for eating, total dependence with two-plus person assist for transfers and toileting. Review of Resident #78's comprehensive care plan revealed a problem related to falls with a nursing intervention initiated 10/14/2024 for gerichair with lap tray. Further review revealed no problems or approaches related to the use of the gerichair with lap tray per facility policy. Review of Resident #78's record failed to reveal documentation of the resident's condition during times the lap tray was in use. Observation on 05/12/2025 at 10:42 a.m. revealed Resident #78 seated in a gerichair in the day room of the facility's secure memory care unit with his feet elevated. There was a lap tray in place attached to the chair in front of Resident #78 with nothing on the tray. During an interview on 05/12/2025 at 10:42 a.m. S9 CNA (Certified Nursing Assistant) reported Resident #78 had the lap tray because he could scoot and would try to stand. S9 CNA further reported Resident #78 could not release the lap tray by himself. Observation on 05/13/2025 at 4:00 p.m. revealed Resident #78 awake, sitting upright in gerichair in the day room of the secure dementia care unit. Lap tray in place to front of chair with nothing on the tray. During an interview on 05/13/2025 at 4:00 p.m. S10 LPN reported the resident had a lap tray in use because they were getting ready for the evening meal and the meal would be placed on the lap tray for staff to feed the resident. Further indicated the lap tray was used to keep him from leaning too far forward when he was sitting upright in the chair. S10 LPN reported Resident #78 was unable to remove the lap tray by himself. During an interview on 05/14/2025 at 1:10 p.m. S4 RN/Director of Quality and Compliance reported the facility did not use restraints, no resident devices were classified as restraints. S4 RN/Director of Quality and Compliance reported if a resident has a lap tray with nothing on it, the lap tray should not be in place. S4 RN/Director of Quality and Compliance further reported a lap tray is placed on a gerichair for activities and meals only. During an interview on 05/14/2025 at 1:50 p.m. S1 Administrator reported residents should not have lap trays on unless they are receiving meals or having activities. Administrator further reported if there is nothing on the lap tray, the tray should not be in place. During an interview on 05/15/2025 at 10:15 a.m. S2 DON (Director of Nursing) reviewed Resident #78's care plan and confirmed there were no problems or approaches related to the use of the gerichair with lap tray, and she didn't know there should be.

Based on record review, observations and interviews the facility failed to ensure medications (inhalations vials) for nebulizer treatments were stored properly for 1 (#72) of 1 resident reviewed for respiratory. Findings: Review of Facility's Resident Rights Policy with a revision date of November 2016 revealed in part: Policy and Purpose: Each and every resident in this facility has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. To meet this requirement residents have rights guaranteed to them under State and Federal Law. Resident of the facility have the right to: Procedures: 24. Self-administer medications when the interdisciplinary team has determined this practice is clinically appropriate. Medications, including over-the-counter medications, should be provided to the nursing staff and are not to be stored in the resident's room unless the requirements are met. Review of Resident #72's May 2025 Physician Orders dated 05/02/2025 revealed Albuterol sulfate 2.5 mg (milligram)/3 ml (milliliters) (0.083%) solution for nebulization; 1 vial inhalation every 4 hours as needed for wheezing if ineffective times two consecutive doses notify physician. Review of Resident #72's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 15 out of 15 indicating cognition intact. Further review of Resident #72's MDS revealed the following active diagnoses but not limited to: debility, cardiorespiratory conditions, heart failure, hypertension, anxiety disorder, atherosclerotic heart disease, bradycardia. Observation on 05/12/2025 at 9:30 a.m. revealed Resident #72's nebulizer inhalant medication at bed side. Observation on 05/12/2025 at 4:06 p.m. revealed Resident #72's nebulizer inhalant medication at bed side. Observation on 05/13/2025 at 8:40 a.m. revealed Resident #72's nebulizer inhalant medication at bed side. Observation on 05/14/2025 at 8:45 a.m. revealed Resident #72's nebulizer inhalant medication at bed side. During an interview on 05/14/2025 at 9:20 a.m. S2 DON (Director of Nursing) reviewed Resident #72's medication self-administration assessment dated [DATE] form completed by S4 RN (Registered Nurse)/ Director of Quality of Compliance and confirmed Resident #72's nebulizer treatments were not ordered at the time of medication self-administration assessment and Resident #72 was not able to self-administer nebulizer treatments. S2 DON reported Resident #72's nebulizer treatments should not have been left at the bedside.

Based on record reviews and interviews the facility failed to ensure MDS (Minimum Data Set) assessments accurately reflected the resident's status for 1 (#24) of 20 (#3, #5, #6, #9, #19, #24, #26, #28, #30, #41, #51, #52, #58, #59, #72, #77, #78, #90, #94, #95) sampled residents reviewed. The facility failed to ensure for Resident #24's most recent MDS assessment dated [DATE] accurately reflected Resident #24's functional ability. Findings: Review of Resident #24's medical record revealed an admit date of 01/16/2023 with diagnoses that included, in part, hemiplegia following cerebral infarction affecting right dominate side, hemiplegia following cerebral infarction affecting left non-dominate side, and generalized muscle weakness. Review of Resident #24's May 2025 physician orders revealed an order dated 09/04/2024 for full range of motion performed to all extremities with morning and bedtime care for hemiplegia. Review of Resident #24's most recent MDS assessment dated [DATE] revealed no functional impairment in range of motion to bilateral upper and lower extremities. During an interview on 05/13/2025 at 2:38 p.m. S5 Medicare Nurse reported Resident #24 was paralyzed and unable to move her extremities. S5 Medicare Nurse reviewed Resident #24's record and acknowledged the MDS assessment on 02/18/2025 indicated Resident #24 had no functional range of motion impairment in bilateral upper and lower extremities and was not accurate.

Based on record review and interview, the facility failed to ensure residents' environment was as free of accident hazards as possible by failing to evaluate residents' fall risk and implement interventions to reduce fall risk for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses that included, in part, coronary artery disease, atherosclerotic heart disease of the native coronary artery without angina pectoris, unspecified anemia, hypertension, macular degeneration, hyperlipidemia, and major depressive disorder. Review of Resident #4's medical record revealed a Fall Risk Assessment had been conducted on 02/10/2025 with a total score of 23. The Fall Risk Assessment form indicated a score of 10 or more indicates a high risk for falls. Further review of Resident #4's medical record failed to reveal any Fall Risk Assessment had been conducted on admission or prior to the 02/10/2025 Fall Risk Assessment. Review of Incident Logs revealed Resident #4 had unwitnessed falls on 02/01/2025, 02/05/2025, 02/09/2025, and 02/10/2025. Review of Resident #4's Baseline Care Plan with start date of 01/31/2025 revealed Resident #4 had safety concerns of fall risk, skin impairment, infection with approaches that included only that Resident #4 needed a pressure reducing mattress and alarms were not applicable. No approaches in regard to fall risk were included in the Baseline Care Plan. During an interview on 02/12/2025 at 12:50 p.m. S2 DON (Director of Nursing) reviewed Resident #4's Baseline Care Plan and reported there were no interventions in regard to Resident #4's fall risk and should have been. During an interview on 02/12/2025 at 12:53 p.m. S3 ADON (Assistant Director of Nursing) reported a fall risk assessment had not been conducted for Resident #4 on admission and should have been. During an interview on 02/12/2025 at 1:15 p.m. S1 Administrator reviewed Resident #4's Baseline Care Plan and reported fall risk interventions should have been included for Resident #4's risk of falls and was not. S1 Administrator further reported a fall risk assessment should have been conducted on admission for Resident #4 who was at risk for falls.

Based on record reviews, observations and interview the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2 (#1, #3) of 3 sampled residents. The facility failed to ensure medications were administered for Resident's #1 and #3 in accordance with the physician's orders and /or within their liberalized medication time blocks. Findings: Review of the facility's Medication Administration Schedule Healthcare Policy and Procedures revealed in part, the following. Effective Date: 03/01/2012. Reviewed /Revised: 06/12/2023. Policy and Purpose: To administer medications and treatments in a liberalized manner in accordance with resident preferences. To facilitate medications compliance, schedule medical care around natural life patterns, and promote continued quality of life through honoring principals of natural awakenings and resident choice. Procedures: 1. Liberalized medication time blocks have been established. Liberalized Time Code Blocks: AM medications administered (7AM - 10:30AM) 7. Medications/treatments should be administered in accordance with physician's order and manufacturer specifications. Medications may be scheduled without regard to manufacturer recommendations based on resident preferences with MD (medical doctor) approval. Rationale must be documented in resident's clinical record. 8. Medication Administration is documented on the Medication Administration record. Each dose is documented as administered. 9. A physician's order for specified times supersedes any liberalized schedule.14. If the liberalized medication pass time blocks do not address medications with multiple dosing schedules, these medications will continue to be scheduled at specific times based on MD order and /or resident preference. Review of Resident #3's September 2024 MAR (Medication Administration Record) on 09/04/2024 at 9:30 a.m. failed to reveal morning medications had been initialed as being administered. Resident #1 Review of Resident #1's Physician's orders revealed the following medication orders were not administered between the liberalized hours of 7:00 a.m. and 10:30 a.m.: 08/28/2024 - Folic acid 1mg (milligram) tablet 1 tab by mouth once daily (given at 10:51 a.m.) 08/22/2024 - Vitamin C 500mg tablet by mouth once daily for wound healing (given at 10:55 am.) 08/22/2024 - Ferrous Sulfate 325mg tablet 1 tab by mouth once daily for iron deficiency (given at 10:54 a.m.) 08/14/2024 - Colace 100mg capsule 1 capsule by mouth twice daily (given at 10:54 a.m.) 08/14/2024 - Ventolin HFA (hydrofluoroalkane) 90 mcg (microgram)/actuation aerosol inhaler 2 puffs inhalation once daily (given at 10:51 a.m.) 08/14/2024 - Pantoprazole 40mg tablet delayed release 1 tab by mouth once daily (given at 10:51 a.m.) 08/14/2024 - Miralax 17 gram/dose oral powder 1 capful by mouth 3 times a week (given at 10:51 a.m.) 08/14/2024 - Asmanex HFA 100 mcg/actuation aerosol inhaler 1 inhalation once daily (given at 10:45 a.m.) 08/13/2024 -Memantine 10 mg tablet 1 tab by mouth twice daily (given at 10:51 a.m.) 08/13/2024 - Eliquis 2.5mg tablet 1 tab by mouth twice daily (given at 10:45 a.m.) 08/13/2024 - Dorzolamide 2% eye drops 1 drop right eye twice daily (given at 10:53 a.m.) 08/13/2024 - Cetirizine 10mg tablet 1 tab by mouth once daily (given at 10:51 a.m.) 08/13/2024 - Brimonidine 0.1% eye drops 1 drop right eye twice daily (given at 10:53 a.m.) Review of Resident #1's September 04, 2024 MAR revealed all morning medications with times to be administered at 07:00 a.m. were initialed being administered between 10:45 a.m. and 10:55 a.m. Resident #3 Review of Resident #3's September 2024 MAR on 09/04/2024 at 10:40 a.m. with S1 LPN (Licensed Practical Nurse) failed to reveal she had initialed Resident #1's morning medications had been administered. Review of Resident #3's September 2024 Physician's orders revealed the following orders: 08/28/2024 Lexapro 10 mg by mouth once daily. Times 7:00. 08/27/2024 Bupropion HCL XL 150 MG 24 hour tablet, extended release by mouth once a day. Times: 07:00. 08/23/2024 Hydralazine 50 mg tablet 1 tablet by mouth 3 times a day. Times 0700, 13:00, 19:00. 08/14/2024 Cranberry Concentrate 500 mg capsules by mouth once daily. Times 07:00. 06/19/2024 Prevacid Solutab 30 mg delayed release, disintegrating tablet by mouth once daily. Times 07:00. 06/29/2024 Losartan 100 mg tablet 1 tablet by mouth daily. Times 0700. 04/25/2024 Potassium chloride extended release 10 meq (milliquivalent) tablet extended release -1 tab by mouth once daily. Times 07:00. 04/26/2024 Furosemide 20 mg 1 tab by mouth once daily. Times 07:00. Review of Resident #3's September 04, 2024 MAR revealed all morning medications with times to be administered at 07:00 a.m. were initialed as not being administered until 11:17 a.m. Medications were not administered according to the physician's orders or within the facility's liberalized medication time blocks. During an interview on 9/04/2024 at 10:45 a.m. S1 LPN reported there was no set time to administer medications. S1 LPN acknowledged she had not administered Resident #3's morning medications and reported the facility had liberalized times to administer medications at any time.

Based on observations, interview and record review the facility failed to ensure 1 (#3) of 3 sampled resident's environment remains as free of accident hazards as possible. The facility failed to have Resident #3's fall mats in place as ordered to prevent injuries. Findings: Observation on 09/04/2024 at 9:00 a.m. revealed 1 fall mat positioned along the floor on the right side of Resident #3's bed. Observation on 09/04/2024 at 10:30 a.m. revealed 1 fall mat positioned along the floor on the right side of Resident #3's bed. During an interview on 09/04/2024 at 10:30 a.m. S2 CNA (Certified Nurse Assistant) reported there should have been 2 fall mats on the floor along each side of Resident #3's bed. Review of Resident #3's Physician's Orders revealed an order dated 08/31/2024 for a low bed with fall mats times 2 to be applied when in bed. Review of Resident #3's Medical Records revealed an admitted [DATE]. Diagnoses include Alzheimer's disease, impaired balance, impaired mobility, muscle weakness, essential hypertension, extrapyramidal and movement disorder unspecified. Review of Resident #3's Fall Risk assessment dated [DATE] revealed level of consciousness is disoriented times three at all times and a history of 3 or more falls. Further review revealed a total score of 18 which indicates resident is a high risk for falls. Review of Resident #3's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 3 which indicates severe cognitive impairment. Further review revealed resident requires one person physical assist with bed mobility, transfers, eating, and toilet use. Review of Resident #3's Care Plan revealed risk factors that require monitoring and interventions to reduce potential for self-injury for falls. Further review revealed approaches are resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors through next review decreasing fall or fall risk to resident.

Based on record review and interview, the facility to ensure each resident received treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care for 1 (Resident #359) of 9 (Residents # 2, #25, #44, #57, #73, #74, #94, #105, and #359) residents reviewed for the use of diuretic medications. The deficient practice resulted in an Immediate Jeopardy for Resident #359 on 6/21/2019 when the resident experienced shortness of breath and did not feel or look well. When the ADON and S9NP were assessing the resident, a review of the information in a folder at the resident's bedside revealed [MEDICATION NAME] 2.5 mg was being incorrectly administered to the resident and that the resident had lost 23 pounds in 10 days. From 6/12/2019 through 6/20/2019, the resident received [MEDICATION NAME] 2.5 mg daily instead of [MEDICATION NAME] 2.5 mg every Monday, Wednesday and Friday as ordered by the physician. On 06/21/19, an order was given by S9NP to administer Normal Saline at 75 cc (cubic centimeters)/hour IV (intravenously) for a total of 500 cc to the resident; however, the IV fluids were never administered to the resident. On 6/24/2019, Resident #359 was sent to the ER (emergency room ) with shortness of breath, shallow respirations, generalized weakness, and abdominal pain. Review of the hospital discharge records revealed that on admit to the hospital on [DATE] at 2:42 am, Resident #359 had a potassium level of 7.5, a BUN (blood urea nitrogen) of 122, and a creatinine level of 5.39. Resident #359 was admitted for acute [MEDICAL CONDITIONS], metabolic acidosis, and shock. On 7/24/2019 at 3:40 pm, S4 Administrator was notified of the Immediate Jeopardy Situation. The Immediate Jeopardy ended 7/26/2019 at 10:40 am when an acceptable plan of removal was presented. The facility's plan of removal included the following: The facility educated and trained their nursing staff on transcribing physician orders [REDACTED]. A policy was developed on 07/25/19 implementing 24 hour chart checks to ensure all new orders are verified and carried out as directed. A policy was implemented effective 07/25/19 which included the required steps if unable to access to successfully place an IV. A policy was implemented on 07/25/19 for weight assessment and intervention. This policy states that weight variances will be reviewed by the household nurse daily who will report those outside of the physician's parameters to the Director of Nurses. Findings: Review of Resident #359's clinical records revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #359's Physician order [REDACTED]. 5/13/2019-[MEDICATION NAME] 40 mg one tablet by mouth twice daily - [MEDICAL CONDITION] Check 0, 1+, 2+, 3+. If 3+ (plus), times 2 consecutive checks call MD (medical doctor). Stop date 6/24/2019. 6/6/2019-Daily weights 6/11/2019 at 2:30 pm begin [MEDICATION NAME] generic ([MEDICATION NAME]) 2.5 mg (milligrams) 1 tablet 30 minutes before am [MEDICATION NAME] Monday, Wednesday and Friday. 6/21/2019- 1. KCL (potassium chloride) 40 meq (milliequivalents) by mouth now, then 40 meq in 4 hours 2. Hold [MEDICATION NAME] times 2 days 3. NS IV at 75ml/hour x 500ml, then d/c 4. In am, KCL 40 meq by mouth bid (twice a day) 5. Repeat RP (renal panel) Sunday morning Review of Resident #359's MDS (Minimum Data Set) dated 6/9/2019 revealed in part, Section C- Cognitive Patterns/BIMS (Brief Interview for Mental Status) Score of 4 which indicated severe cognitive impairment and Section N - Medications received were an anticoagulant times 7 days, an antibiotic times 2 days, and a diuretic times 7 days. Review of S10 LPN change in condition documentation dated 6/20/2019 at 7:49 pm revealed a late entry reflecting at 10:00 am writer was administering med pass this morning and noted Resident #359 having shortness of breath and decreased oxygen saturation below 90 % on RA (room air). Resident #359 stated she was ok, resident noted with 1+ [MEDICAL CONDITION] to bilateral lower extremities. Writer administered as needed oxygen at 2 L/min via NC (nasal cannula). Oxygen saturation level elevated to 95% with no labored breathing noted. Resident #359 was assisted into recliner chair by writer to elevate bilateral lower extremities. No complaints of pain noted. Writer notified NP of resident's change in condition with new orders given to hold evening [MEDICATION NAME] dose and hold [MEDICATION NAME] 2.5 mg (generic diuretic for [MEDICATION NAME]) in the am until Monday, Renal panel lab to be drawn in the am. Review of S6 ADON nurses notes dated 6/20/19 at 4:55 pm documented occupational therapy informed writer that she was concerned about Resident #359 because she was so short of breath and complained of feeling bad in therapy. She asked if writer would assess the resident, writer went to resident's room to assess her, lung fields which were clear to auscultation, murmur noted (not new), and bilateral ankles with 2+ [MEDICAL CONDITION] but this is improved from previous [MEDICAL CONDITION] checks. Writer notified S9 NP of resident's condition and we went to resident's room for her to assess her. Upon reading Dr. ________ (cardiologist) notes in her folder from her visit at his office, it was also noted that she had an order for [REDACTED]. We investigated more and found that Resident #359 had been getting [MEDICATION NAME] 2.5 mg (generic diuretic for [MEDICATION NAME]) every day since 6/12/19. S9 NP notified the cardiologist's office of the medication error. The order was corrected in the computer and S9 NP wrote an order to hold [MEDICATION NAME] 2.5 mg (generic diuretic for [MEDICATION NAME]) in am and also hold resident's evening dose of [MEDICATION NAME] tonight. CMP order placed for tomorrow am to check kidney function. Dr________to see resident tomorrow during rounds. Review of S9 NP Progress Notes for Resident #359 dated 6/20/2019 revealed the following documentation in part: [DIAGNOSES REDACTED].>Fluid volume deficit - suspect likely causing nausea. Tolerating diuretic dosing decrease. RP (renal profile) not done, will order for am. Continue current P[NAME]. [MEDICAL CONDITION] stage 3, baseline Creatinine 1.4, RP in am. [DIAGNOSES REDACTED] Fib -rate controlled. Continue current therapy. Epistasis- resolved. Continue to monitor further symptoms. Review of resident #359's lab results dated 6/21/2019 revealed the following: Potassium - 2.7 Ref. Range 3.5 -5.1 mmol/l BUN - 98 Ref. Range 7 - 25 mg/dl Creatinine - 3.5 Ref. range 0.6 - 1.2 mg/dl Review of S9 NP Progress Notes dated 6/21/2019 for Resident #359 revealed the following: ARF (acute [MEDICAL CONDITION]) or CKD 3(chronic kidney) likely ATN (acute tubular necrosis). Recommended hospitalization but patient refuses. Will begin IVF NS @ 75cc/hr. x 500 cc then dc. Hold [MEDICATION NAME] x 2days, RP 6/23/19. [DIAGNOSES REDACTED] - acute KCL 40 meq po now and again in 4 hours. In am begin KCL40 meq po bid. [MEDICAL CONDITION]- stable. Cautions fluids, avoid salt with meals tomorrow. Plan: Discussed with _______ NP and Dr. _________. Patient refuses to go to the hospital this evening. Family notified by ADON. Review of S11 LPN daily nursing notes dated 6/21/2019 at 4:48 pm documented received a call from lab with critical BUN of 98. S9 NP notified. Review of S1 DON nurse's note dated 6/21/2019 at 6:35 pm documented received new order from S9 NP for 1 KCL 40 meq PO Now and then again in 4 hours. Hold [MEDICATION NAME] X 2 days. NS IVF at 75 ml/hr. x 500 ml then d/c. in am begin KCL 40 meq PO BID. RP (renal panel) on Sunday and call results in to S9 NP. Review of S1 DON daily nursing notes dated 6/21/2019 at 6:43 pm documented writer called RP (responsible party) to report resident's condition. No answer. Left voicemail to call facility. Review of S11 LPN daily nursing notes dated 6/22/2019 at10:22 am documented: 7 am: Resident #359 had not had any fluids per IV due to unable to get site flushed on night shift. [MEDICATION NAME] Lock in place without tenderness or discomfort noted. First B/P taken 88/43. Fluids encouraged and taken well. Med given and taken well. B/P med and [MEDICATION NAME] held. 9 am: Resident had been encouraged to continue drinking. Notified NP of resident condition. Blood pressure at that time 98/60. Review of S11 LPN daily nursing notes dated 6/23/2019 at 12:40 pm documented Resident #359 alert and c/o (complained of) back pain with prn given. IV started by weekend RN on duty. NS @ 75cc/hr. started and site flushed well. PRN given by mouth for c/o pain. Resident #359 stated she was not hungry for lunch but would attempt to eat. Resident ate a few bites and threw it up. PO (by mouth) fluids encouraged and tolerated well. Will continue to monitor. Repeat RP scheduled for am. Review of S1 DON's change in condition notes dated 6/24/2019 at 11:16 am documented writer received report from LPN regarding resident being transferred to ER at around midnight. Resident complained of shortness of breath, shallow respirations, generalized weakness and abdominal pain 7/10. A review of the hospital records revealed Resident #359 was admitted to the hospital on [DATE] at 2:42 am after presenting with shock thought to be secondary to hypovolemia and cardiogenic shock. Resident #359's emergency department notes revealed a potassium level of 7.5, a BUN of 122, and a creatinine level of 5.39. It further stated the resident had acute kidney injury probably. The patient, despite maximal medical treatment, succumbed to her disease and passed away on 07/02/19, which was thought to be secondary to cardiogenic shock with associated [MEDICAL CONDITION]. Review of Resident #359's (MONTH) 2019 MAR (Medication Administration Record) revealed the facility's nurses documented [MEDICATION NAME] 2.5 mg was administered daily from (MONTH) 12, 2019 through (MONTH) 20, 2019. A further review of Resident #359's (MONTH) 2019 MAR (medication administration records) failed to reveal any documentation Normal Saline 0.9% 1000 ml bag 500 ml IV at 75ml/hr. had been administered. Review of (MONTH) 2019's MAR indicated [REDACTED]. June 12, 2019 weight 161 lbs. (pounds), June 14, 2019 weight 159 lbs. June 15, 2019 weight 162.4 lbs. June 16, 2019 weight 154.8 lbs. June 17, 2019 weight 152.4 lbs. June 18, 2019 weight 151.6 lbs. June 19, 2019 weight 150.0 lbs. June 20, 2019 weight 148.8 lbs. During an interview on 7/24/19 at 1:30 pm, S6 ADON stated on Thursday (MONTH) 20, 2019 an occupational therapist asked if she would assess Resident #359 because she did not look good, had shortness of breath and did not feel good. S6 ADON stated Resident #359 was short of breath and her lung sounds were clear to auscultation. She stated Resident #359 looked like she did not feel good. S6 ADON stated since S9 NP (Nurse Practitioner) was coming to the facility to see other residents, she asked her to assess Resident #359. S6 ADON said Resident #359 had been receiving [MEDICATION NAME] before she was seen by her Cardiologist 10 to 11 days before and he ordered another diuretic ([MEDICATION NAME]). She stated there was a red folder in Resident #359's room from her Cardiologist where she was keeping up with her own weights. She stated on the folder there was a sticky note with [MEDICATION NAME] generic ([MEDICATION NAME]) 2.5 mg to be given on Monday, Wednesday, and Friday. S6 ADON stated once she and the NP saw this note, she and S9 NP checked Resident #359's paper chart against the computer orders. S9 ADON stated this is when they discovered Resident #359 had been receiving [MEDICATION NAME] generic ([MEDICATION NAME]) 2.5 mg every day from 6/12/2019 thru 6/20/2019 instead of three times per week on Monday, Wednesday and Friday, as ordered. S6 ADON stated Resident #359 had lost 23 pounds in 10 days. S6 ADON stated she phoned Resident #359's Cardiologist and her physician Dr. _____ to report the medication error. S6 ADON stated Resident #359 refused to go to the hospital to be treated so her physician and her Cardiologist felt like she could be treated at the facility. S6 ADON stated she and the S1DON phoned Resident #359's RP (responsible party) to report what was going on. She stated they left a message and no one ever called back. During an interview on 7/24/2019 at 2:15 pm S1 DON stated on 6/20/2019 after she found out about the incident she started her investigation of what went wrong. S1 DON stated this is a new computer system and does not have a warning when a medication is entered incorrectly. She stated it has always been her policy that she is to get a copy of any physician's orders [REDACTED]. She stated this order was written on a progress note and the nurse that received the order did not give her a copy of it. S1 DON stated she does not have a written policy. S1 DON stated she was never notified the IV could not be started. S1 DON stated S8 LPN is the nurse that entered the medication in the computer. S1 DON stated S8 LPN was on vacation and unavailble for interview during the survey. During an interview on 7/25/2019 at 10:23 am, S9 NP stated she was asked to see Resident #359 on 6/17/2019 by S6 ADON because she was having nausea and vomiting. S9 NP stated resident #359 had a 15 pound weight loss in a quick amount of time. She stated Resident #359 looked very weak and dry. S9 NP stated, on 06/20/19, she and the ADON looked at Resident #359's paper chart. S9 NP stated Resident #359 had been seen by the Cardiologist 2 to 3 weeks ago and he wanted her to have the [MEDICATION NAME] 3 times a week. She stated they phoned the Cardiologist and he felt Resident #359 was dehydrated so they decided to pull the diuretic, her blood pressure was 110/72 and pulse 72. She stated they were a little hesitant about the IV fluids so they decide to hydrate her by mouth. S9 NP stated Resident #359 got a renal profile on 6/19/2019 or 6/20/2019 and that she saw Resident #359 on 6/21/2019. When S9NP saw the resident on 6/21/2019, the resident's potassium was down and her BUN and creatinine were elevated. S9 NP stated she and S6 ADON went in and tried to get Resident #359 to go to the hospital and she refused. S9 NP stated they held the [MEDICATION NAME] and repeated the lab on Sunday. S9 NP stated she did not see Resident #359 after 6/21/2019. During an interview on 7/24/2019 at 1:30 pm, S6 ADON (Assistant Director of Nursing) confirmed Resident #359 never received the IV fluids that were ordered. S6 ADON acknowledged Resident #359 never had IV access that worked and the IV fluids were never administered, although it had been documented. During an interview on 7/25/19 at 3:00 pm S1 DON confirmed she had not done any training with her staff on what to do if a resident has significant weight loss, if the facility is unable to get in touch with a resident's responsible party, and/or if the nursing staff is unable to obtain an IV access on a resident. S1 DON stated she and nursing administration were responsible for monitoring resident weights. S1 DON stated residents were not assigned to specific staff members for monitoring and the facility did not have a process in place to ensure resident weights were monitored. S1 DON could not verify Resident #359's weight loss was reviewed and acted upon. S1 DON further stated Resident #359's family was not notified of the resident's refusal to go to the hospital, and she acknowledged Resident #359's BIMS score was 4 and the resident had recently had a UTI with confusion. S1 DON stated Resident #359 should have been sent to the ER when the facility was unable to administer IV fluids. During an interview on 07/26/19 at 10:40 am, S4 Administrator stated the facility did not have a policy for 24 hour chart reviews and had no policy addressing undesirable resident weights. S4 Administrator stated they do have a policy for IV administration but it was not followed by staff.

Based on facility policy review and interviews the facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #359) of 9 (Residents # 2, #25, #44, #57, #73, #74, #94, #105, and #359) residents. The facility failed to ensure policies and procedures were in place to ensure operations of the facility met the needs of all their residents. The facility failed to have policies and procedures in place to govern the following: 1. 24 hour chart audits to ensure physician's orders [REDACTED]. 2. A procedure to prevent, monitor and intervene for residents with undesirable weights loss, and 3. An IV (intravenous) administration policy with steps to take if unable to access an IV site. The deficient practice resulted in an Immediate Jeopardy for Resident #359 on 6/21/2019 when the resident experienced shortness of breath and did not feel or look well. When the ADON and S9NP were assessing the resident, a review of the information in a folder at the resident's bedside revealed [MEDICATION NAME] 2.5 mg was being incorrectly administered to the resident and that the resident had lost 23 pounds in 10 days. From 6/12/2019 through 6/20/2019, the resident received [MEDICATION NAME] 2.5 mg daily instead of [MEDICATION NAME] 2.5 mg every Monday, Wednesday and Friday as ordered by the physician. On 06/21/19, an order was given by S9NP to administer Normal Saline at 75 cc (cubic centimeters)/hour IV (intravenously) for a total of 500 cc to the resident; however, the IV fluids were never administered to the resident. On 6/24/2019, Resident #359 was sent to the ER (emergency room ) with shortness of breath, shallow respirations, generalized weakness, and abdominal pain. Review of the hospital discharge records revealed that on admit to the hospital on [DATE] at 2:42 am, Resident #359 had a potassium level of 7.5, a BUN (blood urea nitrogen) of 122, and a creatinine level of 5.39. Resident #359 was admitted for acute [MEDICAL CONDITIONS], metabolic acidosis, and shock. On 7/24/2019 at 3:40 pm, S4 Administrator was notified of the Immediate Jeopardy Situation. The Immediate Jeopardy ended 7/26/2019 at 10:40 am when an acceptable plan of removal was presented. The facility's plan of removal included the following: The facility educated and trained their nursing staff on transcribing physician orders [REDACTED]. A policy was developed on 07/25/19 implementing 24 hour chart checks to ensure all new orders are verified and carried out as directed. A policy was implemented effective 07/25/19 which included the required steps if unable to access to successfully place an IV. A policy was implemented on 07/25/19 for weight assessment and intervention. This policy states that weight variances will be reviewed by the household nurse daily who will report those outside of the physician's parameters to the Director of Nurses. Findings: Cross refer to findings at F684. During an interview on 7/24/2019 at 2:15 pm S1 DON stated on 6/20/2019 after she found out about the incident she started her investigation of what went wrong. S1 DON stated this is a new computer system and does not have a warning when a medication is entered incorrectly. She stated it has always been her policy that she is to get a copy of any physician's orders [REDACTED]. She stated this order was written on a progress note and the nurse that received the order did not give her a copy of it. S1 DON stated she does not have a written policy. S1 DON stated she was never notified the IV could not be started. S1 DON stated S8 LPN is the nurse that entered the medication in the computer. S1 DON stated S8 LPN was on vacation and unavailable for interview during the survey. During an interview on 7/25/19 at 3:00 pm S1 DON confirmed she had not done any training with her staff on what to do if a resident has significant weight loss, if the facility is unable to get in touch with a resident's responsible party, and/or if the nursing staff is unable to obtain an IV access on a resident. S1 DON stated she and nursing administration were responsible for monitoring resident weights. S1 DON stated residents were not assigned to specific staff members for monitoring and the facility did not have a process in place to ensure resident weights were monitored. S1 DON could not verify Resident #359's weight loss was reviewed and acted upon. S1 DON further stated Resident #359's family was not notified of the resident's refusal to go to the hospital, and she acknowledged Resident #359's BIMS score was 4 and the resident had recently had a UTI with confusion. S1 DON stated Resident #359 should have been sent to the ER when the facility was unable to administer IV fluids. During an interview on 7/26/2019 at 10:40 am S4 Administrator stated they did not have a policy for 24 hour chart review, and had no policy for what to do for undesirable weights. S4 Administrator stated they do have a policy for IV administration but no specific instructions on what to do if an IV site cannot be accessed.