Every finding on record at Washington Square Healthcare Center

Based on record review, hospital record review, review of email communication, policy review and interview, the facility failed to readmit Resident #69 during the appeal of a discharge notice. After issuing a discharge notice, the resident became distressed, made threats toward the Administrator, and was hospitalized for psychiatric evaluation. Once stabilized and cleared by hospital staff, the facility refused timely readmission and did not provide required documentation showing an inability to meet the resident's ongoing needs or a safe long-term discharge plan, leaving the resident without appropriate long-term placement. This affected one resident (#69) of three residents reviewed for discharge. The facility census was 68.Findings include:Review of the closed medical record revealed Resident #69 was admitted on [DATE] and discharged on 06/09/26. Resident #69 had diagnoses including heart failure, type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), hypertension, and post-traumatic-stress disorder (PTSD). Record review revealed the resident was admitted for long term placement from the Veteran's Affairs after facing eviction from his apartment because he was unable to care for the apartment and himself.Review of the physician's order dated 01/28/26 revealed to assess Resident #69 every shift for behaviors and record. Review of the care plan dated 04/05/26 revealed Resident #69 was resistive to care. Interventions included allowing the resident to make his own decisions and encourage participation in decision making.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had intact cognition. Resident #69 required extensive assistance for all activities of daily living.Review of a 30-Day discharge notice dated 06/08/26, signed by Resident #69, revealed the resident was given a discharge notice stating he would be discharged and transferred from the facility on or prior to 07/12/26 because the facility was unable to meet his care needs and he was a danger to others in the facility. The notice informed the resident of his right to an impartial hearing at the facility regarding the proposed discharge and transfer and how to request a hearing. Review of the Treatment Administration Record (TAR) for June 2026 revealed Resident #69 had no behaviors documented until 06/09/26.Review of the nursing progress note dated 06/09/26 at 10:30 A.M. revealed Resident #69 was seen by the psychiatrist and reported homicidal thoughts pertaining to shooting the Administrator after receiving a thirty-day notice for smoking. He stated he ordered a gun and had it sent to his cousin who was going to bring it. Resident #69 was given a pink slip to the emergency department for a psychiatric evaluation.Review of a psychiatric note dated 06/09/26 at 9:30 A.M. authored by Psychiatric Nurse Practitioner #701revealed Resident #69 was evaluated after staff reported escalating threats, including statements about obtaining a gun to harm the facility administrator. The note also included there were recent concerns included smoking in the room and making verbal threats over the weekend. During assessment, the patient was visibly agitated, expressed anger about a 35 day eviction notice, insisted on confronting the administrator, and made additional violent statements. The patient reported not feeling safe, was unable to agree to a safety plan, and displayed behavior that raised significant safety concerns for both the resident and others. Due to the severity of the threats and inability to contract for safety, an involuntary psychiatric hospitalization was initiated for emergency evaluation and stabilization. The note did not include any information related to the resident's ability to return to the facility following evaluation and if stabilization was achieved. Review of a thirty-day notice form dated 06/09/26 revealed Resident #69 was given an Immediate Discharge Notice, effective 06/09/26 because the resident poses a risk and is a danger to the residents and staff. The notice included at this time, the facility proposed to relocate the resident to the local hospital. The notice informed the resident of his right to an impartial hearing at the facility regarding the proposed discharge and transfer and how to request a hearing. The resident signed the form and wrote in June 10.Review of the Immediate Discharge Notice dated 06/09/26 revealed Resident #69 was given an Immediate Discharge Notice for the safety of staff and other residents in the facility.Review of the medical record revealed Resident #69 was transported to the emergency department on 06/09/26 after reporting homicidal ideation toward the Administrator following receipt of a thirty day discharge notice for smoking. The note included the resident was pink slipped for psychiatric evaluation.Review of the hospital transfer form dated 06/09/26 revealed Resident #69 was being sent to the hospital for homicidal ideations but on the assessment, it was marked the resident had no behavioral issues noted and no interventions completed.Review of the emergency room evaluation dated 06/09/26 for Resident #69 revealed the resident presented to the emergency department for psychiatric evaluation after being homicidal at his nursing home after receiving an eviction notice. Resident #69 denied homicidal ideations and stated, no comment when asked. Lab work showed an acute kidney injury. The resident was given a liter of normal saline and repeat lab work was ordered. The lab work did not show improvement, and a bladder scan was ordered which showed urinary retention. A Foley catheter was placed. Resident #69 was medically cleared on 06/12/26 and admitted to the psychiatric unit.Review of the psychiatric history and physical dated 06/12/26 revealed Resident #69 was admitted to the hospital after making homicidal threats at his nursing home. Resident #69 reported to the psychiatrist his girlfriend of 20 years passed away five weeks ago, and he was depressed. On examination, Resident #69 was tearful and said that he was grieving, and he wished the facility staff would just understand that. The resident reported he never actually wanted to hurt anyone. The resident denied access to guns.Review of a facility social service progress note dated 06/12/26 at 9:18 A.M. revealed she (the facility social worker) spoke with the social worker at the hospital and informed her Resident #69 would need to get his car from the facility parking lot. Review of a hospital social service note dated 06/12/26 at 3:26 P.M. authored by Hospital Licensed Social Worker (LSW) #702 revealed she spoke with administrative staff from the nursing home who said Resident #69 was not permitted to return to the facility. They stated they gave the resident an Immediate Discharge Notice and he signed the paper. Review of email communication dated 06/18/26 at 3:02 P.M. between Regional Administrator #581 and the Ombudsman #700 revealed the Regional Administrator was following up for the Administrator regarding the decision to issue an Immediate Discharge Notice to Resident #69.Review of an email dated 06/18/26 at 7:02 P.M. from Ombudsman #700 to Regional Administrator #581 revealed the Ombudsman she was not questioning the Immediate Discharge versus the 30-Day Discharge for the resident. Ombudsman #700 indicated the issue was that it was not a proper discharge. The hospital was listed as the location, which was not a discharge location. She informed Regional Administrator #581 that she had been in contact with Resident #69 and the hospital, and there had been no concerns related to the resident's behavior. The resident sought treatment and was ready to return. Ombudsman #700 suggested readmitting the resident and following the correct (discharge) process. The Ombudsman agree there was a safety issue that needed to be addressed, but currently, the resident's rights were being violated. She asked if the facility would take Resident #69 back.Review of an mail dated 06/18/26 at 7:42 P.M. from Regional Administrator #581 to Ombudsman #700 revealed they (the facility) were discussing and would get back to her as soon as possible. Review of an email dated 06/18/26 at 7:51 P.M. from Ombudsman #700 to Regional Administrator #581 revealed if the facility had not made a decision by the end of the day, she would schedule a hearing, but the hearing request could be rescinded in the event the resident returned.There were no follow-up emails provided. Review of hospital paperwork dated 06/19/26 revealed Resident #69 was calm, cooperative, and was brighter today, smiling more. He stated he was doing good and hoped he could return to the nursing home because he had friends there. He reported he made a statement that he was going to hurt someone in administration there but stated, I would never do anything. He stated he gets upset sometimes and says things he does not mean. He denied suicidal homicidal ideation intent or plan, denied auditory or visual hallucinations. The paperwork included the resident had been taking his medications, has had no behavioral disturbances, sleep and appetite reported to be fair.Review of hospital paperwork dated 06/24/26 revealed Resident #69 was calm and cooperative. He stated he was doing okay and just waiting to hear whether he would be able to go back to the nursing home. He stated he really hoped he was able to as he reported overall, he was doing well there and had friends. He denied suicidal homicidal ideation intent or plan, denied auditory or visual hallucinations. He had been taking his medications, had no behavioral disturbances, sleep and appetite reported to be fair. Review of a social service note dated 06/26/26 revealed the facility social worker only became aware on this date, two weeks after transfer, that Resident #69 had no safe discharge location (as the facility refused to allow him to return) and only then began assisting with referrals. On 06/29/26 at 10:10 A.M. interview with Ombudsman #700 revealed Resident #69 was known as a quiet older individual who used a scooter and had no prior history of violence, though the nursing home reported the resident threatened the administrator and referenced shooting him. The resident told her that he may have made the statement (about shooting) but does not clearly remember and believed he was only venting, adding that he had no weapons and would not act on such comments. The resident said he signed Immediate Discharge papers but was never given a 30 day discharge notice, despite the nursing home later claiming otherwise. The Ombudsman indicated they had received discharge paperwork that appeared inaccurate, with incorrect dates and a second page listing a different resident's name and stated that she was never properly notified by the facility of any discharge. She noted that a discharge hearing was scheduled for 07/01/26, and that the behavioral health hospital was attempting to keep the resident until the hearing, though she was uncertain whether they could legally do so, and the resident was very distressed by the situation.An interview 06/29/26 at 1:45 P.M., with Regional Clinical Director #580 revealed although the facility historically accepted residents with psychiatric conditions, the facility refused to readmit Resident #69 despite the hospital's determination that he was medically and psychiatrically stable. She reported the decision was based on the resident's earlier verbal statement about ordering a gun, although she acknowledged there was no verification of this information. She confirmed the facility would not accept the resident back.As of 06/30/26, Resident #69 remained hospitalized with no evidence he was receiving acute medical or psychological care due to the facility refusing to allow him to return, pending a discharge hearing or assisting with discharge to an appropriate agreed upon long term care location that met the resident's needs.Review of the facility's undated Resident Transfer and Discharge Policy revealed residents sent to an acute care setting shall be permitted to return to the facility unless documentation clearly shows why the facility can no longer care for the resident. The policy also stated the facility would ensure safe discharge planning.This deficiency represents non-compliance identified under Complaint Number 3052695.

Based on record review and interview, the facility failed to demonstrate effective leadership of the overall facility operations to ensure each resident attained/maintained their highest practicable physical, mental, and psychosocial well-being. This had the potential to affect all 74 residents residing in the facility.Findings include:Review of the job description for Registered Nurse (RN)/Assistant Director of Nursing (ADON) revealed it was signed by RN/ADON #663 on 05/08/25. The position summary included the nurse would assist the Director of Nursing with management and training of the nursing services staff and the overall management of resident care; be aware of and adhere to residents' bill of rights; be aware of resident abuse reporting law; demonstrate availability to be on call 24 hours a day for nursing emergencies; make rounds upon entering the building each day; and be responsible for ensuring that nursing staff were aware of their job descriptions and the facilities expectations for resident care. There was nothing in the position summary regarding the ordering of supplies. Review of the job description for the Director of Nursing revealed it was signed by the DON on 10/02/25. The position summary included the nurse, under the supervision of the administrator, had authority, responsibility, and accountability for functions, activities and training for the nursing services staff, in addition to the Therapy Department and its functions within the facility; in the absence of the Administrator, assumed responsibility for the facility; was responsible for the overall management of resident care 24 hours a day, seven days a week; conducted periodic reviews that the facility and personnel are in compliance with state code requirements; met with all licensed staff on a routine basis to review nursing and facility issues; ensured plans were in place to correct employee concerns; and was aware of resident abuse reporting law. Review of the job description for the Administrator revealed it was signed by the Administrator on 04/25/26. The position summary included under the direction of the regional vice president the Administrator led and directed the overall operations of the facility in accordance with resident needs, government regulations, and company polices to maintain quality of care for residents while achieving the facility business objectives; was aware of resident abuse reporting law; ensured understanding of, and compliance with all rules regarding residents' rights; and supervised, conducted and participated in department and facility education activities and staff meetings. During the onsite investigation, the following concerns related to the Administrator's, DON's, and RN/ADON #663's role responsibilities were identified: a. Review of the email dated 05/13/26 at 3:39 P.M. from Ombudsman #698 to DON revealed Ombudsman #698 asked if the facility had insulin needles available to provide residents with insulin per doctor's orders and to please provide evidence that such was available for example a picture.Interview on 05/19/26 at 10:37 A.M. with Licensed Practical Nurse (LPN) #620 revealed there was a week recently that the facility was out of insulin syringes; therefore, if a resident had a vial of insulin the nurses could not give the insulin. She stated the nurses had no choice but to borrow and administer insulin from other residents that had insulin pens instead of the vials. She stated, We had no choice, I do not know who I borrowed from just went through the cart until found whoever I could find with the same insulin that the resident needed. LPN #620 verified she had used other residents' insulin on other residents for approximately one week until the supply of insulin syringes came in. She revealed she had notified RN/ADON #663 and she was aware the facility was out of insulin syringes and that the nurses were taking and using other residents' insulin. She stated all the nurses at the facility were doing it. LPN #620 revealed she most likely did take Resident #32's insulin or gave her someone else's insulin.Interview on 05/19/26 at 11:21 A.M. with LPN #674 revealed for about a week the facility was without insulin syringes and that she did take another resident's unopened insulin injection pen and administer it to another resident. She had placed that resident's name on the insulin pen. She could not remember whose insulin pen she took from and who she gave it to.Interview on 05/19/26 at 11:29 A.M. with LPN #675 revealed she had taken other residents' insulin to administer to other residents as residents did not have their insulin as ordered. She stated, I know it is wrong. I just do not really have a choice as they need their insulin. She revealed she knew she took Resident #12's insulin vial and gave it to Resident #15 or it was the other way around as one of them did not have any insulin. LPN #675 verified she had taken other residents' insulin and gave it to other residents but could not remember the exact residents she did.Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she completed the ordering of supplies including insulin syringes. She stated nobody had brought to her attention that the facility was out of syringes. She became aware of the concern about a week ago when Ombudsman #698 contacted the facility that a nurse had reported to them the facility was out of insulin syringes. She revealed the facility had syringes and she placed an extra box in her office that the nurses had access to as back up. She was not aware that nurses were taking and administering residents' insulin that belonged to another resident.Interview on 05/19/26 at 2:32 PM and 05/26/26 at 12:58 P.M. with DON revealed she had received notification from Ombudsman #698 on 05/13/26 of concern of not having insulin syringes in the building and verified she did not interview any residents and/or nurses if there was a concern with not getting their insulin as ordered and/or investigate further besides checking if the facility currently had insulin syringes. She stated as of 05/26/26 they had investigated regarding nurses taking other residents' insulin and administering to other residents and LPN #620 and LPN #675 had stated they did. She did not have witness statements from the nurses as they had stated it verbally on investigation. She revealed LPN #620 and LPN #675 were terminated for misappropriation. Interview on 05/19/26 at 3:01 P.M. with Ombudsman #698 revealed it was reported to her by Resident #32 that the facility was out of insulin syringes and they were borrowing insulin pens from other residents. They sent the facility an email regarding the concern on 05/13/26.Review of witness statement dated 05/22/26 at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day.Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin.b. Interview on 05/18/26 at 12:05 P.M. with Resident #32 revealed she recently spoke with Ombudsman #698 as she had a concern on 05/13/26 that Former LPN #649 did not administer her first dose of insulin until late afternoon around 4:30 P.M. She revealed she was to have her blood sugar checked at breakfast, lunch and dinner but that Former LPN #649 never checked her breakfast or lunch blood sugar and/or gave her insulin if needed per her sliding scale. The first time he came in was at 4:30 P.M. and at that time he checked her blood sugar and gave her insulin. She questioned him why he had not given her breakfast or lunch insulin, and he had stated he was tied up and could not get to her sooner. She revealed then at 5:30 P.M. (one hour later) he had attempted to come back into the room to check her blood sugar and give her insulin as he stated the 4:30 P.M. dose was her lunch dose, and he was now doing the dinner check. She told him he cannot do that and refused as she was not taking the insulin that close together for fear of bottoming out her blood sugar. She reported the incident to several nurses including RN #648, and LPN #620 as she felt this was neglectful as she was concerned if he was doing this to other residents that may not be cognitively intact to know the difference.Interview on 05/18/26 at 3:37 P.M. with RN #648 revealed Resident #32 had reported to her that Former LPN #649 had not given her insulin on 05/13/26. She stated she did not report the incident as she thought the certified nursing assistant (CNA) had but was not sure of the name of the CNA.Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed Resident #32 had reported to her that Former LPN #649 did not check her morning or lunch blood sugar and/or administer her insulin. She stated she did not report the incident as she thought Resident #32 was going to report it.Interview on 05/20/26 at 11:15 A.M. with Former LPN #649 revealed he was new at the facility and was just getting a routine down but the last day he worked, 05/13/26, he verified he obtained Resident #32's morning blood sugar before breakfast and administered her insulin but was not able to get to her lunch blood sugar check and possible insulin coverage until around 2:00 P.M. or 3:00 P.M. He stated she did not appear upset until he had gone back before dinner to check her blood sugar again and she felt it was too soon and refused. He verified the blood sugar at lunch was to be checked before lunch at 11:00 A.M. and he was three to four hours late on checking and administering her insulin. He stated, It was just the course of the day as he got behind. He verified he did not contact the Director of Nursing and/or physician that the blood sugar and/or insulin was not administered on time. He stated when he worked at the facility the management did not help when he got behind so really there was nothing else he could have done.c. Interview on 05/19/26 at 10:09 A.M. with RN #648 revealed when she came on duty LPN #620 was at the medication cart, and she was awaiting to receive report from LPN #620 when Resident #43 walked onto [NAME] Unit and started to talk with her. She used to work on his unit, and they had a good rapport so every morning he usually came over to talk to her when she came on duty. She stated Resident #43 had not said anything to LPN #620 when he came up to them and started to talk with her in a calm manner. LPN #620 immediately told him, You do not need to be over here. RN #648 revealed Resident #43 then stated in a calm manner he came over to talk to her (RN #648), and LPN #620 stated, If you do not leave, I am calling the police. RN #648 again stated that Resident #43 was calm and did not display any behavior. RN #648 stated, Yes I feel she (LPN #620) kind of threatened him as he was just on the unit talking with me and not doing anything. He then appeared upset and left the unit. She did not report the incident to management.Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed there was a night that there was an altercation with Resident #43 as he was yelling in the middle of the night and they contacted the police. Later in the morning he had come over to [NAME] Unit at shift change and started swearing at her and calling her names. She told him to go back on the other side. LPN #620 verified she had told him if he did not go to his side she was calling the police. She revealed she notified RN/Assistant Director of Nursing (ADON) #663 about the incident and that she had said I did wrong as she said she should have just been quiet and not tell him to go to the other side or that she was contacting the police if he did not leave.Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she could not remember all the details of the incident on 05/03/26 as she had not slept well when she had received the phone call from LPN #620, but does remember LPN #620 contacting her stating something about Resident #43 was yelling at her and she thought she had asked LPN #620 if she yelled back as she had the tendency to. She was not sure if that was when she had stated she told him to leave the unit or she was calling the police. She had used that as an educational moment that she could not do that but was unsure as she did not remember the full conversation. RN/ADON #663 verified she had not investigated the incident any further after the phone call.d. Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed there was a week recently that the facility was out of insulin syringes; therefore, if a resident had a vial of insulin the nurses could not give the insulin. She stated the nurses had no choice but to borrow and administer insulin from other residents that had insulin pens instead of the vials. She stated, We had no choice, I do not know who I borrowed from just went through the cart until found whoever I could find with the same insulin that the resident needed. LPN #620 verified she had used other residents' insulin on other residents for approximately one week until the supply of insulin syringes came in. She revealed she had notified RN/ADON #663 and she was aware the facility was out of insulin syringes and that the nurses were taking and using other residents' insulin. She stated all the nurses at the facility were doing it. LPN #620 revealed she most likely did take Resident #32's insulin or gave her someone else's insulin.Interview on 05/19/26 at 11:21 A.M. with LPN #674 revealed for about a week the facility was without insulin syringes and that she did take another resident's unopened insulin injection pen and administer it to another resident. She had placed that resident's name on the insulin pen. She could not remember whose insulin pen she took from and who she gave it to.Interview on 05/19/26 at 11:29 A.M. with LPN #675 revealed she had taken other residents' insulin to administer to other residents as residents did not have their insulin as ordered. She stated, I know it is wrong. I just do not really have a choice as they need their insulin. She revealed she knew she took Resident #12's insulin vial and gave it to Resident #15 or it was the other way around as one of them did not have any insulin. LPN #675 verified she had taken other residents' insulin and gave it to other residents but could not remember the exact residents she did.Interview on 05/19/26 at 3:01 P.M. with Ombudsman #698 revealed it was reported to her by Resident #32 that the facility was out of insulin syringes and they were borrowing insulin pens from other residents.Review of witness statement dated 05/22/26 at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day.Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin.e. Interview on 05/19/26 at 11:29 A.M. with Licensed Practical Nurse (LPN) #675 revealed residents in the [NAME] unit had prolonged incontinence as residents were not changed for prolonged time as their wheelchair seat cushions were saturated. She revealed she reported the incident to Registered Nurse (RN)/Assistant Director of Nursing (ADON) #663, and Certified Nursing Assistant (CNA) #638 came in off duty and yelled at her for reporting the situation. She stated she did find it intimidating especially to come in when not scheduled. She did let RN/ADON #663 know what CNA #638 did but did not feel anything was done. f. She revealed Former CNA #702 was having sex with Former Residents #79 and #80 for money. Former Resident #80 went around stating Former CNA #702 was his girlfriend and that she had borrowed money from him as well. Former CNA #702 was terminated but continued to come and see Former Resident #80. Staff (Former CNAs #702, #703 and #704) took Former Resident #75's bank card before he passed and used his bank card as well as one of them took his leather jacket. She heard CNA #610 go up to Resident #18 and stated, If I show you my boobs will you give me 200 hundred dollars? She was at the local convenient store and witnessed CNA #638 sell drugs to Resident #43. When asked how she knew it was drugs she revealed past experience know what is going on. She revealed RN/ADON #663 had a relationship with CNA #638 so hard to report as once LPN #675 reported him for care concerns and he came up to the facility when he was off duty as RN/ADON #663 most likely told him and threatened the nurse and stated, I had to come to work to check a {explicit}. Also, CSM #701 revealed CNA #684 was selling drugs to Residents #43 and #72. She revealed there was intimidation, so nobody reported anything as it was an unsafe work environment. She did not feel comfortable reporting the allegations as once she filed a grievance and was written up the next day as it was what the facility did, especially if reporting, they come after the person that reported not the person that was abusing the residents. She did not feel comfortable going to anyone at the facility to report and was not aware how to report any other means including anonymous.g. Interview on 05/21/26 at 9:09 A.M. with RN/ADON/Wound Nurse #663 revealed she oversaw wound care at the facility. She had an outside wound provider come in on a weekly basis to see all wounds including pressure and surgical. She verified FR #77 was not seen by the outside wound provider. She confirmed there was no assessment of the surgical wound including measurements, appearance, number of retention sutures and/or anything regarding the measurement of the wound dehiscence as noted in the hospital note. She verified the only skin assessments in his record were on 04/04/26 which did not have that he had an abdominal incision, and on 04/08/26 and 04/15/26 it had that he had an abdominal incision but no description of it. She verified there was a treatment order on return from the hospital on [DATE] that included cleansing with saline, applying with an abdominal pad and taping with soft cloth adhesive, but it was not completed as ordered. She verified she usually sees all wounds, completes the measurements and assessments and ensures the resident had a treatment, but it was overlooked as in her position it was just a lot to keep up with wounds and infection control. She verified in her position she felt it was a lot to keep up with including wounds, infection control, ordering of supplies and the day-to-day oversight of operations. This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint survey completed 03/25/26.

Based on record review, interview, and review of facility policy, facility staff failed to report allegations of rights violations, misappropriation, neglect and/or abuse in a timely manner. This affected seven residents (Residents #18, #32, #43, #72, #75, #79 and #80) out of 11 residents reviewed for reporting of abuse and/or resident rights violations. This had the potential to affect 32 residents residing in the [NAME] Unit (Residents #1, #3, #4, #5, #6, #9, #12, #13, #16, #18, #21, #22, #27, #28, #33, #34, #35, #38, #39, #40, #42, #43, #47, #49, #51, #55, #60, #63, #68, #69, #72 and #73) and 25 residents (Residents #1, #3, #8, #11, #12, #15, #16, #27, #28, #31, #32, #36, #37, #39, #41, #42, #44, #46, #49, #54, #60, #69, #70, #72 and #73) identified on insulin. The facility census was 74.Findings include:1. Review of closed medical record for Former Resident #75 revealed an admission date of 08/26/25 and he passed away 10/25/25 at the facility under hospice services. His diagnoses included chronic obstructive pulmonary disease, schizophrenia, and chronic respiratory failure. There was nothing in his medical record regarding misappropriation including staff taking his bank card and/or leather jacket. Review of significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Former Resident #75 had impaired cognition. 2. Review of medical record for Resident #72 revealed an admission date of 12/12/25 and diagnoses including diabetes, difficulty walking and hyperlipidemia. There was nothing in his medical record regarding abuse including staff selling him drugs. Review of Quarterly MDS assessment dated [DATE] revealed Resident #72 had intact cognition. Interview on 05/20/26 at 3:17 P.M. with Resident #72 denied any abuse and/or any staff selling him drugs. 3. Review of medical record for Resident #43 revealed an admission date of 10/10/25 and his diagnoses included chronic kidney disease requiring dialysis, and cellulitis. Review of Quarterly MDS assessment dated [DATE] revealed Resident #43 had intact cognition. Interview on 05/20/26 at 3:15 P.M. with Resident #43 denied any allegations of abuse including staff selling him drugs. 4. Review of closed medical record for Former Resident #80 revealed an admission date of 04/17/25 and he had passed away on 04/13/26 under hospice services. His diagnoses included malignant neoplasm of the prostate, diabetes, and hypertension. There was nothing in his medical record regarding sexual abuse and/or misappropriation. Review of Quarterly MDS assessment dated [DATE] revealed Former Resident #80 had severe cognitive impairment. 5. Review of closed medical record for Former Resident #79 revealed an admission date of 05/08/25 and he passed away on 01/25/26 under hospice services. His diagnoses included liver cell carcinoma, cirrhosis of the liver, and hypertension. There was nothing in his medical record regarding sexual abuse and/or misappropriation. Review of Quarterly MDS assessment dated [DATE] revealed Former Resident #79 had intact cognition. 6. Review of medical record for Resident #18 revealed an admission date of 08/06/24 and his diagnosis included hypertension, and diabetes. There was nothing in his medical record regarding abuse including sexual and/or being propositioned for money. Review of Quarterly MDS assessment dated [DATE] revealed Resident #18 had impaired cognition.Interview on 05/20/26 at 3:10 P.M. with Resident #18 revealed he did not want to provide any details and/or be interviewed as he was not answering any questions. Interview on 05/19/26 at 11:29 A.M. with Licensed Practical Nurse (LPN) #675 revealed residents in the [NAME] unit had prolonged incontinence as residents were not changed for prolonged time as their wheelchair seat cushions were saturated. She revealed she reported the incident to Registered Nurse (RN)/Assistant Director of Nursing (ADON) #663, and Certified Nursing Assistant (CNA) #638 came in off duty and yelled at her for reporting the situation. She stated she did find it intimidating especially to come in when not scheduled. Interview on 05/20/26 at 2:12 P.M. with Resident #32 revealed Confidential Staff Member #701 had revealed to her several disturbing things that had occurred in the [NAME] Unit and she was concerned as many things were abusive. She revealed Confidential Staff Member (CSM) #701 had told her Former CNA #702 was having sex with two Former Residents #79 and #80, and CNA #610 was lifting her shirt and showing her breasts for money to residents on the [NAME] Unit. She revealed CSM #701 also told her CNA #638 was selling drugs at the facility as CSM #701 had told her she witnessed him selling drugs to Resident #43 at the local convenience store. She stated she was concerned regarding the safety of residents in the [NAME] Unit. Interview on 05/20/26 at 2:42 P.M. with CSM #701 stated she had a fear of retaliation and wanted to remain anonymous but was concerned regarding sexual abuse, selling of drugs and misappropriation occurring in the [NAME] Unit. She revealed Former CNA #702 was having sex with Former Residents #79 and #80 for money. Former Resident #80 went around stating Former CNA #702 was his girlfriend and that she had borrowed money from him as well. Former CNA #702 was terminated but continued to come and see Former Resident #80. Staff (Former CNAs #702, #703 and #704) took Former Resident #75's bank card before he passed and used his bank card as well as one of them took his leather jacket. She heard CNA #610 go up to Resident #18 and stated, If I show you my boobs will you give me 200 hundred dollars? She was at the local convenient store and witnessed CNA #638 sell drugs to Resident #43. When asked how she knew it was drugs she revealed past experience know what is going on. She revealed RN/ADON #663 had a relationship with CNA #638 so hard to report as once LPN #675 reported him for care concerns and he came up to the facility when he was off duty as RN/ADON #663 most likely told him and threatened the nurse and stated, I had to come to work to check a {explicit}. Also, CSM #701 revealed CNA #684 was selling drugs to Residents #43 and #72. She revealed there was intimidation, so nobody reported anything as it was an unsafe work environment. She did not feel comfortable reporting the allegations as once she filed a grievance and was written up the next day as it was what the facility did, especially if reporting, they come after the person that reported not the person that was abusing the residents. She did not feel comfortable going to anyone at the facility to report and was not aware how to report any other means including anonymous. She verified she had told Resident #32 the concerns that were occurring in the [NAME] Unit. She was unable to provide exact dates of when these events had taken place, but stated she felt sexual abuse, selling of drugs, and misappropriation was still occurring especially since some staff remain at the facility and work in the [NAME] unit. Interview on 05/20/26 at 4:20 P.M. with Administer from other Facility #700, Regional Nurse #696, Director of Nursing (DON) and Administrator were notified of the above allegations. Interview on 05/21/26 at 7:45 A.M. with Regional Nurse #696 revealed they went through previous self-reported incidents (SRIs) and were not aware of the above allegations as the allegations had not been reported prior to 05/20/26 and there were no previous investigations. Interview on 05/26/26 at 9:52 A.M. with Regional Nurse #696 and Human Resources #685 revealed there was a corporate compliance hotline that was available 24 hours a day staff could report any allegation including anonymous and that it was reviewed upon hire. They revealed the above allegations were not reported on the hotline. 7. Review of medical record for Resident #32 revealed an admission date of 10/05/23 and diagnoses included diabetes, anemia, depression and cellulitis. Review of Quarterly MDS dated [DATE] revealed Resident #32 was cognitively intact and received insulin. Review of care plan dated 07/17/26 revealed Resident #32 had diabetes. Interventions included medications as ordered, dietary consult, and discussing mealtimes, portion sizes, and dietary restrictions.Review of May 2026 Physician orders and Medication Administrator Record (MAR) revealed Resident #32 had the following orders: check blood sugar before meals at 7:00 A.M., 11:00 A.M. 4:00 P.M. and at bedtime (9:00 P.M.); and provide Humalog insulin subcutaneous (SC) (a rapid acting insulin) per sliding scale coverage based on the blood sugar. On 05/13/26 Former Licensed Practical Nurse (LPN) #649 documented Resident #32's blood sugar at 7:00 A.M. as 256 and that he administered eight units of Humalog insulin (SC) per sliding scale. He documented her blood sugar at 11:00 A.M. as 290 and he administered eight units of Humalog insulin SC per sliding scale. He documented at 4:00 P.M. Resident #32 refused her blood sugar check and possible sliding scale coverage. Review of blood sugar summary for Resident #32 revealed on 05/13/26 it was documented at 8:30 A.M. Former LPN #649 obtained her blood sugar, and it was 256 and the next time her blood sugar was taken was 3:20 P.M. and it was 290. There was no dinner blood sugar documented. Interview on 05/18/26 at 12:05 P.M. with Resident #32 revealed she recently spoke with Ombudsman #698 as she had a concern on 05/13/26 that Former LPN #649 did not administer her first dose of insulin until late afternoon around 4:30 P.M. She was to have her blood sugar checked at breakfast, lunch and dinner but that Former LPN #649 never checked her breakfast or lunch blood sugar and/or gave her insulin if needed per her sliding scale. She revealed the first time he came in was at 4:30 P.M. and at that time he checked her blood sugar and gave her insulin. She questioned him why he had not given her breakfast or lunch insulin and he had stated he was tied up and could not get to her sooner. She revealed then at 5:30 P.M. (one hour later) he had attempted to come back into the room to check her blood sugar and give her insulin as he stated the 4:30 P.M. dose was her lunch dose, and he was now doing the dinner check. She revealed she told him he cannot do that and refused as she was not taking the insulin that close together for fear of bottoming out her blood sugar. She reported the incident to several nurses including RN #648, and LPN #620 as she felt this was neglectful as she was concerned if he was doing this to other residents that may not be cognitively intact to know the difference. Interview on 05/18/26 at 1:00 P.M. with DON revealed she was not aware of any times Resident #32 did not receive her insulin as ordered as the incident on 05/13/26 was not reported to her. Interview on 05/18/26 at 2:02 P.M. with Ombudsman #698 revealed Resident #32 had brought up regarding not getting her insulin as ordered. Interview on 05/18/26 at 3:37 P.M. with RN #648 revealed Resident #32 had reported to her that Former LPN #649 had not given her insulin on 05/13/26. She did not report the incident as she thought the certified nursing assistant (CNA) had but was not sure of the name of the CNA. Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed Resident #32 had reported to her that Former LPN #649 did not check her morning or lunch blood sugar and/or administer her insulin. She did not report the incident as she thought Resident #32 was going to report it. She verified Resident #32 was upset and that she did state that she felt Former LPN #649 was an unsafe nurse to be working at the facility. Interview on 05/20/26 at 11:15 A.M. with Former LPN #649 revealed he was new at the facility and was just getting a routine down but the last day he worked, 05/13/26, he verified he obtained Resident #32's morning blood sugar before breakfast and administered her insulin but was not able to get to her lunch blood sugar check and possible insulin coverage until around 2:00 P.M. or 3:00 P.M He revealed Resident #32 did not appear upset until he had gone back before dinner to check her blood sugar again and she felt it was too soon and refused. He verified the blood sugar at lunch was to be checked before lunch at 11:00 A.M. and he was three to four hours late on checking and administering her insulin. He stated, It was just the course of the day as he got behind. He verified he did not contact the DON and/or physician that the blood sugar and/or insulin was not administered on time. He revealed when he worked at the facility, management did not help when he got behind so really there was nothing else he could have done. 8. Review of medical record for Resident #43 revealed an admission date of 10/10/25 and his diagnoses included chronic kidney disease, hypertension, and dependance on renal dialysis. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition, and no behaviors were identified.Review of care plan last revised 05/05/26 revealed Resident #43 had a behavior problem related to demanding medications for immediate administration, attention seeking, verbal aggression, swearing towards staff, and making false allegations. Interventions included adjusting voice tone; behavior contract given; caregivers to provide opportunities for positive interaction and attention; stop and talk with him when passing by; intervene as necessary to protect rights of others; speak in a calm manner; take to an alternate location as needed; and move to a less stimulating environment. There was nothing in the care plan regarding not allowing Resident #43 on the [NAME] Unit. Review of Resident #43's behavior contract dated 05/05/26 revealed over the past six months Resident #43 had displayed negative behaviors that had affected residents around him, the staff designated to care for him, and his roommate's ability to receive care. The plan listed as tools the resident could utilize: the facility concern form process, the Administrator and/or Director of Nursing (DON) were available to discuss concerns, and he refused to see psychological services. There was nothing in the behavioral contract regarding restricting him from a specified unit or staff to call the police if he did not leave a unit, especially if Resident #43 was calm and demonstrating no behaviors.Review of care plan last revised 05/06/26 revealed Resident #43 demonstrated verbally abusive behaviors related to coping skills, mental illness, poor impulse control as the resident belittled staff while yelling at staff in hallways. Interventions included adjusting voice tone; assess and anticipate needs; assess resident's coping skills and support system; allow time for resident to express self and feelings toward the situation; and when resident becomes agitated intervene before agitation escalates, guide away from source, engage calmly in conversation if response was aggressive the staff was to walk calmly away and approach later. There was nothing in the care plan regarding restricting Resident #43 on the [NAME] Unit.Interview on 05/19/26 at 8:51 A.M. with Resident #43 revealed an incident occurred on Sunday, 05/03/26, as he was supposed to have pain medication around 2:45 A.M. and it was 4:10 A.M. He looked for the nurse as he was in significant pain from a bad tooth. He finally found the nurse (Licensed Practical Nurse #620) on the other unit, [NAME] Unit, and asked her what was up with not getting his pain medication. He stated they got into an altercation because she had said she was not giving him his pain medication and then she called the police. The police came and then he received his pain medication. He revealed that he knew Registered Nurse (RN) #648 was scheduled to come in on 05/03/26 at 7:00 A.M., so he went to talk to her on the [NAME] Unit as he stated he always talked to her every morning that she worked. He started to talk with RN #648 when Licensed Practical Nurse (LPN) #620 stated to get off the unit or that she would call the police. LPN #620 repeated it a few times. He stated, She threatened me, as he revealed he had never said anything to LPN #620 when he walked onto the unit and felt it was against his right that he could not be on the unit when he was just talking with RN #648. He stated that LPN #620 was no longer on duty as RN #648 had relieved her, so he did not understand why he did not have the right to be on the unit but indicated he left the unit.Interview on 05/19/26 at 10:09 A.M. with RN #648 revealed when she came on duty LPN #620 was at the medication cart, and she was awaiting to receive report from LPN #620 when Resident #43 walked onto [NAME] Unit and started to talk with her. She used to work on his unit, and they had a good rapport so every morning he usually came over to talk to her when she came on duty. She stated Resident #43 had not said anything to LPN #620 when he came up to them and started to talk with her in a calm manner. LPN #620 immediately told him, You do not need to be over here. RN #648 revealed Resident #43 then stated in a calm manner he came over to talk to her (RN #648), and LPN #620 stated, If you do not leave, I am calling the police. RN #648 again stated that Resident #43 was calm and did not display any behavior. RN #648 stated, Yes I feel she (LPN #620) kind of threatened him as he was just on the unit talking with me and not doing anything. He then appeared upset and left the unit. She did not report the incident to management.Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed there was a night that there was an altercation with Resident #43 as he was yelling in the middle of the night and they contacted the police. Later in the morning he had come over to [NAME] Unit at shift change and started swearing at her and calling her names. She told him to go back on the other side. LPN #620 verified she had told him if he did not go to his side she was calling the police. She revealed she notified RN/Assistant Director of Nursing (ADON) #663 about the incident and that she had said I did wrong as she said she should have just been quiet and not tell him to go to the other side or that she was contacting the police if he did not leave.Review of Resident #43's nursing notes dated 05/03/26 revealed there was no documentation regarding Resident #43 going to the [NAME] Unit in the morning at change of shift swearing at LPN #620 and calling her names.Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she could not remember all the details of the incident on 05/03/26 as she had not slept well when she had received the phone call from LPN #620, but does remember LPN #620 contacting her stating something about Resident #43 was yelling at her and she thought she had asked LPN #620 if she yelled back as she had the tendency to. She was not sure if that was when she had stated she told him to leave the unit or she was calling the police. She had used that as an educational moment that she could not do that but was unsure as she did not remember the full conversation. RN/ADON #663 verified she had not investigated the incident any further after the phone call.Interview on 05/19/26 at 2:32 P.M. with DON verified it had not been reported to her by RN #648 or to any other management regarding Resident #43 being on [NAME] Unit and LPN #620 telling him to leave the unit or she was calling the police, or that RN #648 felt LPN #620 threatened Resident #43.Interview on 05/19/26 at 4:35 P.M. with Regional Nurse #696 and RN #648 who came into the facility to speak with this surveyor revealed Regional Nurse #696 stated RN #648 had not felt LPN #620 was threatening Resident #43. This surveyor read aloud her interview and after reading it, RN #648 stated, That is correct. Then Regional Nurse #696 stated to RN #648, I thought you said LPN #620 did not threaten him, and then RN #648 stated, Yes she did not threaten him. RN #648 then continued stating she felt it was Resident #43's home and he had the right to be on any unit and should not be told to leave the unit or if he did not the police would be called. RN #648 verified again Resident #43 was calm that morning and had not said anything to LPN #620.Review of facility policy labeled, Resident Rights Policy and Procedure, dated 2026 revealed the purpose of the policy was to ensure the preservation of every resident's right to a dignified exitance, self-determination, and communication with and access to persons and services inside and outside the facility. Every resident had the right to be treated with respect and dignity including the right to be free from any psychical or chemical restraints imposed for purposes of discipline or convenience. Also, each resident had the right to interact with members of the community both inside and outside of the facility.Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation, dated 2026 revealed residents were free from abuse, neglect, misappropriation of their property and exploitation. When the facility had identified abuse the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately, reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. This deficiency represents non-compliance investigated under Complaint Numbers 2991563 and 2993004 and is a recite to the complaint survey completed 04/20/26.

Based on record review, interview, and review of facility policy, the facility failed to ensure the medical record contained accurate information. This affected two residents (Residents #32 and #77) out of 11 records reviewed for documentation accuracy. The facility census was 74. Findings include:1. Review of medical record for Resident #32 revealed an admission date of 10/05/23 and diagnoses included diabetes, anemia, depression and cellulitis. Review of Quarterly MDS assessment dated [DATE] revealed Resident #32 was cognitively intact and received insulin.Review of care plan dated 07/17/26 revealed Resident #32 had diabetes. Interventions included medications as ordered, dietary consult, and discussing mealtimes, portion sizes, dietary restrictions and ongoing monitoring.Review of May 2026 Physician orders and Medication Administrator Record (MAR) revealed Resident #32 had the following orders: check blood sugar before meals at 7:00 A.M., 11:00 A.M., 4:00 P.M. and at bedtime (9:00 P.M.); and provide Humalog insulin subcutaneous (SC) (a rapid acting insulin) per sliding scale coverage based on the blood sugar. On 05/13/26 Former Licensed Practical Nurse (LPN) #649 documented her blood sugar at 7:00 A.M. as 256 and that he administered eight units of Humalog insulin SC per sliding scale. He also documented her blood sugar at 11:00 A.M. was 290 and he administered eight units of Humalog insulin SQ per sliding scale. He documented at 4:00 P.M. Resident #32 refused her blood sugar check and possible sliding scale coverage.Review of blood sugar summary for Resident #32 revealed on 05/13/26 it was documented at 8:30 A.M. Former LPN #649 obtained her blood sugar, and it was 256 and the next time her blood sugar was taken was 3:20 P.M. and it was 290. There was no dinner blood sugar documented.Interview on 05/18/26 at 12:05 P.M. with Resident #32 revealed she recently spoke with Ombudsman #698 as she had a concern on 05/13/26 that Former LPN #649 did not administer her first dose of insulin until late afternoon around 4:30 P.M. She revealed she was to have her blood sugar checked at breakfast, lunch and dinner but that Former LPN #649 never checked her breakfast or lunch blood sugar and/or gave her insulin if needed per her sliding scale. The first time he came in was at 4:30 P.M. and at that time he checked her blood sugar and gave her insulin. She questioned him why he had not given her breakfast or lunch insulin, and he had stated he was tied up and could not get to her sooner. She revealed then at 5:30 P.M. (one hour later) he had attempted to come back into the room to check her blood sugar and give her insulin as he stated the 4:30 P.M. dose was her lunch dose, and he was now doing the dinner check. She told him he cannot do that and refused as she was not taking the insulin that close together for fear of bottoming out her blood sugar. She reported the incident to several nurses including RN #648, and LPN #620 as she felt this was neglectful as she was concerned if he was doing this to other residents that may not be cognitively intact to know the difference. Interview on 05/18/26 at 2:02 P.M. with Ombudsman #698 revealed Resident #32 had brought up regarding not getting her insulin as ordered.Interview on 05/20/26 at 11:15 A.M. with Former LPN #649 revealed he was new at the facility and was just getting a routine down but the last day he worked, 05/13/26, he verified he obtained Resident #32's morning blood sugar before breakfast and administered her insulin but was not able to get to her lunch blood sugar check and possible insulin coverage until around 2:00 P.M. or 3:00 P.M. He stated she did not appear upset until he had gone back before dinner to check her blood sugar again and she felt it was too soon and refused. He verified the blood sugar at lunch was to be checked before lunch at 11:00 A.M. and he was three to four hours late on checking and administering her insulin. He stated, It was just the course of the day as he got behind. He verified he did not contact the Director of Nursing and/or physician that the blood sugar and/or insulin was not administered on time. He verified on the MAR he had inaccurately documented that he had checked her blood sugar and administered her insulin at 11:00 A.M. as ordered and the documentation was inaccurate as he had not obtained the blood sugar and/or provided her insulin until 2:00 P.M. or after. 2. Review of medical record for Former Resident (FR) #77 revealed an admission date of 02/13/24 and his diagnoses included hypotension, diabetes, chronic kidney disease, cerebral infarction, sepsis with acute organ dysfunction, septic shock, endocarditis, perforated bowel, history of cardiac arrest, and prolapsed ostomy.Review of care plan dated 12/12/25 revealed FR #77 had the potential for pressure injury, surgical wound, rash, cellulitis, skin tears, and vascular wounds. Interventions included performing weekly skin assessments, reporting and documenting any irregularities, and administer treatments as ordered. Review of nursing notes dated 03/31/26 at 3:42 P.M. completed by unknown agency nurse revealed FR #77 arrived back to the facility and he refused to allow the nurse to assess his skin, but FR #77 did mention he had a wound to his buttocks. Review of after visit summary dated 04/02/26 on the medication list there was no orders for arixtra (anti-coagulant), bumetanide (diuretic), and/or octreotide (treats severe diarrhea). Under the wound care documentation and therapy revealed he had an active sacrum wound that was described as a deep tissue injury that was dry and intact. On wound assessment dated [DATE] and 04/02/26 the area was denuded, pink, red, and the peri wound was fragile, edematous, with erosion and was warm. He also had a right BKA (below the knee amputation) pressure injury wound that was active. On assessment the wound was clean, dry and intact and the peri-wound was fragile. The wound instructions were to cleanse with saline and apply foam. Review of April 2025 Physician Orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed arixtra 2.5 milligrams (mg) subcutaneous (SC) daily was discontinued on 04/02/26, bumetanide (diuretic) 0.5 mg by mouth every Monday, Wednesday, and Friday was discontinued on 04/02/26 and octreotide 50 micrograms (mcg) SC three time a day (active) for refractory high-output diarrhea was discontinued on 04/02/26. There was no treatment orders for wounds to his coccyx, left lateral foot, and right BKA stump. Review of admission Medicare Five Day MDS assessment dated [DATE] revealed FR #77 had intact cognition. He required substantial to maximum staff assistance with toileting hygiene, showers, and lower dressing. He required supervision with rolling left and right. Review of Nurse Practitioner (NP) #693's progress note dated 04/02/26 at 12:39 P.M. for FR #77 revealed she consulted due to status post hospitalization. The note revealed under review of systems he had a coccyx wound, left lateral foot wound, right BKA wound and abdominal surgical incision. The note revealed under physical exam: skin: warm, wound; other: coccyx, left lateral foot, right BKA stump, abdominal surgical incision. The progress note revealed to continue wound care for the chronic leg wound and monitor for secondary infection. Under medication management active medications relevant to chronic kidney disease was bumetanide 0.5 mg by mouth every Monday, Wednesday, and Friday (use with caution, monitor for hypovolemia, and electrolyte loss) and arixtra 2.5 mg SC daily (anticoagulation, monitor for bleeding risk especially with renal impairment). Under the medication and nutrition antidiarrheal therapy section NP #603 noted octreotide 50 mcg SC three times a day (active) for refractory high-output diarrhea. Review of Skin Check Evaluation dated 04/04/26 completed by LPN #608 revealed FR #77 had an abrasion to the top of his scalp and an abrasion to his left hand. There was nothing on the assessment regarding his abdominal surgical incision, wounds to his coccyx, left lateral foot, and right BKA. Review of Skin Check Evaluation dated 04/08/26 completed by LPN/Unit Manager #627 revealed FR #77 had a surgical incision to his abdomen. There was nothing on the assessment regarding wounds to his coccyx, left lateral foot, and right BKA. Review of NP #693 progress note dated 04/09/26 at 8:40 P.M. revealed she consulted for FR #77 as a follow up and noted under physical exam the skin was warm, wound, and under other: coccyx, left lateral foot, right BKA stump and abdominal surgical incision. Review of NP #693 progress note dated 04/13/26 at 10:47 P.M. revealed she consulted for FR #77 as follow up and noted under review of systems, skin: other: coccyx wound, left lateral foot, right BKA wound, abdominal surgical incision. Under physical exam she noted under skin, warm, wound, other: coccyx, left lateral foot, right BKA stump, abdominal surgical incision. Review of Skin Check Evaluation dated 04/15/26 completed by LPN/Unit Manager #627 revealed FR #77 had a surgical incision to his abdomen. There was nothing on the assessment regarding wounds to his coccyx, left lateral foot, and right BKA. Review of NP #693 progress note dated 04/16/26 at 9:07 P.M. revealed she consulted for FR #77 as follow up and revealed under physical exam, skin: warm, wound, other: coccyx, left lateral foot, right BKA stump, abdominal surgical incision. Interview on 05/21/26 at 9:09 A.M. with RN/ADON #663 revealed she was responsible for the wounds at the facility. She stated she had not looked at FR #77's coccyx, left lateral foot, and right BKA on return from the hospital on [DATE] to when he was sent to the hospital on [DATE]. She verified the nursing note dated 03/31/26 at 3:42 P.M. completed by unknown agency nurse revealed FR #77 arrived back to the facility and he refused to allow the nurse to assess his skin, but FR #77 did mention he had a wound to his buttocks. She verified on the after-summary consult dated 04/02/26 under the wound care documentation and therapy revealed he had an active sacrum wound that was described as a deep tissue injury that was dry and intact. On wound assessment dated [DATE] and 04/02/26 in the hospital the area was described as denuded, pink, red, and the peri wound was fragile, edematous, with erosion and was warm. He also had a right BKA pressure injury wound that was active. On assessment in the hospital on [DATE] and 04/02/26 the wound was clean, dry and intact and the peri-wound was fragile. The wound instructions were to cleanse with saline and apply foam. She revealed she can only go by the skin assessments completed on 04/04/26, 04/08/26 and 04/15/26 and the assessments did not have that FR #77 had wounds to his coccyx, left lateral foot, and right BKA. She verified NP #693 progress notes dated 04/02/26, 04/09/26, 04/13/26, and 04/16/26 all included that FR #77 had wounds to his coccyx, left lateral foot, and right BKA. She stated she felt these notes were inaccurate. Interview on 05/21/26 at 10:10 A.M. with NP #693 verified on her progress note dated 04/02/26 for FR #77 on return from the hospital the following under medication management active medications relevant to chronic kidney disease was bumetanide 0.5 mg by mouth every Monday, Wednesday, and Friday (use with caution, monitor for hypovolemia, and electrolyte loss) and arixtra 2.5 mg SC daily (anticoagulation, monitor for bleeding risk especially with renal impairment). Under the medication and nutrition antidiarrheal therapy section NP #603 noted octreotide 50 mcg SC three times a day (active) for refractory high-output diarrhea. NP #693 was asked if FR #77 was to continue these medications as listed in her progress note as they were not on the physician orders and/or MAR. She stated she does not put the medications into her progress note instead she uses artificial intelligence (AI) to pull the medications from one system to another and that it was a mistake as he was not to receive those medications per the after visit summary from the hospital. She revealed she did not see his skin including his coccyx, left lateral foot, and right BKA so she was unaware if he had those wounds. After reviewing her progress notes noted on 04/02/26, 04/09/26, 04/13/26, and 04/16/26 all included that FR #77 had wounds to his coccyx, left lateral foot, and right BKA, she stated again their system at times pulls from other systems (using AI) so it was possible he did not have these wounds, she was unsure. Review of facility policy labeled, Administering Medications, dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed. Medications were to be administered in accordance with prescriber orders including required time frames. Medications were to be administered within one hour of prescribed time unless otherwise specified. The nurse administering the medication checks the label three times to verify right resident, right medication, right dose, right time, and right method. If a drug was withheld, refused or given at a time other than the scheduled time the individual administering the medication shall initial and circle the MAR space provided for that drug or dose. Review of facility policy labeled, Charting and Documentation, dated July 2017 revealed the medical record should facilitate communication between the interdisciplinary team regarding the resident's response to care. Documentation in the medical record would be objective, complete and accurate. This deficiency represents non-compliance investigated under Complaint Number 2993004 and is a recite to the complaint surveys completed 03/25/26 and 04/20/26.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected two residents (Residents #32 and #73) out of eight residents reviewed for medication administration. The facility census was 74.Findings include:1. Review of Resident #73's medical record revealed an admission date of 12/22/25 and his diagnoses included chronic obstructive pulmonary disease (COPD), multiple sclerosis, hypertension, and peripheral vascular disease. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had impaired cognition and received a diuretic (medication that help move extra fluids out of the body). Review of care plan dated 10/03/23 revealed Resident #73 had COPD. Interventions included monitoring for difficulty breathing, giving aerosol and inhalers as ordered, and monitoring for signs of respiratory infection. Review of May 2026 Physician Orders and May 2026 Medication Administration Record (MAR) revealed Resident #73 had the following orders: Lasix (diuretic) oral tablet 80 milligrams (mg) by mouth in the morning related to COPD dated 07/07/26 that was scheduled for 7:00 A.M.; and fluticasone propionate suspension 50 micrograms (mcg) per actuation (act) (pre-measured spray or puff), give one spray in each nostril one time a day for nasal congestion that was ordered for 8:00 A.M. Per the MAR he had not refused his nasal spray for the month of May 2026 from 05/01/26 to 05/19/26. Observation of medication administration on 05/19/26 at 8:11 A.M. completed by Agency Registered Nurse (RN) #697 revealed she obtained Resident #73's morning medications from the medication cart as ordered but omitted his fluticasone propionate suspension 50 mcg per act nasal spray and Lasix 80 mg tablet. She administered the medications, returned to the cart and signed off the medications as administered. Interview on 05/19/26 at 8:49 A.M. with Agency RN #697 after review of medication orders verified she had not given Resident #73 his fluticasone propionate suspension nasal spray 50 mcg per act as she stated he usually refused it. She verified that she had not offered or asked Resident #73 if he wanted it. She also verified she had not given Resident #73 his Lasix 80 mg tablet as she stated, I just missed it as she did not see the order. Interview on 05/19/26 at 9:19 A.M. with Resident #73 revealed he always took his nasal spray as he had allergies but that the nurse did not give it to him this morning. Review of nursing note dated 05/19/26 at 12:14 P.M. completed by RN/Assistant Director of Nursing (ADON) #663 revealed Nurse Practitioner (NP) #694 was notified that Resident #73 did not take his Lasix or fluticasone propionate suspension with his morning medications. NP #694 gave an order to give one time dose of Lasix 80 mg by mouth and fluticasone propionate suspension one spray each nostril. The medications were then administered. 2. Review of medical record for Resident #32 revealed an admission date of 10/05/23 and diagnoses included diabetes, anemia, depression and cellulitis. Review of Quarterly MDS assessment dated [DATE] revealed Resident #32 was cognitively intact and received insulin. Review of care plan dated 07/17/26 revealed Resident #32 had diabetes. Interventions included medications as ordered, dietary consult, and discussing mealtimes, portion sizes, dietary restrictions and ongoing monitoring. Review of May 2026 Physician orders and Medication Administrator Record (MAR) revealed Resident #32 had the following orders: check blood sugar before meals at 7:00 A.M., 11:00 A.M., 4:00 P.M. and at bedtime (9:00 P.M.); and provide Humalog insulin subcutaneous (SC) (a rapid acting insulin) per sliding scale coverage based on the blood sugar. On 05/13/26 Former Licensed Practical Nurse (LPN) #649 documented her blood sugar at 7:00 A.M. as 256 and that he administered eight units of Humalog insulin SC per sliding scale. He also documented her blood sugar at 11:00 A.M. was 290 and he administered eight units of Humalog insulin SQ per sliding scale. He documented at 4:00 P.M. Resident #32 refused her blood sugar check and possible sliding scale coverage. Review of blood sugar summary for Resident #32 revealed on 05/13/26 it was documented at 8:30 A.M. Former LPN #649 obtained her blood sugar, and it was 256 and the next time her blood sugar was taken was 3:20 P.M. and it was 290. There was no dinner blood sugar documented. Interview on 05/18/26 at 12:05 P.M. with Resident #32 revealed she recently spoke with Ombudsman #698 as she had a concern on 05/13/26 that Former LPN #649 did not administer her first dose of insulin until late afternoon around 4:30 P.M. She revealed she was to have her blood sugar checked at breakfast, lunch and dinner but that Former LPN #649 never checked her breakfast or lunch blood sugar and/or gave her insulin if needed per her sliding scale. The first time he came in was at 4:30 P.M. and at that time he checked her blood sugar and gave her insulin. She questioned him why he had not given her breakfast or lunch insulin, and he had stated he was tied up and could not get to her sooner. She revealed then at 5:30 P.M. (one hour later) he had attempted to come back into the room to check her blood sugar and give her insulin as he stated the 4:30 P.M. dose was her lunch dose, and he was now doing the dinner check. She told him he cannot do that and refused as she was not taking the insulin that close together for fear of bottoming out her blood sugar. She reported the incident to several nurses including RN #648, and LPN #620 as she felt this was neglectful as she was concerned if he was doing this to other residents that may not be cognitively intact to know the difference. Interview on 05/18/26 at 1:00 P.M. with Director of Nursing revealed she was not aware of any times Resident #32 did not receive her insulin as ordered. Interview on 05/18/26 at 2:02 P.M. with Ombudsman #698 revealed Resident #32 had brought up regarding not getting her insulin as ordered. Interview on 05/18/26 at 3:37 P.M. with RN #648 revealed Resident #32 had reported to her that Former LPN #649 had not given her insulin on 05/13/26. She stated she did not report the incident as she thought the certified nursing assistant (CNA) had but was not sure of the name of the CNA. Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed Resident #32 had reported to her that Former LPN #649 did not check her morning or lunch blood sugar and/or administer her insulin. She stated she did not report the incident as she thought Resident #32 was going to report it. Interview on 05/20/26 at 11:15 A.M. with Former LPN #649 revealed he was new at the facility and was just getting a routine down but the last day he worked, 05/13/26, he verified he obtained Resident #32's morning blood sugar before breakfast and administered her insulin but was not able to get to her lunch blood sugar check and possible insulin coverage until around 2:00 P.M. or 3:00 P.M. He stated she did not appear upset until he had gone back before dinner to check her blood sugar again and she felt it was too soon and refused. He verified the blood sugar at lunch was to be checked before lunch at 11:00 A.M. and he was three to four hours late on checking and administering her insulin. He stated, It was just the course of the day as he got behind. He verified he did not contact the Director of Nursing and/or physician that the blood sugar and/or insulin was not administered on time. He stated when he worked at the facility the management did not help when he got behind so really there was nothing else he could have done. Review of facility policy labeled, Administering Medications, dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed. Medications were to be administered in accordance with prescriber orders including required time frames. Medications were to be administered within one hour of prescribed time unless otherwise specified. The nurse administering the medication checks the label three times to verify right resident, right medication, right dose, right time, and right method. This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint surveys completed 03/25/26 and 04/20/26.

Based on record review, interview, and review of a Self-Reported Incident (SRI) and facility policy, the facility failed to provide insulin to residents using accepted standards of clinical practice. This affected four residents (Residents #12, #15, #16 and #32) out of five residents reviewed for diabetic care. This had the potential to affect 25 residents (Residents #1, #3, #8, #11, #12, #15, #16, #27, #28, #31, #32, #36, #37, #39, #41, #42, #44, #46, #49, #54, #60, #69, #70, #72 and #73) identified on insulin. The facility census was 74. Findings include:1. Review of medical record for Resident #32 revealed an admission date of 10/05/23 and diagnoses included diabetes, anemia, cellulitis, and depression. Review of care plan last revised 07/18/25 revealed Resident #32 had diabetes. Interventions included medication as ordered, dietary consult for nutritional regimen with ongoing monitoring as needed, and discuss mealtimes, portion sizes, dietary restrictions as needed. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and was on insulin.Review of May 2026 Physician Orders revealed Resident #32 had the following insulin orders: Lantus SoloStar Subcutaneous (SC) Solution Pen-injector 100 units per milliliter (ml) insulin, inject 38 units SC at bedtime due to diabetes; and Humalog Kwik pen SC solution pen-injector 100 units per ml, inject as per sliding scale before meals and at bedtime for diabetes. Interview on 05/18/26 at 12:05 P.M. and 05/20/26 at 2:12 P.M. with Resident #32 revealed she was concerned as she had heard nurses talking that they were sharing insulin needles between residents because they were out of insulin syringes and she was concerned regarding infection control if this was accurate. She discussed the concern with Licensed Practical Nurse (LPN) #620 who stated they were not sharing the pen needles, instead they were sharing the insulin pens between residents which Resident #32 still did not feel was safe, but LPN #620 stated she had no choice as the facility was out of insulin syringes. She revealed LPN #620 had stated they had used her insulin pens on others as well as other residents' insulin pens on her. 2. Review of Resident #15's medical record revealed an admission date of 06/12/25 and his diagnoses included diabetes, hypertension and mood disorder. Review of care plan dated 06/23/25 revealed Resident #15 had diabetes. Interventions included medications as ordered, blood sugars as ordered and monitoring for signs of hyperglycemia and hypoglycemia. Review of Quarterly MDS assessment dated [DATE] revealed he had severe cognitive impairment and was on insulin. Review of May 2026 Physician Orders revealed Resident #15 had an order for Lantus Solostar SC solution pen-injector 100 units per ml insulin, inject 35 units SC every morning and bedtime due to diabetes. 3. Review of Resident #12's medical record revealed an admission date of 07/31/14 and his diagnoses included diabetes, chronic kidney disease, and major depression. Review of care plan dated 07/02/25 revealed Resident #12 had diabetes. Interventions included medications as ordered, dietary consult for nutritional regimen with ongoing monitoring and monitoring for hypoglycemia and hyperglycemia symptoms. Review of Quarterly MDS assessment dated [DATE] revealed Resident #12 was cognitively intact and was on insulin. Review of May 2026 Physician Orders revealed Resident #12 had an order for Lantus insulin solution, inject 96 units SC in the morning due to diabetes. 4. Review of the email dated 05/13/26 at 3:39 P.M. from Ombudsman #698 to Director of Nursing (DON) revealed Ombudsman #698 asked if the facility had insulin needles available to provide residents with insulin per doctor's orders and to please provide evidence that such was available for example a picture. Review of the email dated 05/13/26 at 4:05 P.M. from DON to Ombudsman #698 stated she verified that she spoke with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #663 who placed the supply orders and she stated the facility was never out. There were currently five boxes in the central supply room and an emergency supply in her office. Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed there was a week recently that the facility was out of insulin syringes; therefore, if a resident had a vial of insulin the nurses could not give the insulin. She stated the nurses had no choice but to borrow and administer insulin from other residents that had insulin pens instead of the vials. She stated, We had no choice, I do not know who I borrowed from just went through the cart until found whoever I could find with the same insulin that the resident needed. LPN #620 verified she had used other residents' insulin on other residents for approximately one week until the supply of insulin syringes came in. She revealed she had notified RN/ADON #663 and she was aware the facility was out of insulin syringes and that the nurses were taking and using other residents' insulin. She stated all the nurses at the facility were doing it. LPN #620 revealed she most likely did take Resident #32's insulin or gave her someone else's insulin. Interview on 05/19/26 at 11:21 A.M. with LPN #674 revealed for about a week the facility was without insulin syringes and that she did take another resident's unopened insulin injection pen and administer it to another resident. She had placed that resident's name on the insulin pen. She could not remember whose insulin pen she took from and who she gave it to. Interview on 05/19/26 at 11:29 A.M. with LPN #675 revealed she had taken other residents' insulin to administer to other residents as residents did not have their insulin as ordered. She stated, I know it is wrong. I just do not really have a choice as they need their insulin. She revealed she knew she took Resident #12's insulin vial and gave it to Resident #15 or it was the other way around as one of them did not have any insulin. LPN #675 verified she had taken other residents' insulin and gave it to other residents but could not remember the exact residents she did. Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she completed the ordering of supplies including insulin syringes. She stated nobody had brought to her attention that the facility was out of syringes. She became aware of the concern about a week ago when Ombudsman #698 contacted the facility that a nurse had reported to them the facility was out of insulin syringes. She revealed the facility had syringes and she placed an extra box in her office that the nurses had access to as back up. She was not aware that nurses were taking and administering residents' insulin that belonged to another resident. Interview on 05/19/26 at 3:01 P.M. with Ombudsman #698 revealed it was reported to her by Resident #32 that the facility was out of insulin syringes and they were borrowing insulin pens from other residents. Review of SRI #274748 dated 05/19/26 at 8:34 P.M. revealed an SRI was filed by the Administrator regarding an allegation of misappropriation involving LPN #620 and LPN #675 taking insulin from Resident #12 and giving the insulin to another resident (Resident #16). The SRI revealed LPN #620 and LPN #675 took insulin from residents without their consent. Interview on 05/20/26 at 11:38 A.M. with RN #635 revealed the last day she worked she heard the facility was out of insulin syringes. She had to borrow at times other residents' insulin for another resident as they were out but was unable to remember who she had borrowed from. Review of witness statement dated 05/22/26 at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day. Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin. Interview on 05/26/26 at 12:58 P.M. with DON revealed they had investigated regarding nurses taking other residents' insulin and administering it to other residents and LPN #620 and LPN #675 had stated they did. She stated she did not have witness statements from them as they had stated it verbally on investigation. LPN #620 and LPN #675 were terminated for misappropriation. Review of facility policy labeled, Administering Medications, dated April 2019 revealed insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident.This deficiency represents non-compliance investigated under Complaint Number 2991563.

Based on observation, interview, record review and review of facility policy, the facility failed to provide showers for residents dependent on staff for activities of daily living (ADL) per their preference and/or as scheduled. This affected two residents (Residents #25 and #70) out of three residents reviewed for ADL care. This had the potential to affect 35 residents (Residents #1, #3, #5, #8, #13, #15, #19, #20, #21, #22, #23, #24, #25, 27, #29, #32, #33, #42, #44, #47, #48, #49, #50, #54, #55, #56, #57, #59, #60, #62, #66, #69, #70, #71 and #72) dependent on staff for ADL care including showers. The facility census was 74. Findings include:1. Review of medical record for Resident #70 revealed an admission date of 05/21/25 and his diagnoses included diabetes, heart failure, major depression, and hypertension.Review of Kardex care plan dated 06/04/25 revealed Resident #70 required extensive assist from one staff for showers, and he was dependent on two staff assist for transfers with use of a mechanical lift (a device designed to transfer a resident from surface to surface).Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had intact cognition and required substantial to maximum assistance with showers and was dependent on staff for shower transfers. Review of task bar Bath/Shower documentation from 04/22/26 to 05/21/26 revealed Resident #70 was to receive a shower every Wednesday and Saturday in the evening. He received a partial bed bath on 04/22/26, and a bed bath on 04/24/26, 04/26/26, 05/03/26 (seven days after), 05/06/26, 05/09/26 and 05/21/26 (11 days after). Interview on 05/19/26 at 9:58 A.M. with Resident #70 revealed getting a bed bath and/or shower was an issue as he felt it had been over three weeks since his last bed bath/shower. He stated he preferred to have a shower twice a week as he felt with a bed bath staff did not get him clean enough, but that staff only would give him a bed bath. Observation at the time of the interview of Resident #70's ostomy bag revealed there was a brown, black substance surrounding the ostomy appliance and on the bag. 2. Review of medical record for Resident #25 revealed an admission date of 04/28/26 and his diagnoses included legal blindness, schizoaffective disorder, hypertension, and chronic pain syndrome.Review of task bar Bath/Shower documentation from 04/28/26 to 05/19/26 revealed Resident #25 was to receive a bath or shower every Tuesday and Friday morning. The documentation revealed he had a shower 05/05/26, 05/08/26, and a partial bed bath on 05/12/26. There was no documentation he had a shower or bath from 05/12/26 to 05/19/26 (seven days). Review of Medicare Five Day MDS assessment dated [DATE] revealed Resident #25 had impaired cognition and required partial to moderate assistance with showers and transfers. Review of Kardex care plan dated 05/05/26 revealed Resident #25 needed assistance from one staff for bathing, and transfers. Review of care plan dated 05/16/26 revealed Resident #25 had impaired visual function as he was legally blind. Interventions included to tell the resident where placing items and be consistent. Interview on 05/19/26 at 9:25 A.M. with Resident #25 revealed he was upset about his care as he was to receive a shower every Tuesday and Friday but that the aides would not assist him with one as he stated they do not help me. He revealed he preferred a shower twice a week and since he had been at the facility he had only received two in three weeks. Interview on 05/19/26 at 9:52 A.M. with Certified Nursing Assistant (CNA) #647, and CNA #631 revealed at times there were only two aides on the [NAME] Unit, and they could not get to all the assigned showers. They revealed there were times when they had up to eight showers a day and could not get them all done. Interview on 05/19/26 at 2:32 P.M. with Director of Nursing revealed staff documented in the electronic medical record all showers and baths per the task bar and they do not have shower sheets. Interview on 05/19/26 at 2:42 P.M. with CNA #651 revealed residents were not getting their showers or baths as scheduled as not enough staff and at times some of the aides do not do their showers. She revealed she went to the Former Administrator #699 regarding the concern of residents not getting their showers but felt as if she was attacked for bringing up the concern. Interview on 05/21/26 at 10:47 A.M. with Regional Nurse #696 verified Resident #70 was to have a shower every Wednesday and Saturday in the evening. She verified he went from 04/26/26 to 05/03/26 (seven days), and from 05/09/26 to 05/21/26 (11 days) without a shower. Also, she verified Resident #25's task bar Bath/Shower documentation from 04/28/26 to 05/19/26 revealed Resident #25 was to receive a bath or shower every Tuesday and Friday morning. The documentation revealed he had not had a shower or bath from 05/12/26 to 05/19/26 (seven days). Review of facility policy labeled, Activities of Daily Living (ADL), Supporting, dated March 2018 revealed residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care including hygiene (bathing). This deficiency represents non-compliance investigated under Complaint Number 2991563.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure ostomy care was provided as recommended. This affected two residents (Residents #70 and #77) out of three residents reviewed for ostomy care. This had the potential to affect five Residents (#36, #48, #61, #70 and #77) who the facility identified with ostomies. The facility census was 74.Findings include:1. Review of medical record for Former Resident (FR) #77 revealed an admission date of 02/13/24 and his diagnoses included hypotension, diabetes, chronic kidney disease, cerebral infarction, sepsis with acute organ dysfunction, septic shock, endocarditis, perforated bowel, history of cardiac arrest, and prolapsed ostomy.Review of care plan dated 08/07/25 revealed FR #77 had an alteration in gastrointestinal status related to colostomy. Interventions included empty ostomy bag each shift and as needed, give medications as ordered, monitor skin around stoma for irritation, sit upright for all meals and obtain and monitor lab work as ordered. There was nothing in his care plan regarding changing of his ostomy bag (a medical device worn outside the body to collect waste from the stoma, a surgically created opening in the abdomen) and or measuring the output. Review of care plan dated 12/12/25 revealed FR #77 had potential for pressure injury, a surgical wound, rash, cellulitis, skin tear, and vascular wound. Interventions included performing weekly skin assessments, reporting and documenting irregularities, protecting skin from moisture, encouraging adequate nutrition, evaluating and assessing pain control, and administering treatments as ordered. There was nothing in the care plan regarding an actual surgical incision with sutures to his abdomen. Review of April 2026 Treatment Administration Record (TAR) revealed no treatment order and/or documentation for his surgical incision with retention sutures (heavy, nonabsorbable stitches used in high-tension wound closures) that was recommended on his discharge instructions to cleanse with saline, apply an abdominal pad and tape with soft cloth adhesive. There also was no order on the TAR including for stoma assessment: inspect daily for color, edema, bleeding, or signs of ischemia, peristomal skin monitoring including monitor for breakdown, irritation, or infection and use barrier creams as needed. In addition, there was no order to monitor ostomy output that included recording volume, consistency, and frequency of effluent every shift and to notify the physician if high output of greater that 1200 milliliters (ml) per day, or sudden decrease or signs of obstruction as indicated in Nurse Practitioner (NP) #693's progress note dated 04/02/26. Review of admission Medicare Five Day Minimum Data Set (MDS) assessment dated [DATE] revealed FR #77 had intact cognition and he had an ostomy. He required substantial to maximum assistance with his toileting needs. Review of nursing note dated 04/01/26 at 8:01 P.M. and completed by Licensed Practical Nurse (LPN) #649 revealed at 6:30 P.M., FR #77 asked for help changing his ostomy bag for the fourth time during the shift and it had been ten minutes since the last change. There was no visible stool when the bag was removed but there was intestine exposed of approximately eight to ten inches. FR #77 denied pain and Emergency Rescue Squad (EMS) was contacted to send to the emergency room (ER). Review of After Visit Summary dated 04/02/26 revealed FR #77 was seen in the hospital for a prolapsed ostomy. The summary revealed past surgical history included on 07/28/25 of an exploratory laparotomy with total abdominal colectomy, and ileostomy due to peritonitis and septic shock. On 03/13/26 he had an exploratory laparotomy small bowel resection application of an active temporary abdominal closure system to manage open abdomen wounds (ABTHRA), and on 03/15/26 laparotomy exploratory surgery was performed. Hospital Admitting Physician #692 noted FR #77 was admitted due to a prolapsed stoma as he presented in the ER with approximately 7.5 inches to eight inches of stoma protruding from his abdomen. There was a one centimeter (cm) wound dehiscence (the splitting open of the surgical area) noted. The discharge instructions included wound care for his surgical wound to medial upper abdomen that was closed with retention sutures from laparotomy completed on 03/13/26. The instructions included cleansing with saline, applying an abdominal pad and tape with soft cloth adhesive. Department of general surgery consulted due to the ostomy prolapse of eight inches of bowel was hanging out. The ostomy prolapse resolved on its own, his ostomy appeared healthy and he was having output from his ostomy. Review of NP #693 progress note dated 04/02/26 at 12:39 P.M. revealed she consulted due to status post hospitalization. The progress noted on assessment an abdominal surgical wound but no description of the wound. She recommended assessing for dehydration, including monitoring oral intake, monitoring ostomy output and signs of volume depletion as she may consider intravenous fluids if evidence of hypovolemia (abnormally low volume of circulating blood or fluid in the body). She ordered ostomy care and monitoring that included stoma assessment: inspect daily for color, edema, bleeding, or signs of ischemia. She also ordered peristomal skin monitoring including monitoring for breakdown, irritation, or infection and use of barrier creams as needed. In addition, she ordered to monitor ostomy output that included recording volume, consistency, and frequency of effluent every shift and to notify the physician if high output of greater than 1200 milliliters (ml) per day, or sudden decrease or signs of obstruction. Review of Skin Check Evaluation dated 04/04/26 completed by LPN #608 revealed FR #77 had an abrasion to the top of his scalp and an abrasion to his left hand. There was nothing on the assessment regarding his abdominal surgical incision with retention sutures. Review of Skin Check Evaluation dated 04/08/26 completed by LPN/Unit Manager #627 revealed FR #77 had a surgical incision to his abdomen. There was no description including measurement. Review of Skin Check Evaluation dated 04/15/26 and completed by LPN/Unit Manager #627 revealed FR #77 had a surgical incision to his abdomen. There was no description including measurement. Review of NP #694's progress note dated 04/15/26 at 10:13 P.M. revealed she consulted and noted his abdomen was non-tender and non-distended. He had an ileostomy and a mid-abdominal incision with bumper sutures (high tension wound closure to secure the area). There was no description of the incision site. Review of NP #693's progress note dated 04/16/26 at 4:15 P.M. revealed she consulted and noted he had an ileostomy and abdominal surgical incision. There was no description of the incision site. She continued to recommend assessing for dehydration, including monitoring oral intake, monitoring ostomy output and signs of volume depletion as she may consider intravenous fluids if evidence of hypovolemia. She continued to order ostomy care and monitoring that included stoma assessment: inspecting daily for color, edema, bleeding, or signs of ischemia. She also ordered peristomal skin monitoring including monitoring for breakdown, irritation, or infection and use of barrier creams as needed. In addition, she ordered to monitor ostomy output that included record volume, consistency, and frequency of effluent every shift and to notify the physician if high output of greater than 1200 ml per day, or sudden decrease or signs of obstruction. Review of nursing note dated 04/17/26 at 8:05 A.M. completed by LPN #632 revealed the nurse was called to the room as FR #77 was unresponsive and not able to be aroused. He was sent to the ER. Interview on 05/19/26 at 11:32 A.M. and 05/26/26 at 10:50 A.M. with Primary Care Physician (PCP) #695 revealed he was FR #77's physician and was aware of his abdominal incision but had not visibly assessed it. He verified per the hospital notes there was a one cm dehiscence of the surgical wound, and the discharge instructions included wound care for his surgical wound to the medial upper abdomen was to cleanse with saline, apply an abdominal pad and tape with soft cloth adhesive. He verified the facility should have been doing his surgical wound treatment at least daily. He also revealed they should have been at least changing his ostomy appliance weekly to twice a week or more often as needed, monitoring his output and emptying daily or more as needed. Interview on 05/21/26 at 9:09 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Wound Nurse #663 revealed she oversaw wound care at the facility. She had an outside wound provider come in on a weekly basis to see all wounds including pressure and surgical. She verified FR #77 was not seen by the outside wound provider. She confirmed there was no assessment of the surgical wound including measurements, appearance, number of retention sutures and/or anything regarding the measurement of the wound dehiscence as noted in the hospital note. She verified the only skin assessments in his record were on 04/04/26 which did not have that he had an abdominal incision, and on 04/08/26 and 04/15/26 it had that he had an abdominal incision but no description of it. She verified there was a treatment order on return from the hospital on [DATE] that included cleansing with saline, applying with an abdominal pad and taping with soft cloth adhesive, but it was not completed as ordered. She verified she usually sees all wounds, completes the measurements and assessments and ensures the resident had a treatment, but it was overlooked as in her position it was just a lot to keep up with wounds and infection control. Interview on 05/21/26 at 9:28 A.M. with LPN/Unit Manager #627 revealed she looked at the surgical wound but could not provide any details including measurements, how many sutures, if the area had dehisced, and/or any other description. She stated she recalled that his site was nothing out of the ordinary, and it was the RN/ADON/Wound Nurse #663 or outside wound provider who completed the measurements and description of the wounds. Interview on 05/21/26 at 10:10 A.M. with NP #693 verified she consulted and saw FR #77 during his stay at the facility. She was aware that he had a surgical incision to his abdomen and a ileostomy but had not seen and/or evaluated. She revealed she had seen him when he was outside on the patio and it was not appropriate to lift his shirt in that area. She verified the facility should have been following her orders including assessing for dehydration including monitoring oral intake, monitoring ostomy output and signs of volume depletion as she may consider intravenous fluids if evidence of hypovolemia. She also ordered ostomy care and monitoring that included stoma assessment: inspecting daily for color, edema, bleeding, or signs of ischemia. She ordered peristomal skin monitoring including monitoring for breakdown, irritation, or infection and use of barrier creams as needed. In addition, she ordered to monitor ostomy output that included recording volume, consistency, and frequency of effluent every shift and to notify the physician if high output of greater than 1200 ml per day, or sudden decrease or signs of obstruction.Interview on 05/21/26 at 11:54 A.M. with NP #694 verified she had seen FR #77 on 04/15/26 as she saw him mainly for his blood pressure that day. She revealed she did not complete a thorough assessment of his abdomen as he briefly lifted his shirt, and she noted no unusual complications including infections. She was unable to describe the incision, if the wound had dehisced, number of sutures, and/or its measurement. Interview on 05/26/26 at 11:44 A.M. with Regional Nurse #696 verified there was an order from the hospital on [DATE] that included cleansing with saline, applying an abdominal pad and taping with soft cloth adhesive. She also verified on the hospital record dated 04/02/26 there was documentation that the wound had a one cm dehiscence, and on return from the hospital there was no documentation that the treatment was completed as ordered and/or an assessment of the abdominal wound completed, including measurements, description, and number of sutures. She also verified there was no documentation regarding ileostomy care including NP #693's recommendations that included ostomy care and monitoring that included stoma assessment: inspecting daily for color, edema, bleeding, or signs of ischemia, peristomal skin monitoring including monitoring for breakdown, irritation, or infection and use of barrier creams as needed. In addition, there was no documentation regarding monitoring ostomy output that included recording volume, consistency, and frequency of effluent every shift and to notify the physician if high output of greater than 1200 ml per day, or sudden decrease or signs of obstruction. She also verified NP #693's recommendations to monitor ostomy output and signs of volume depletion as she may consider intravenous fluids if evidence of hypovolemia. 2. Review of medical record for Resident #70 revealed an admission date of 05/21/25 and his diagnoses included diabetes, heart failure, sepsis and hypertension. Review of care plan dated 06/04/25 revealed Resident #70 had an alteration in gastrointestinal status related to colostomy. Intervention included empty ostomy bag each shift and as needed, give medications as ordered, monitor for abdominal distention, and monitor skin around stoma for irritation. There was nothing in the care plan regarding changing the ostomy bag. Review of Physician Orders and Treatment Administration Records (TAR) for March 2026, April 2026 and May 2026 revealed there were no orders for Resident #70's ostomy bag including monitoring his stoma area, changing his bag and/or emptying his bag. There was no documentation when Resident #70's ostomy bag was last changed. Review of Quarterly MDS assessment dated [DATE] revealed Resident #70 had intact cognition and an ostomy. He required substantial to maximum assistance with his toileting needs. Interview and observation on 05/19/26 at 9:58 A.M. with Resident #70 revealed they only changed his ostomy appliance when it ruptured and/or fell off. He had been wearing the current ostomy bag for about one month as that was the last time they had changed it. He stated he was used to the ostomy bag being changed about weekly to twice a week but that was not what they did at this facility. Observation of the ostomy bag revealed it had dark brown, black substance surrounding the ostomy appliance and on the bag. Interview on 05/19/26 at 2:32 P.M. with Director of Nursing verified there were no colostomy orders including monitoring/assessing the stoma site, emptying colostomy bag, and/or changing of the colostomy bag. She verified she had no documentation as to when Resident #70's bag was changed last. Review of facility policy labeled, Colostomy/Ileostomy Care, dated October 2010 revealed the purpose of the procedure was to provide guidelines that aided in preventing exposure of the resident's skin to fecal matter. There was nothing in the policy regarding frequency of changing the ostomy bag, emptying the bag and checking the stoma area. The policy revealed the following information should be recorded in the resident's record: date and time the ostomy care was provided, if there were any breaks in the resident's skin, signs of infection, and/or excoriation of the skin.This deficiency represents non-compliance investigated under Complaint Number 2993004.

Based on observation, interview, record review, review of the Centers for Medicare and Medicaid services (CMS) memorandum QSO-24-08-NH, and review of facility policy, the facility failed to utilize enhanced barrier precautions (EBP) for Resident #54 during high contact resident care. This affected one resident (Resident #54) out of two residents observed for EBP. This had the potential to affect 27 residents (Residents #1, #3, #5, #9, #10, #19, #20, #21, #31, #34, #36, #39, #41, #43, #45, #44, #48, #53, #54, #56, #60, #61, #66, #67, #69 #70 and #73) identified by the facility on EBP.Findings include:Review of medical record for Resident #54 revealed an admission date of 12/31/20 and her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, chronic obstructive pulmonary disease, and pulmonary edema. Review of care plan dated 10/07/25 revealed Resident #54 required EBP due to a feeding tube (a flexible tube inserted in the stomach to provide fluids and/or nutrition). Interventions included providing EBP including gloves, gown, mask, face shield for staff to wear during high contact resident care activities including dressing, bathing, hygiene care, assistance with toileting, and transferring. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had impaired cognition and required a feeding tube. She required substantial to maximum assistance with toileting hygiene, upper body dressing, and personal hygiene. She was dependent on staff for lower dressing, bathing and/or showers. Review of May 2026 Physician Orders revealed Resident #54 had an order dated 05/23/25 for EBP due to feeding tube. Observation on 05/19/26 at 9:40 A.M. revealed Certified Nursing Assistant (CNA) #631, and CNA #647 entered Resident #54's room to provide morning hygiene and incontinence care. There was signage on the outside of the door that indicated she was on EBP as well as a bag hanging on the inside of the door with personal protective equipment (PPE) including gowns, gloves and masks. Resident #54 had an enteral feeding tube in her stomach that was connected to the feeding pump. CNA #631 and CNA #647 proceeded to perform hand hygiene and applied gloves. They did not apply a gown. CNA #631 and CNA #647 completed morning hygiene and incontinence care including rolling Resident #54 towards them and she came in direct contact with both their uniforms/clothing. They then doffed their gloves and performed hand hygiene. Interview on 05/19/26 at 9:52 A.M. with CNA #631 and CNA #647 verified there was signage on the doorway for Resident #54 to be on EBP and they did not apply a gown during her care. CNA #647 verified they were supposed to wear a gown especially because the resident had a feeding tube. Interview on 05/19/26 at 11:19 A.M. with Regional Nurse #696 verified anytime staff were providing high contact care including hygiene and incontinence care for Resident #54 they were to wear EBP including a gown as she had a feeding tube. Interview on 05/19/26 at 2:08 P.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Infection Control #663 verified during high contact care activities EBP was to be worn including a gown for Resident #54 as she had a feeding tube. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the CMS, Department of Health & Human Services revealed EBP were indicated for residents with indwelling medical devices including feeding tubes even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). EBP was an infection control measure designed to reduce transmission of MDRO and employs targeted gown and glove use during high contact care activities. High contact care activities included dressing, bathing, transferring, providing hygiene, changing incontinence products, and/or assisting with toileting. The effective date for implementation of EBP under the guidelines was 04/01/24.Review of facility policy labeled, Enhanced Barrier Precautions, dated 2021 revealed EBP were utilized to prevent the spread of MDRO to residents. EBP referred to infection prevention and control interventions designed to reduce transmission of MDRO during high contact care activities. EBP applied to residents even if not known to be infected with an MDRO but had a wound or indwelling device. Indwelling devices included central lines, urinary catheters, and feeding tubes. Gloves and a gown were to be applied prior to performing high contact resident care activities including dressing, bathing, transferring, providing hygiene, changing incontinence products, and/ or assisting with toileting. This deficiency represents non-compliance investigated under Complaint Number 2991563.

Based on record review, interview, and facility policy review, the facility failed to ensure resident rights were maintained. This affected one Resident (#43) out of 11 residents reviewed for resident rights. The facility census was 74.Findings include:Review of medical record for Resident #43 revealed an admission date of 10/10/25 and his diagnoses included chronic kidney disease, hypertension, and dependence on renal dialysis. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition, and no behaviors were identified.Review of care plan last revised 05/05/26 revealed Resident #43 had a behavior problem related to demanding medications for immediate administration, attention seeking, verbal aggression, swearing towards staff, and making false allegations. Interventions included adjusting voice tone; behavior contract given; caregivers to provide opportunities for positive interaction and attention; stop and talk with him when passing by; intervene as necessary to protect rights of others; speak in a calm manner; take to an alternate location as needed; and move to a less stimulating environment. There was nothing in the care plan regarding not allowing Resident #43 on the [NAME] Unit. Review of Resident #43's behavior contract dated 05/05/26 revealed over the past six months Resident #43 had displayed negative behaviors that had affected residents around him, the staff designated to care for him, and his roommate's ability to receive care. The plan listed as tools the resident could utilize: the facility concern form process, the Administrator and/or Director of Nursing (DON) were available to discuss concerns, and he refused to see psychological services. There was nothing in the behavioral contract regarding restricting him from a specified unit or staff to call the police if he did not leave a unit, especially if Resident #43 was calm and demonstrating no behaviors. Review of care plan last revised 05/06/26 revealed Resident #43 demonstrated verbally abusive behaviors related to coping skills, mental illness, poor impulse control as the resident belittled staff while yelling at staff in hallways. Interventions included adjusting voice tone; assess and anticipate needs; assess resident's coping skills and support system; allow time for resident to express self and feelings toward the situation; and when resident becomes agitated intervene before agitation escalates, guide away from source, engage calmly in conversation if response was aggressive the staff was to walk calmly away and approach later. There was nothing in the care plan regarding restricting Resident #43 on the [NAME] Unit. Interview on 05/19/26 at 8:51 A.M. with Resident #43 revealed an incident occurred on Sunday, 05/03/26, as he was supposed to have pain medication around 2:45 A.M. and it was 4:10 A.M. He looked for the nurse as he was in significant pain from a bad tooth. He finally found the nurse (Licensed Practical Nurse #620) on the other unit, [NAME] Unit, and asked her what was up with not getting his pain medication. He stated they got into an altercation because she had said she was not giving him his pain medication and then she called the police. The police came and then he received his pain medication. He revealed that he knew Registered Nurse (RN) #648 was scheduled to come in on 05/03/26 at 7:00 A.M., so he went to talk to her on the [NAME] Unit as he stated he always talked to her every morning that she worked. He started to talk with RN #648 when Licensed Practical Nurse (LPN) #620 stated to get off the unit or that she would call the police. LPN #620 repeated it a few times. He stated, She threatened me, as he revealed he had never said anything to LPN #620 when he walked onto the unit and felt it was against his right that he could not be on the unit when he was just talking with RN #648. He stated that LPN #620 was no longer on duty as RN #648 had relieved her, so he did not understand why he did not have the right to be on the unit but indicated he left the unit. Interview on 05/19/26 at 10:09 A.M. with RN #648 revealed when she came on duty LPN #620 was at the medication cart, and she was awaiting to receive report from LPN #620 when Resident #43 walked onto [NAME] Unit and started to talk with her. She used to work on his unit, and they had a good rapport so every morning he usually came over to talk to her when she came on duty. She stated Resident #43 had not said anything to LPN #620 when he came up to them and started to talk with her in a calm manner. LPN #620 immediately told him, You do not need to be over here. RN #648 revealed Resident #43 then stated in a calm manner he came over to talk to her (RN #648), and LPN #620 stated, If you do not leave, I am calling the police. RN #648 again stated that Resident #43 was calm and did not display any behavior. RN #648 stated, Yes I feel she (LPN #620) kind of threatened him as he was just on the unit talking with me and not doing anything. He then appeared upset and left the unit. She did not report the incident to management. Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed there was a night that there was an altercation with Resident #43 as he was yelling in the middle of the night and they contacted the police. Later in the morning he had come over to [NAME] Unit at shift change and started swearing at her and calling her names. She told him to go back on the other side. LPN #620 verified she had told him if he did not go to his side she was calling the police. She revealed she notified RN/Assistant Director of Nursing (ADON) #663 about the incident and that she had said I did wrong as she said she should have just been quiet and not tell him to go to the other side or that she was contacting the police if he did not leave. Review of Resident #43's nursing notes dated 05/03/26 revealed there was no documentation regarding Resident #43 going to the [NAME] Unit in the morning at change of shift swearing at LPN #620 and calling her names. Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she could not remember all the details of the incident on 05/03/26 as she had not slept well when she had received the phone call from LPN #620, but does remember LPN #620 contacting her stating something about Resident #43 was yelling at her and she thought she had asked LPN #620 if she yelled back as she had the tendency to. She was not sure if that was when she had stated she told him to leave the unit or she was calling the police. She had used that as an educational moment that she could not do that but was unsure as she did not remember the full conversation. RN/ADON #663 verified she had not investigated the incident any further after the phone call. Interview on 05/19/26 at 2:32 P.M. with DON verified it had not been reported to her by RN #648 or to any other management regarding Resident #43 being on [NAME] Unit and LPN #620 telling him to leave the unit or she was calling the police, or that RN #648 felt LPN #620 threatened Resident #43. Interview on 05/19/26 at 4:35 P.M. with Regional Nurse #696 and RN #648 who came into the facility to speak with this surveyor revealed Regional Nurse #696 stated RN #648 had not felt LPN #620 was threatening Resident #43. This surveyor read aloud her interview and after reading it, RN #648 stated, That is correct. Then Regional Nurse #696 stated to RN #648, I thought you said LPN #620 did not threaten him, and then RN #648 stated, Yes she did not threaten him. RN #648 then continued stating she felt it was Resident #43's home and he had the right to be on any unit and should not be told to leave the unit or if he did not the police would be called. RN #648 verified again Resident #43 was calm that morning and had not said anything to LPN #620. Review of facility policy labeled, Resident Rights Policy and Procedure, dated 2026 revealed the purpose of the policy was to ensure the preservation of every resident's right to a dignified exitance, self-determination, and communication with and access to persons and services inside and outside the facility. Every resident had the right to be treated with respect and dignity including the right to be free from any psychical or chemical restraints imposed for purposes of discipline or convenience. Also, each resident had the right to interact with members of the community both inside and outside of the facility. This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint survey completed 03/25/26.

Based on record review, interview, review of a Self-Reported Incident (SRI) and facility policy, the facility failed to timely investigate into allegations that led to misappropriation of insulin. This affected four residents (Residents #12, #15, #16 and #32) out of five residents reviewed for misappropriation of their insulin. This had the potential to affect 25 residents (Residents #1, #3, #8, #11, #12, #15, #16, #27, #28, #31, #32, #36, #37, #39, #41, #42, #44, #46, #49, #54, #60, #69, #70, #72 and #73) identified on insulin. The facility census was 74.Findings include:1. Review of medical record for Resident #32 revealed an admission date of 10/05/23 and diagnoses included diabetes, anemia, cellulitis, and depression. Review of care plan last revised 07/18/25 revealed Resident #32 had diabetes. Interventions included medication as ordered, dietary consult for nutritional regimen with ongoing monitoring as needed, and discuss mealtimes, portion sizes, dietary restrictions as needed. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and was on insulin.Review of May 2026 Physician Orders revealed Resident #32 had the following insulin orders: Lantus SoloStar Subcutaneous (SC) Solution Pen-injector 100 units per milliliter (ml) insulin, inject 38 units SC at bedtime due to diabetes; and Humalog Kwik pen SC solution pen-injector 100 units per ml, inject as per sliding scale before meals and at bedtime for diabetes. Interview on 05/18/26 at 12:05 P.M. and 05/20/26 at 2:12 P.M. with Resident #32 revealed she was concerned as she had heard nurses talking that they were sharing insulin needles between residents because they were out of insulin syringes and she was concerned regarding infection control if this was accurate. She discussed the concern with Licensed Practical Nurse (LPN) #620 who stated they were not sharing the pen needles, instead they were sharing the insulin pens between residents which Resident #32 still did not feel was safe, but LPN #620 stated she had no choice as the facility was out of insulin syringes. She revealed LPN #620 had stated they had used her insulin pens on others as well as other residents' insulin pens on her.2. Review of Resident #15's medical record revealed an admission date of 06/12/25 and his diagnoses included diabetes, hypertension and mood disorder. Review of care plan dated 06/23/25 revealed Resident #15 had diabetes. Interventions included medications as ordered, blood sugars as ordered and monitoring for signs of hyperglycemia and hypoglycemia. Review of Quarterly MDS assessment dated [DATE] revealed he had severe cognitive impairment and was on insulin. Review of May 2026 Physician Orders revealed Resident #15 had an order for Lantus Solostar SC solution pen-injector 100 units per ml insulin, inject 35 units SC every morning and bedtime due to diabetes.3. Review of Resident #12's medical record revealed an admission date of 07/31/14 and his diagnoses included diabetes, chronic kidney disease, and major depression. Review of care plan dated 07/02/25 revealed Resident #12 had diabetes. Interventions included medications as ordered, dietary consult for nutritional regimen with ongoing monitoring and monitoring for hypoglycemia and hyperglycemia symptoms. Review of Quarterly MDS assessment dated [DATE] revealed Resident #12 was cognitively intact and was on insulin. Review of May 2026 Physician Orders revealed Resident #12 had an order for Lantus insulin solution, inject 96 units SC in the morning due to diabetes.4. Review of the email dated 05/13/26 at 3:39 P.M. from Ombudsman #698 to Director of Nursing (DON) revealed Ombudsman #698 asked if the facility had insulin needles available to provide residents with insulin per doctor's orders and to please provide evidence that such was available for example a picture. Review of the email dated 05/13/26 at 4:05 P.M. from DON to Ombudsman #698 stated she verified that she spoke with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #663 who placed the supply orders and she stated the facility was never out. There were currently five boxes in the central supply room and an emergency supply in her office.Interview on 05/19/26 at 10:37 A.M. with LPN #620 revealed there was a week recently that the facility was out of insulin syringes; therefore, if a resident had a vial of insulin the nurses could not give the insulin. She stated the nurses had no choice but to borrow and administer insulin from other residents that had insulin pens instead of the vials. She stated, We had no choice, I do not know who I borrowed from just went through the cart until found whoever I could find with the same insulin that the resident needed. LPN #620 verified she had used other residents' insulin on other residents for approximately one week until the supply of insulin syringes came in. She revealed she had notified RN/ADON #663 and she was aware the facility was out of insulin syringes and that the nurses were taking and using other residents' insulin. She stated all the nurses at the facility were doing it. LPN #620 revealed she most likely did take Resident #32's insulin or gave her someone else's insulin. Interview on 05/19/26 at 11:21 A.M. with LPN #674 revealed for about a week the facility was without insulin syringes and that she did take another resident's unopened insulin injection pen and administer it to another resident. She had placed that resident's name on the insulin pen. She could not remember whose insulin pen she took from and who she gave it to.Interview on 05/19/26 at 11:29 A.M. with LPN #675 revealed she had taken other residents' insulin to administer to other residents as residents did not have their insulin as ordered. She stated, I know it is wrong. I just do not really have a choice as they need their insulin. She revealed she knew she took Resident #12's insulin vial and gave it to Resident #15 or it was the other way around as one of them did not have any insulin. LPN #675 verified she had taken other residents' insulin and gave it to other residents but could not remember the exact residents she did. Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she completed the ordering of supplies including insulin syringes. She stated nobody had brought to her attention that the facility was out of syringes. She became aware of the concern about a week ago when Ombudsman #698 contacted the facility that a nurse had reported to them the facility was out of insulin syringes. She revealed the facility had syringes and she placed an extra box in her office that the nurses had access to as back up. She was not aware that nurses were taking and administering residents' insulin that belonged to another resident.Interview on 05/19/26 at 2:32 P.M. and 05/26/26 at 12:58 P.M. with DON revealed she had received notification from the Ombudsman #698 on 05/13/26 of concern of not having insulin syringes in the building and verified she did not interview any residents and/or nurses if there was a concern with not getting their insulin and/or not having insulin syringes to provide insulin as ordered and/or investigate further besides checking if the facility currently had insulin syringes. She revealed as of 05/26/26 they had investigated regarding nurses taking other residents' insulin and administering to other residents and LPN #620 and LPN #675 had stated they did. She did not have witness statements from the nurses as they had stated it verbally on investigation. She revealed LPN #620 and LPN #675 were terminated for misappropriation. Interview on 05/19/26 at 3:01 P.M. with Ombudsman #698 revealed it was reported to her by Resident #32 that the facility was out of insulin syringes and they were borrowing insulin pens from other residents. She revealed they sent the facility an email regarding the concern on 05/13/26.Review of SRI #274748 dated 05/19/26 at 8:34 P.M. revealed an SRI was filed by the Administrator regarding an allegation of misappropriation involving LPN #620 and LPN #675 taking insulin from Resident #12 and giving the insulin to another resident (Resident #16). The SRI revealed LPN #620 and LPN #675 took insulin from residents without their consent.Review of witness statement dated 05/22/26 at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day.Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin.Review of facility policy labeled, Resident Right to Freedom from Abuse, Neglect, and Exploitation, dated 2026 revealed residents were to be free from abuse, neglect, misappropriation of their property and exploitation. The facility would conduct a thorough investigation of the alleged violation. This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint survey completed 03/25/26.

Based on record review, observation, interview and policy review, the facility failed to ensure a resident was properly transported in a wheelchair to prevent injury. Actual harm occurred on 03/13/26 when Resident #5, who had hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) in his right leg and required a wheelchair for mobility, was transported to an appointment under the supervision of Transporter #719. Transporter #719 failed to maintain proper positioning of Resident #5, causing his right leg to press into the leg rests. His foot also repeatedly hit the ground when being pushed in a wheelchair to his physician appointment. Resident #5 winced in pain and complained of pain in his right leg to the staff at the physician's office. Resident #5 developed bruising and a wound infection of the right leg and was hospitalized on [DATE]. Resident #5 was diagnosed with an acute, nondisplaced transverse fracture of the proximal tibial metaphysis. No surgical intervention was recommended and Resident #5 returned to the facility on [DATE] on opioid pain medication, anticoagulant medication (blood thinner) and orders for non-weight bearing on the right leg. This affected one (Resident #5) of three residents reviewed for accidents. The facility census was 67. Findings include:Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side.Review of the care plan revised 02/28/26 revealed Resident #5 had hemiplegia related to a stroke. Interventions included reposition as tolerated every two hours. Resident #5 had self-care deficits that included dressing, personal hygiene, eating, toileting and bathing. Resident #5 required extensive assistance of one to two staff for bed mobility and was dependent on staff for bathing and toileting and required a Hoyer (mechanical lift) for transfers. Review of the Medication Administration Record (MAR) dated March 2026 revealed Resident #5 had an outside appointment with a physician on 03/13/26 at 1:00 P.M.Review of the note from the physician office dated 03/13/26, revealed Resident #5 was referred to the center's hematology office for an initial visit due to anemia. Physician #980 wrote the resident had aphasia, chronic psychosis, was unable to give any history, was not able to answer questions, and was only able to state that his right leg hurt. Physician #980 documented Resident #5 was there with an aide from the facility however the aide did not have any information regarding the resident's health history, status or complaints. health history was obtained from medical records sent with referral. Physician #980 noted there was worse edema in the right extremity than the left. Review of late entry progress note, effective date of 03/13/26 and created date of 03/16/26, authored by the Assistant Director of Nursing (ADON) revealed she had been requested in the facility's transport bus at approximately 3:00 P.M. for assistance with repositioning of Resident #5. Upon entering the bus, Resident #5 was leaning back in his chair with buttocks slightly slid forward, however ADON could see the wheelchair seat in between his legs, and it did not appear Resident #5 was going to fall from the wheelchair. Both of Resident #5's feet were firmly planted on the ground and lateral legs were resting against the leg rests on the outside of the legs. Resident #5 legs were repositioned, and aide had placed legs on the leg rests and maneuvered the chair out of the transport van.Review of the facility document Disciplinary Action Report: Written or Verbal dated 03/13/26 for Transporter #719 revealed it was a written final warning. The reason for the warning was employee needs to ensure residents are positioned in wheelchairs appropriately and secured in van appropriately with every transport. Corrective action required: if a resident is not positioned appropriately, the resident needs to be returned to their nurse. If employee fails to comply within 30 days, progressive disciplinary action will occur. The disciplinary action was signed by the Administrator and Human Resources (HR) #626 and Transporter #719 refused to sign.Review of a nursing note dated 03/14/26 at 5:25 A.M. authored by Licensed Practical Nurse (LPN) #722 revealed the aide alerted the nurse that Resident #5 had a large bruise and fluid filled sac the right lower extremity. Upon assessment this nurse observed a bruise measuring approximately 11 centimeters (cm) wide and 16 cm long. There was a fluid filled sac measuring approximately 6 cm wide and 11cm long with a tear in the center measuring approximately 4 cm long and 1.5 cm wide with serosanguineous [clear, bloody] drainage. area drained, cleansed with normal saline. An ABD pad was applied and covered with gauze. The Director of Nursing (DON) and the Resident #5's physician was notified. There was no documentation Resident #5's was notified. Review of the nursing note dated 03/14/26 at 6:10 A.M. written by the (DON) documented she came to assess a bruise to the right lower extremity. The ADON stated Resident #5 had an incident on the transport bus on 03/13/26. Resident #5 slid down in a chair and the left leg had pressed up against the footrest. The DON wrote this lines up with placement and injury. The ADON stated she and staff had assisted with repositioning in the chair and the resident had minimal pain which had been controlled with Tylenol. The DON wrote that the Nurse Practitioner was notified and a new order was obtained to cleanse right lower leg with normal saline solution, apply petroleum gauze and a dry dressing until healed. The DON wrote that a message was left with Resident #5's family to notify. Review of a late entry Provider Note, effective date of 03/14/26 at 11:00 A.M. and created date of 04/11/26, revealed Physician #806 stated they were notified of injury to patient's right lower extremity. He is severely aphasic with a right hemiparesis due to stroke. He was in the facility transport bus and checked by nursing home staff. Based on the way he was found as described in the notes due to the flaccidity of his right side he slid in the chair and the right lower extremity was up against the leg rest during his transport. That extremity ended up with a bruise clearly caused by the pressure of the leg rest on his very flaccid leg. Review of the progress note entry dated 03/14/26 at 6:12 A.M. authored by LPN #722 revealed the entry was a Situation, Background, Assessment and Recommendation (SBAR)) entry. LPN #722 documented the reported change of condition was fever with a temperature of 100.7 degrees Fahrenheit (F), relevant medical history was cancer, diabetes, the resident had pain, and the primary care provider was notified and started Resident #5 on Cephalexin (an antibiotic) 500 milligrams twice a day and Tylenol for temperature and pain. There was no documentation Resident #5's representative was notified. Review of the progress note dated 03/14/26 at 9:31 A.M. authored by Nurse Practitioner (NP) #981 revealed the NP received a call from LPN #722 reporting a bruise to the right lower extremity with a fluid filled center. The blister opened and pus expressed. LPN #722 was concerned it might be cellulitis. Temperature 100.7 degrees F. Review of a progress note dated 03/15/26 at 2:52 A.M. authored by LPN #722 revealed Resident #5 was sent out to the emergency room after being found with slurred speech, shaking and eyes rolling back in his head by a certified nursing assistant (CNA). Resident #5's family and the DON were notified.Review of the hospital records dated 03/15/26 revealed Resident #5 presented to the hospital on [DATE] with altered mental status. Resident #5 was sent to the hospital from his nursing facility due to a chief complaint of altered mental status and a fall. The fall happened last Friday during transfer. X-ray of the right tibia/fibula revealed an acute, nondisplaced transverse fracture of the proximal tibial metaphysis. Orthopedic surgery was consulted with no plans for surgical intervention. A computed tomography (CT) of the tibia fibula right without contrast (scan of the bones in the right lower leg) result on 03/15/26 indicated Resident #5 had a nondisplaced fracture of the proximal tibia, soft tissue edema about the leg, and small suprapatellar joint effusion. An X-ray of the tibia fibula right (two views) revealed an acute, nondisplaced transverse fracture of the proximal tibial metaphysis (below the knee joint). The care coordination section of the record documented Resident #5 was admitted for altered mental status, a fall and a right tibia fracture. Resident #5 was provided with intravenous (IV) Zosyn (an antibiotic) and fluids. The resident was a poor historian and could provide no history. He did state he felt fine. He was discharged back to the nursing facility on 03/16/26 on narcotic pain medication, anticoagulant medication and non-weight bearing on right leg. Review of a written statement provided by physician office Resident #5 had visited on 03/13/26 was dated 03/17/26 authored by Office Manager #812. It documented Resident #5 had arrived at the center on 03/13/26 in a van and was put into a wheelchair. The transporter was observed yelling at patient and was not very patient with him per the secretary. Resident #5's right leg was elevated on a pillow and his leg kept falling off. Resident #5 had complained of pain when he arrived and while being placed in an exam room. This information was reported to the Ombudsman via telephone.Review of a written statement dated 03/17/26 authored by physician office Secretary #813 revealed Resident #5 had arrived at the facility with transportation driver who had appeared upset and stated, he was having a bad day with the patient. The transport driver had gone out the van to get Resident #5 and he had got into the patients face and was yelling at him. Resident #5's legs were not in the footrests at any time during his visit and driver was very rough with patient.During an interview on 04/14/26 at 8:25 A.M., LPN #722 stated she had worked the night shift on 03/13/25. At 2:00 A.M. she had been notified by CNA #615 that Resident #5 had a large bruise on his leg. LPN #722 stated she immediately went to Resident #5's room and observed the area, obtained measurements and called the DON and NP #981. LPN #722 stated Resident #5 was unable to state what had occurred and she stated she had looked through Resident #5's medical records and no documentation was done regarding the injury. LPN #722 stated Resident #5 had not verbalized pain however she had noticed he was having facial grimacing when she had cleaned the area. LPN #722 stated the DON had arrived at the facility at approximately 4:00 A.M. and she stated the DON had informed her Resident #5 had slid out of his wheelchair per the ADON. LPN #722 stated she had returned the next day on 03/15/26 to 03/16/26 and during the evening she noticed Resident #5 had a decline from the previous shift. LPN #722 stated she had assessed Resident #5 and he had an elevated temperature, he was shaking and she had observed his eyes rolling back into his head. LPN #722 stated she had contacted NP #981 who advised sending Resident #5 to the hospital for evaluation. LPN #722 stated she had later been informed Resident #5 had a broken tibia. During an interview on 04/14/26 at 8:52 A.M., Ombudsman #801 stated she had been notified of Resident #5 having a fall on 03/13/26 in the facilities transport van by LPN #511 during an outside appointment.During an interview on 04/14/26 at 9:36 A.M., CNA #705 stated she had been told Resident #5 had a fall on the transport bus. She observed Resident #5 after he had returned from the hospital and his right leg was in a brace and she had observed a bruise and a large, scabbed area. CNA #705 stated Resident #5 was unable to say exactly what happened and but did say they did this. Resident #5 was unable to move himself and he was total care for his activities of daily living. CNA #705 stated he had preferred to stay in bed most of the time and when he had gotten up to a wheelchair the chair appeared to be too small for him and he had not fit in it properly. CNA #705 verified his right leg should not drag the ground when he was in wheelchair because he could not move it himself. During observation at the time of the interview, Resident #5 was in bed, on his back. Resident #5's right leg had a large, discolored area to the outer portion and he was not wearing a brace at that time. During an interview on 04/14/26 at 10:54 A.M., Transporter #719 stated he had transported Resident #5 to an outside appointment on 03/13/26. Transporter #719 stated when he had arrived back at the facility at approximately 3:00 P.M. he had observed Resident #5 sliding down in his wheelchair and had called for assistance with repositioning him. Transporter #719 stated the ADON had come out to the transportation van and had repositioned him and Resident #5 was then taken inside the facility by staff. Transporter #719 stated Resident #5 had not fallen out of the wheelchair and had no complaints of pain during transportation. Transporter #719 stated he had not received a disciplinary write up for Resident #5's transportation.During an interview on 04/15/26 at 7:51 A.M., CNA #615 stated she had been present on 03/13/26 when Resident #5 had returned from his appointment and she had been informed he had a fall in the transport van. She assisted with using a Hoyer lift to assist Resident #5 back into bed and she had not observed any injuries. CNA #615 stated at approximately 4:30 A.M. she had assisted Resident #5 with care and as she removed his blanket the blanket was wet, and she had observed what looked like a hole on his leg that had burst open and a large bruise. CNA #615 stated she had immediately informed the nurse and asked Resident #5 what happened; however, he had not been able to say.During an interview on 04/15/26 at 9:19 A.M., the ADON stated on 03/13/26 at approximately 3:00 P.M. she had been in the hallway and several employees had come inside and stated Resident #5 needed assistance with repositioning on the transport van. She went outside and saw Transporter #719 on the bus with Resident #5. Resident #5 was in his wheelchair and he was not in danger of falling out of the chair. Both of Resident #5's legs were planted firmly on the ground, and his leg was up against the metal part of the wheelchair. She called other staff to come out and help reposition Resident #5. She did not see any injuries and Resident #5 had not complained of pain. CNA #610 took Resident #5 back into the facility and she did not see Resident #5 after that. The DON had been alerted later that evening about the bruise to Resident #5's leg and stated the DON had called her to see if she was aware of any injuries and she told the DON about the incident on the transportation van earlier that afternoon.During an interview on 04/15/26 at 9:54 A.M., the DON stated she received a call from LPN #722 on 03/14/26 at around 4:00 A.M. and was informed of a bruise and a fluid filled blister to Resident #5's right leg. The DON stated LPN #722 had asked if the injury was considered an injury of unknown origin and the DON stated she needed to gather some information to determine what occurred. The DON stated she had arrived at the facility shortly after LPN #722 had called and she had observed Resident #5's leg and observed the blister and a significant bruise and stated LPN #722 had obtained the measurements. The DON stated she had called the ADON to ask if she had been aware of any concerns and the ADON had informed of Resident #5 needing repositioning while on the transport van, and his leg was resting on the metal part of the wheelchair and it was likely how the bruising had occurred. The DON stated Resident #5 had not complained of pain or appeared to be in pain, however LPN #722 had administered Tylenol. She educated LPN #722 on how to document the incident and stated it was not an injury of unknown origin and the injury had likely occurred when his leg was against the wheelchair on the transportation bus. The DON further stated LPN #722 had contacted the NP who had given orders for an antibiotic due to the increased temperature and the warmth on his left leg. The DON recalled speaking with the Physician the next day and had been informed Resident #5 had a tibia fracture. The DON confirmed the injury occurred during the transport of Resident #5. During an interview on 04/15/26 at 11:27 A.M., Physician #806 stated she spoke to the DON and floor nurse about Resident #5 and the incident on 03/13/26. She looked through the notes and the hospital documents. Physician #806 stated based on what she knew the resident did not have a fall but was transferred from the van and was slipping out of position and the leg might have hit against the leg rest. Physician #806 stated if he was slipping the whole trip in the van and hitting the leg rest that would be how the bruise would happen and if a hard enough blow was repeated at some point, the bone could have been damaged. Physician #806 stated the DON told her it happened in the van and not in the facility. Physician #806 verified Resident #5 could not move his right leg on his own and was non-ambulatory. During an interview on 04/15/26 at 1:03 P.M., the Secretary #813 from the physician office where Resident #5 had his appointment stated on 03/13/26, Transporter #719 had arrived at the facility in the afternoon and had appeared to be upset and he had stated I have had the worst day and I need to check this resident in. Secretary #813 stated Transporter #719 exited the facility. She saw him outside the building in Resident #5's face and he was flailing his arms around and was yelling at Resident #5. Secretary #813 stated Transporter #719 had entered the facility with Resident #5 and she his legs were not in the leg rest and his right leg was repeatedly hitting the ground while he was being pushed in the wheelchair. Secretary #813 stated the staff had assisted with placing Resident #5 into a room and when the staff had moved his leg Resident #5 had winced in pain. Secretary #813 stated she had reported the incident to the office manager. Secretary #813 stated the wheelchair looked too small to fit Resident #5. During an interview on 04/15/26 at 2:56 P.M., Ombudsman #814 stated she had emailed the facility regarding a transportation issue regarding Resident #5 that occurred on 03/13/26. Ombudsman #814 stated the DON had provided her with a copy of Transporter #719's disciplinary write up via email.This deficiency represents non-compliance investigated under Complaint number 2978911.

Based on record review, interview, review of the facility Self-Reported Incident (SRI) and review of facility policy, the facility failed to report allegations of abuse to the state agency as required. This affected one (Resident #5) of three residents reviewed for abuse. The facility census was 67.Findings include:Review of Resident #5's medical records revealed an admission date of 07/18/22 with diagnoses including but not limited to cerebral infarction, hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, unspecified psychosis, unspecified anxiety disorder, malignant neoplasm of colon, altered mental status, hypertension (high blood pressure), need for assistance for personal care, muscle atrophy, type two diabetes and aphasia (acquired language disorder affecting communication).Review of the care plan revised on 02/28/26 revealed Resident #5 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included staff to converse with Resident #5 during care. Resident #5 had a stoke with right sided weakness. Interventions included address emotional issues and teach families that stoke residents can have emotional liability and depression. Resident #5 had hemiplegia related to stoke. Interventions included reposition as tolerated every two hours. Resident #5 was dependent with bathing, toileting and extensive assistance with bed mobility and required a mechanical lift for transfers. Further review of the care plan revealed no hearing impairment or hearing appliance was noted on the plan of care up to the most recent revision date of 04/07/26. Review of the Medication Administration Record (MAR) dated March 2026 revealed Resident #5 had an outside appointment at The Hope Center (a comprehensive cancer treatment center) on 03/13/26 at 1:00 P.M.Review of a written statement provided by The Hope Center dated 03/17/26 authored by Office Manager #812 revealed Resident #5 had arrived at the center on 03/13/26 in a van and was put into a wheelchair. The transporter [Transporter #719] was observed yelling at patient and was not very patient with him per the secretary. This information was noted as reported to the Ombudsman via telephone. Review of staff statement dated 03/17/26 authored by the Hope Center Secretary #813 revealed Resident #5 had arrived at the facility with transportation driver (Transporter #719) who had appeared upset and stated, he was having a bad day with the patient. Transport driver had gone out the van to get Resident #5 and he had got into the patients face and was yelling at him. Resident #5's legs were not in the feet rest at any time during his visit and driver was very rough with patient. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 required max assistance with eating, was dependent with toileting and bathing and personal hygiene. Resident #5 was dependent with bed mobility and transfers and was non ambulatory. Observation on 04/14/26 at 9:28 A.M. revealed Resident #5 was alert while resting in bed but demonstrated impaired verbal communication and was unable to answer questions. Telephone interview on 04/14/26 at 1:18 P.M. with the Hope Center Office Manager (OM) #812 revealed Resident #5 had an appointment on 03/13/26 at approximately 1:00 P.M. at The Hope Center (a comprehensive cancer treatment center) where Office Manager #812 worked. OM #812 stated she had been made aware by the center's Secretary #813 that Transporter #719 had arrived at the Hope Center with Resident #5 and Transporter #719 was observed to have been yelling at Resident #5 who had an upset look on his face after being yelled at by Transporter #719. OM #812 verified this was reported to the Ombudsman. Interview on 04/14/26 at 10:54 A.M. with Transporter #719 revealed he had transported Resident #5 to an outside appointment on 03/13/26. Transporter #719 denied he had yelled at Resident #5 and provided no further comments. Telephone interview on 04/15/26 at 1:37 P.M. with the Hope Center Secretary #813 revealed on 03/13/26 Transporter #719 had arrived at the facility in the afternoon and had appeared to be upset and he had stated I have had the worst day and I need to check this resident in. Secretary #813 stated Transporter #719 had then exited the facility, and walked back to the resident. When asked to describe what she saw next, Secretary #813 stated Transporter #719 was within an inch of the residents' face, flailing his arms up and down and yelling at him. I had my hand on the phone ready to call the police. Secretary #813 stated she had reported the incident to the office manager (OM #812). Interview on 04/16/26 at 11:11 A.M. with the Administrator, Director of Nursing (DON) the Regional Director of Operations (RDO) #805 and [NAME] President of Operations (VPO) #901, revealed they had not received any communication directly from the Hope Center regarding concerns with Transporter #719 and Resident #5. VPO #901 confirmed a meeting with the Ombudsman occurred and the Ombudsman said Transporter #719 appeared to be frustrated with Resident #5 and nothing was reported about Transporter #719 yelling at the resident. Telephone interview on 04/16/26 at 12:05 P.M. with Ombudsman #814 revealed she had been made aware by the Hope Center staff having witnessed Transporter #719 yelling at Resident #5 and they were concerned for the resident so reported it to the Ombudsman. Ombudsman #814 stated she had a video conference with RDO #805 and VPO #901 as well as Ombudsman #801 on 04/09/26 at 11:00 A.M. and had informed them of the allegations made by the Hope Center staff concerning the treatment of Resident #5 by the transporter from the facility and she told them the resident was observed being yelled at by Transporter #719. Ombudsman stated she had received digital confirmation from RDO #805 and VPO #901 confirming attendance at the video conference on 04/09/26 at 11:00 A.M.Review of Self-Reported Incident (SRI) #273384 dated 04/16/26 revealed an investigation had been started related to allegations of staff to resident verbal abuse of Resident #5.Review of facility policy titled Abuse, Neglect and Exploitation undated, revealed the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Mental abuse includes, but is not limited to, humiliation, harassment, threats of deprivation or punishment. Mistreatment means inappropriate treatment or exploitation of a resident. An immediate investigation is warranted when suspicions of abuse or neglect occur. The facility will make efforts to ensure all residents are protected from physical and psychological harm during and after the investigation. Examples included but were not limited to responding immediately to protect the alleged victim and protection from retaliation. Reporting of all alleged violations to the state agency no later than 24 hours if the event did not involve abuse and did not result in serious bodily injury. This deficiency represents noncompliance as an incidental finding investigated under Complaint 2978911.

Based on observation, interview and record review the facility failed to ensure accurate documentation of blood sugar values. This affected one resident (#69) of three residents reviewed for medication administration. The facility census was 67.Review of Resident #69's medical records revealed an admission date of 12/12/25. Diagnoses included diabetes, hypertension and difficulty walking. Review of care plan dated 03/11/26 revealed Resident #69 had diabetes. Interventions included administer diabetic medications as ordered, monitor/document/report signs and symptoms of hyperglycemia (high blood sugar) that included increased thirst.Review of physician orders for April 2026 included administer Humalog (fast acting insulin) subcutaneously per sliding scale before meals and at bedtime.Review of Medication Administration Record (MAR) revealed on 04/16/26 Licensed Practical Nurse (LPN) #614 documented Resident #69's blood sugar of 131 (normal range is 60-100). Resident #69's sliding scale indicated no insulin required for a blood sugar reading of less than 150.Review of Resident #69's vital signs documentation revealed a blood sugar reading of 131 on 04/16/26 recorded at 9:45 A.M. by LPN #614 and a reading of 400 recorded on 04/16/26 at 10:26 A.M.Interview on 04/16/26 at 9:53 A.M. with Resident #69 revealed his blood sugar had not been taken yet. During interview Resident #69 was shaking and had asked for ice water. Regional Director of Operations (RDO) #805 was present at time of interview and was asked if facility staff could provide Resident #69 with water, and RDO #805 stated he could. RDO#805 returned with Resident #69's water, which Resident #69 had quickly drank. After completion of interview Resident #69 stated my head doesn't feel right. Resident #69 was taken to LPN #614 who had stated he had not taken Resident #69's blood sugar due to the previous nurse had taken it. LPN #614 was asked about the recorded blood sugar reading of 131 he had documented and LPN #614 stated he didn't know where that number had come from and verified he documented a blood sugar value of 131 that he did not actually obtain from Resident #69. LPN #614 had then proceeded to obtain Resident #69's blood sugar and a reading of 472 was observed. LPN #614 had then stated he would check Resident #69's orders and administer insulin according to his sliding scale.Follow up interview on 04/16/16 at 3:30 P.M. with Resident #69 revealed his blood sugar had not been taken since previous observation and he still felt off. Resident #69 had then wheeled himself out to LPN #614 and LPN #614 stated he had not obtained another blood sugar check and had used the previous reading to administer Resident #69's insulin. LPN #614 had proceeded to obtain Resident #69's blood sugar and a reading of 400 was observed. LPN #614 stated Resident #69's afternoon insulin could be administered at 4:00 P.M. and had then obtained Resident #69's insulin pen and had drawn up 10 units of Humalog. LPN #614 had then administered 10 units of Resident #69's Humalog.Interview on 04/20/26 at 2:08 P.M. with Director of Nursing (DON) revealed no specific facility policy related to diabetic management. DON further stated blood sugars should have been documented accurately and should not be documented other than the person who had obtained themThis deficiency represents non-compliance investigated under Complaint number 2978911.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #69 was free from a significant medication error. This affected one resident (#69) of three residents reviewed for medication administration. The facility census was 67. Findings include:Review of Resident #69's medical records revealed an admission date of 12/12/25. Diagnoses included diabetes, hypertension and difficulty walking. Review of care plan dated 03/11/26 revealed Resident #69 had diabetes. Interventions included administer diabetic medications as ordered, monitor/document/report signs and symptoms of hyperglycemia (high blood sugar) that included increased thirst.Review of physician orders for April 2026 included administer Humalog (fast acting insulin) subcutaneously per sliding scale before meals and at bedtime. If blood sugar 150 to 200 milligrams per deciliter (mg/dl) give two units, 201 to 250 give four units, 251 to 300 give six units, 301 to 350 give eight units, 351 to 400 give 10 units and if over 401 contact physician. Review of Medication Administration Record (MAR) revealed on 04/16/26 Licensed Practical Nurse (LPN) #614 documented Resident #69's blood sugar of 131 (normal range is 60-100). Resident #69's sliding scale indicated no insulin required for a blood sugar reading of less than 150.Review of Resident #69's vital signs documentation revealed a blood sugar reading of 131 on 04/16/26 recorded at 9:45 A.M. by LPN #614 and a reading of 400 recorded on 04/16/26 at 10:26 A.M.Interview on 04/16/26 at 9:53 A.M. with Resident #69 revealed his blood sugar had not been taken yet. During interview Resident #69 was shaking and had asked for ice water. Regional Director of Operations (RDO) #805 was present at time of interview and was asked if facility staff could provide Resident #69 with water, and RDO #805 stated he could. RDO #805 returned with Resident #69's water, which Resident #69 had quickly drunk. After completion of interview Resident #69 stated my head doesn't feel right. Resident #69 was taken to LPN #614 who had stated he had not taken Resident #69's blood sugar due to the previous nurse had taken it. LPN #614 was asked about the recorded blood sugar reading of 131 he had documented and LPN #614 stated he didn't know where that number had come from. LPN #614 then verified he had signed off on the blood sugar reading of 131 but did not actually check the blood sugar. LPN #614 had then proceeded to obtain Resident #69's blood sugar and a reading of 472 was observed. LPN #614 had then stated he would check Resident #69's orders and administer insulin according to his sliding scale.Follow up interview on 04/16/26 at 3:30 P.M. with Resident #69 revealed his blood sugar had not been taken since previous observation and he still felt off. Resident #69 had then wheeled himself out to LPN #614 and LPN #614 stated he had not obtained another blood sugar check and had used the previous reading to administer Resident #69's insulin. LPN #614 had proceeded to obtain Resident #69's blood sugar and a reading of 400 was observed. LPN #614 stated Resident #69's afternoon insulin could be administered at 4:00 P.M. and had then obtained Resident #69's insulin pen and had drawn up 10 units of Humalog. LPN #614 had then administered 10 units of Resident #69's Humalog.Interview on 04/20/26 at 2:08 P.M. with Director of Nursing (DON) revealed no specific facility policy related to diabetic management. DON further stated blood sugars should have been documented accurately and should not be documented other than the person who had obtained them, The DON verified not obtaining a blood sugar for a resident on sliding scale insulin to determine if insulin was needed was a medication error. Review of the facility policy titled Nursing Care of the Older Adult with Diabetes, revised 11/2020, revealed the provider will order the frequency of glucose monitoring and establish glycemic targets for individual residents. If on insulin, monitor blood glucose levels as ordered. Assist the resident with specific medication regimen as ordered. The nurse will document the blood sugar history over the last 48 hours and the dose and time of the antihyperglycemic given. This deficiency represents an incidental finding investigated under Complaint 2978911and is an example of continued non-compliance from the survey dated 03/25/26.

Based on record review, observation, interview, and review of facility policy the facility failed to coordinate transportation services that were resident centered following a surgical procedure for the highest practicable well-being for Resident #41, and failed to adequately monitor Resident #5 following a change in health status resulting in hospitalization. This affected two residents ( Resident #5 and #41 ) of five residents reviewed for quality of care . The facility census was 67.Findings include:Findings include: 1.Review of Resident #5's medical records revealed an admission date of 07/18/22. Diagnoses included hemiplegia with right side weakness, muscle weakness and need for personal care assistance. Review of the care plan revised 02/28/26 revealed Resident #5 had hemiplegia related to a stroke. Interventions included reposition as tolerated every two hours. Resident #5 had self-care deficits that included dressing, personal hygiene, eating, toileting and bathing. Resident #5 required extensive assistance of one to two staff for bed mobility and was dependent with bathing and toileting and required a Hoyer (mechanical lift) for transfers. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 required max assistance with eating, was dependent with toileting and bathing and personal hygiene. Resident #5 was dependent with bed mobility and transfers and was non ambulatory. Review of a progress note dated 03/14/26 timed 5:26 A.M. authored by Licensed Practical Nurse (LPN) #722 revealed an aide had alerted her of a large bruise and a fluid filled sac on Resident #5's right lower extremity. Bruise measured 11 centimeters (cm) wide and 16 cm long with a fluid filled sac measuring 6 cm wide and 11 cm long with a tear in the center that measured 4 cm long and 1.5 cm wide with serosanguinous (blood tinged) drainage. Area was cleansed with normal saline and covered with absorbent dressing and kerlex and the Director of Nursing (DON) and physician were notified. Review of a progress note dated 03/14/26 timed 6:10 A.M. authored by the DON revealed she had arrived at the facility to assess Resident #5's right leg. Upon speaking with the Assistant Director of Nursing (ADON) she had been advised Resident #5 had an incident on the transport bus on 03/13/26 and had slid down in chair and leg had had pressed against the footrest which lined up with the placement and injury on Resident #5's leg. ADON stated she and staff had assisted Resident #5 with repositioning and Resident #5 had minimal pain which had been controlled with Tylenol. Nurse Practitioner had been notified and new orders to cleanse the area with normal saline, apply xeroform (wound dressing) and dry dressing. Review of a progress note dated 03/14/26 timed 6:12 A.M. authored by LPN #722 revealed vital signs were within a normal range with the exception of an elevated temperature of 100.7 degrees. Review of a progress note dated 03/14/26 timed 6:43 A.M. authored by LPN #722 revealed Tylenol 325 mg two tablets was given for pain and temperature. Review of on call physician progress note dated 03/14/26 (untimed) revealed staff reported bruise to right lower extremity with fluid filled center. Resident #5 had sustained a skin tear and blister had opened up, and during treatment they were able to express pus. Resident #5 had a temperature of 100.7 degrees. Orders were given to administer Cephalexin (antibiotic) 500 milligrams (mg) twice a day for five days. Review of late entry progress note created on 03/16/26 for an effective date of 03/13/26 authored by ADON revealed she had been requested in the facilities transport bus at approximately 3:00 P.M. for assistance with repositioning of Resident #5. Upon entering the bus Resident #5 was found to be leaning back in his chair with buttocks slightly slid forward, however ADON could see the wheelchair seat in between his legs, and it did not appear Resident #5 was going to fall from the wheelchair. Both of Resident #5's feet were firmly planted on the ground and lateral legs were resting against the leg rests on the outside of the legs. Resident #5 legs were repositioned, and aide had placed legs on the leg rests and maneuvered the chair out of the transport van. Review of progress note dated 03/15/26 timed 2:52 A.M. authored by LPN #722 revealed she had been alerted by an aide that Resident #5 was not himself and had increased shaking/tremors, eyes rolling back and increased slurred speech with an elevated temperature of 99.1. The NP had been notified, and orders were received to send Resident #5 to the hospital. Further review of Resident #5's medical records revealed no evidence of temperature, pulse, or blood pressure monitoring of Resident #5's change in condition related to the right leg injury or elevated temperature between 03/14/26 at 7:00 A.M. to 03/15/26 at 2:52 A.M. Review of the hospital records dated 03/15/26 revealed Resident #5 presented to the hospital on [DATE] with altered mental status (AMS). A computed tomography (CT) tibia fibula right without contrast (scan of the bones in the right lower leg) result on 03/15/26 indicated Resident #5 had a nondisplaced fracture of the proximal tibia, soft tissue edema about the leg, and small suprapatellar joint effusion. An X-ray of the of the tibia fibula right (two views) revealed an acute, nondisplaced transverse fracture of the proximal tibial metaphysis (below the knee joint). The care coordination section of the record indicated Resident #5 was admitted for AMS, fall and right tibia fracture. Orthopedic surgery was consulted with no plans for surgical intervention. Resident #5 was provided with intravenous (IV) Zosyn (an antibiotic) and fluids. He was discharged back to the nursing facility on 03/16/26 on narcotic pain medication, anticoagulant medication and non-weight bearing on right leg. Telephone interview on 04/14/26 at 8:25 A.M. with LPN #722 revealed she had worked on 03/13/25 from approximately 6:30 P.M. to 03/14/25 until approximately 7:30 A.M. LPN #722 stated at approximately 2:00 A.M. she had been notified by Certified Nursing Assistant (CNA) #615 Resident #5 had a large bruise to his leg. LPN #722 stated she had immediately went to Resident #5's room and observed the area and had obtained measurement and called the DON and the NP. LPN #722 stated Resident #5 was unable to state what had occurred and she stated she had looked through Resident #5's medical records and no documentation was done regarding the injury. LPN #722 stated Resident #5 had not verbalized pain however she had noticed he was having facial grimacing when she had cleaned the area. LPN #722 stated the DON had arrived at the facility at approximately 4:00 A.M. and she stated the DON had informed her Resident #5 had slid out of his wheelchair per the ADON. LPN #722 stated she had returned the next day on 03/15/26 to 03/16/26 and during the evening she had noted Resident #5 to have had a decline from the previous shift. LPN #722 stated she had assessed Resident #5 and he had an elevated temperature, he was shaking and she had observed his eye rolling back into his head. LPN #722 stated she had contacted the NP who had advised to send Resident #5 to the hospital for evaluation. LPN #722 stated she had later been informed Resident #5 had a broken tibia. LPN #722 further stated the DON had advised that she not document her findings in Resident #5's medical records and had asked that she write her findings down on paper, however LPN #722 had refused and had documented her assessment in Resident #5's medical records. Interview on 04/15/26 at 7:51 A.M. with CNA #615 revealed on 03/14/26 at approximately 4:30 A.M. she had assisted Resident #5 with care and as she removed his blanket the blanket was wet and she had observed what looked like a hole that had burst open and a large bruise. CNA #615 stated she had immediately informed the nurse and asked Resident #5 what happened, however he had not been able to say. An interview on 04/15/26 at 9:54 A.M. with DON verified no documented evidence in Resident #5's medical records of vital signs monitoring for Resident #5's change in condition related to the right leg injury or elevated temperature between 03/14/26 at 7:00 A.M. to 03/15/26 at 2:52 A.M. The facility could not provide a policy on Quality of Care. 2. Review of the medical record for Resident #41 revealed an admission date of 10/10/25 with diagnosis of cellulitis, pain in left knee, chest pain, chronic kidney disease stage five, end stage renal disease, dependence on renal dialysis, hypertension, hepatitis C, noncompliance with medical regimen due to unspecified reason, cocaine abuse, alcohol abuse. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #41 had intact cognition ( Brief Interview Mental Status score of 15 . No indicators of psychosis, no behavior symptoms present, no rejection of care exhibited. Supervision was needed for toilet hygiene, set up assist for personal hygiene. Supervision was needed to roll left and right in bed. Moderate assistance to walk ten feet. No pressure ulcers. Resident #41 received hemodialysis. Review of the Care Plan Report, date initiated 11/05/25, revealed Resident #41 had hypertension related to chronic kidney disease. Interventions include hypertensive medication, monitor for side effects such as hypotension or increased heart rate, monitor and document any edema and notify the physician. Further review of the medical record revealed a Mercy Health hospital visit dated 03/01/26 where Resident #41 was seen for neck swelling and was diagnosed with acute deep vein thrombosis. New medication of Eliquis was started and Vascular Surgery in Cleveland was to be contacted. Review of a Nursing Note dated 03/06/26 at 6:13 P.M. written by Registered Nurse (RN )#603 revealed Resident #41 returned from an appointment with orders to stop Eliquis and surgery scheduled for Monday 03/09/26. Review the After Visit Summary dated 03/10/26 from the Cleveland Clinic revealed a date of admission [DATE] and date of discharge 03/10/26 for end stage renal disease and left upper extremity brachial axillary loop graft and ligation of a brachial pre-conditioning fistula. Resident #41 recovered in the PACU (patient acute care unit) and step- down unit. Resident #41 was cleared for discharge post-op day one to a skilled nursing facility. Discharge instructions included daily wound inspection to ensure the site remained clean and dry, nursing staff monitor and report any fever, chills, localized infection, uncontrolled bleeding or numbness and coldness in the extremities and report to the surgeon immediately. Discharge instructions were printed on 03/10/26 at 10:32 A.M. Review of a Nursing Note dated 03/10/26 at 10:16 P.M. written by Licensed Practical Nurse (LPN) # 622 revealed Resident #41 returned at an unknown time this shift. Resident #41 was upset because of transportation taking so long and he was outside. Resident #41 refused to give the nurse paperwork from the appointment. Resident requested as needed pain medication at 6:45 P.M. for a pain rating of six (moderate pain) out of ten . Vitals were obtained that revealed blood pressure 126/74, pulse 86, oxygen 96 percent. Resident #41 refused a skin assessment. Resident had a bandage to left arm that was clean and intact. Follow up with physician in the morning. Review of Medication Administration Record, dated March 2026, revealed Resident #41 had a pain level recorded at six (moderate pain) and was administered oxycodone-acetaminophen (narcotic pain medication with a non-narcotic pain medication) 10-325 milligrams one tablet by mouth for moderate to severe pain. The order start date was 03/10/26 and the time stamp on the MAR was 6:56 P.M. Further review of the March 2026 MAR revealed Resident #41 did not receive the 5:00 P.M. dose of Sodium Bicarbonate (a medication prescribed for dialysis patients to prevent metabolic acidosis/high blood acid) oral tablet 650 milligrams related to chronic kidney disease, and Sevelamer HCL (a medication used to control phosphorus levels) tablet 800 milligrams at 5:00 P.M. because Resident #41 was LOA (leave of absence). Interview on 04/08/26 at 12:00 P.M. with Activities Assistant (AA) #719 revealed Resident #41 stayed in the hospital overnight after his procedure. AA #719 stated he and the Activity Director (AD) #612 picked up Resident #41 when they could. Interview on 04/08/26 at 12:01 P.M. with the Administrator revealed Resident #41 needed transportation to the Cleveland Clinic in Cleveland for a procedure. The Administrator stated he had no knowledge of Resident #41's procedure and need for transportation to Cleveland. The Administrator stated he drove up with AA # 719 the morning of 03/09/26 to Cleveland to ensure Resident #41 had his procedure on time but when the hospital explained Resident #41 would be ready for pick up at 8:00 P.M. the Administrator explained the facility could not pick Resident #41 up that late. The Administrator stated the Nurse Practitioner agreed to keep Resident #41 overnight so the facility could pick Resident #41 up in the morning. The Administrator verified the over-night hospital stay was due to the lack of transportation back to the facility. Interview on 04/08/26 at 12:10 P.M. with the AD #612 revealed she picked Resident #41 up on 03/10/26 later in the day because the facility bus was busy all day long. AD #612 stated she and AA #719 drove to Cleveland and brought Resident #41 back to the facility around 4:30 P.M. or 5:00 P.M. Interview on 04/08/26 at 12:10 P.M. with Assistant Director of Nursing #519 revealed the facility did not know Resident #41 had a surgery in Cleveland until the day before and the facility assumed he had a ride until we found out he needed picked up. Interview on 04/08/26 at 12:30 P.M. with facility Transportation Scheduler #600 revealed the resident, or nurse was to provide appointment paperwork to her to schedule transportation to and from appointments, if she did not receive notification she cannot schedule transportation. Interview on 04/08/26 at 1:00 P.M. with Certified Nursing Assistant (CNA) #512 revealed Resident #41 called him on 03/10/26 when he was discharged from the hospital at 10:00 A.M. asking for the facility to pick him up. Resident #41 called the facility on 03/10/26 every twenty minutes asking to be picked up. Interview on 04/08/26 at 1:10 P.M. with CNA #725 revealed Resident #41 did not return to the facility until late in the evening on 03/10/26 after his surgery. Resident #41 kept calling the facility for someone to pick him up. CNA #725 verified on her cell phone Resident #41 called her at 10:00 A.M. and called the facility nurse station prior. Resident #41 left a voice message at 2:06 P.M. stating he was still in Cleveland. Resident #41 stated he had his phone charger in the facility van and his phone battery was low. CNA #725 stated she observed AA #719 in the facility until 3:00 P.M. when he left to pick up Resident #41. Interview on 04/08/26 at 4:00 P.M. with Transportation Scheduler #600 verified the facility drove Resident #41 to Cleveland on 03/09/26 and left for Cleveland on 03/10/26 at 4:00 P.M. Interview on 04/08/26 at 4:58 P.M. with Resident #41 revealed the Cleveland Clinic set up his appointment and notified him through email when his surgery was scheduled. Resident #41 stated he told the nurse the day and time of his surgery but was told by the nurse I needed to find my own ride. Resident #41 stated he then told the Administrator in fear he would not have a ride to Cleveland for his surgery. Resident #41 verified he received dialysis on 03/10/26, received his morning medication and ate prior to discharge from the hospital. Resident #41 stated the hospital told him his ride was on the way so Resident #41 assumed the facility transportation would be at the Cleveland Clinic in 45 minutes, therefore he told the nurse he would wait outside for his transportation. Resident #41 stated he waited two to three hours outside until the facility picked him up, he stated he called the facility to notify them he was discharged around 10:00 A.M. Interview on 04/08/26 at 5:20 P.M. with Registered Nurse (RN) #603 revealed she was notified by Resident #41 of his upcoming surgery on 03/09/26 after Resident #41 gave his paperwork to her. RN #603 stated she was not sure of the facility protocol for resident transportation to surgery and documentation because she worked in the facility as needed. RN #603 verified she wrote a progress note but did not write an order or notify the transportation scheduler because the scheduler was gone for the day and verified she did not confirm if Resident #41 had transportation to and from his surgery. Interview on 04/09/26 at 10:10 A.M. with Transportation Scheduler #600 revealed if a nurse does not put an order in the medical record or bring the paperwork to her office she would not know to arrange transportation for that resident. If a nurse received information on an appointment during the evening or weekends the nurse could put the paperwork in her box outside her office. Interview on 04/09/26 at 10:11 A.M. with the DON revealed nurse staff should put outside appointments in the Medical Record Orders Tab to ensure visibility across all shifts and departments. If a nurse received paperwork after hours they can put the paperwork in a box outside the transportation scheduler door. The nurse is expected to notify the transportation scheduler or the DON if an outside appointment was made and a resident needed transportation. Interview on 04/09/26 at 5:25 P.M. with the DON revealed Resident #41 was admitted to the hospital after his procedure for observation. The DON verified RN #603 was notified on Resident #41 surgery in Cleveland but did not notify the DON or the transportation scheduler. Interview on 04/13/26 at 12:46 P.M. with the DON verified Resident #41 was upset about his late return and had stayed overnight in the hospital because there was no one from the facility to go get him after his procedure. The DON verified as a result of the delayed return Resident #41 did not receive all of his 5:00 P.M. medications as ordered and was in moderate pain upon return to the facility. Review of facility policy titled Transporting a Resident ( Facility Van) dated March 2026, revealed the facility would provide residents a safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deemed necessary. This deficiency represents non-compliance investigated under Master Complaint Number 2978911 and Complaint Number 2967092.

Based on record review, review of witness statements, interviews and review of facility policy, the facility failed to ensure Resident #5 was free from verbal abuse by a staff member. This affected one resident (#5) out of three residents reviewed for abuse. The facility census was 67.Findings include:Review of Resident #5's medical records revealed an admission date of 07/18/22 with diagnoses including but not limited to cerebral infarction, hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, unspecified psychosis, unspecified anxiety disorder, malignant neoplasm of colon, altered mental status, hypertension (high blood pressure), need for assistance for personal care, muscle atrophy, type two diabetes and aphasia (acquired language disorder affecting communication). Review of the care plan revised on 02/28/26 revealed Resident #5 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included staff to converse with Resident #5 during care. Resident #5 had a stoke with right sided weakness. Interventions included address emotional issues and teach families that stoke residents can have emotional liability and depression. Resident #5 had hemiplegia related to stoke. Interventions included reposition as tolerated every two hours. Resident #5 was dependent with bathing, toileting and extensive assistance with bed mobility and required a mechanical lift for transfers. Further review of the care plan revealed no hearing impairment or hearing appliance was noted on the plan of care up to the most recent revision date of 04/07/26. Review of the Medication Administration Record (MAR) dated March 2026 revealed Resident #5 had an outside appointment at The Hope Center (a comprehensive cancer treatment center) on 03/13/26 at 1:00 P.M. Review of a written statement provided by The Hope Center dated 03/17/26 authored by Office Manager #812 revealed Resident #5 had arrived at the center on 03/13/26 in a van and was put into a wheelchair. The transporter [Transporter #719] was observed yelling at patient and was not very patient with him per the secretary. This information was noted as reported to the Ombudsman via telephone. Review of staff statement dated 03/17/26 authored by the Hope Center Secretary #813 revealed Resident #5 had arrived at the facility with transportation driver (Transporter #719) who had appeared upset and stated, he was having a bad day with the patient. Transport driver had gone out the van to get Resident #5 and he had got into the patients face and was yelling at him. Resident #5's legs were not in the feet rest at any time during his visit and driver was very rough with patient. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 required max assistance with eating, was dependent with toileting and bathing and personal hygiene. Resident #5 was dependent with bed mobility and transfers and was non ambulatory. Observation on 04/14/26 at 9:28 A.M. revealed Resident #5 was alert while resting in bed but demonstrated impaired verbal communication and was unable to answer questions. Telephone interview on 04/14/26 at 1:18 P.M. with the Hope Center Office Manager (OM) #812 revealed Resident #5 had an appointment on 03/13/26 at approximately 1:00 P.M. at The Hope Center (a comprehensive cancer treatment center) where Office Manager #812 worked. OM #812 stated she had been made aware by the center's Secretary #813 that Transporter #719 had arrived at the Hope Center with Resident #5 and Transporter #719 was observed to have been yelling at Resident #5 who had an upset look on his face after being yelled at by Transporter #719. OM #812 verified this was reported to the Ombudsman. Interview on 04/14/26 at 10:54 A.M. with Transporter #719 revealed he had transported Resident #5 to an outside appointment on 03/13/26. Transporter #719 denied he had yelled at Resident #5 and provided no further comments. Telephone interview on 04/15/26 at 1:37 P.M. with the Hope Center Secretary #813 revealed on 03/13/26 Transporter #719 had arrived at the facility in the afternoon and had appeared to be upset and he had stated I have had the worst day and I need to check this resident in. Secretary #813 stated Transporter #719 had then exited the facility, and walked back to the resident. When asked to describe what she saw next, Secretary #813 stated Transporter #719 was within an inch of the residents' face, flailing his arms up and down and yelling at him. I had my hand on the phone ready to call the police. Secretary #813 stated she had reported the incident to the office manager (OM #812). Interview on 04/16/26 at 11:11 A.M. with the Administrator, Director of Nursing (DON) the Regional Director of Operations (RDO) #805 and [NAME] President of Operations (VPO) #901, revealed they had not received any communication directly from the Hope Center regarding concerns with Transporter #719 and Resident #5. VPO #901 confirmed a meeting with the Ombudsman occurred and the Ombudsman said Transporter #719 appeared to be frustrated with Resident #5 and nothing was reported about Transporter #719 yelling at the resident. Telephone interview on 04/16/26 at 12:05 P.M. with Ombudsman #814 revealed she had been made aware by the Hope Center staff having witnessed Transporter #719 yelling at Resident #5 and they were concerned for the resident so reported it to the Ombudsman. Ombudsman #814 stated she had a video conference with RDO #805 and VPO #901 as well as Ombudsman #801 on 04/09/26 at 11:00 A.M. and had informed them of the allegations made by the Hope Center staff concerning the treatment of Resident #5 by the transporter from the facility and she told them the resident was observed being yelled at by Transporter #719. Ombudsman stated she had received digital confirmation from RDO #805 and VPO #901 confirming attendance at the video conference on 04/09/26 at 11:00 A.M. Review of facility policy titled Abuse, Neglect and Exploitation undated, revealed the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Mental abuse includes, but is not limited to, humiliation, harassment, threats of deprivation or punishment. Mistreatment means inappropriate treatment or exploitation of a resident. An immediate investigation is warranted when suspicions of abuse or neglect occur. The facility will make efforts to ensure all residents are protected from physical and psychological harm during and after the investigation. Examples included but were not limited to responding immediately to protect the alleged victim and protection from retaliation. Reporting of all alleged violations to the state agency no later than 24 hours if the event did not involve abuse and did not result in serious bodily injury. This deficiency represents noncompliance as an incidental finding investigated under Complaint 2978911.

Based on interview and record review, the facility failed to ensure the resident representative was immediately notified about a leg injury and failed to ensure proper notification to the representative of an outside medical appointment for Resident #5. This effected one resident ( Resident #5) of six residents ( #3, #5, #30, #31, #41,and #58) reviewed for change in condition. The facility census was 67.Findings include:Review of the medical record for Resident #5 revealed an admission date of 07/18/22 with diagnoses including but not limited to cerebral infarction, hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, unspecified psychosis, unspecified anxiety disorder, malignant neoplasm of colon, altered mental status, hypertension (high blood pressure), need for assistance for personal care, muscle atrophy, type two diabetes and aphasia (acquired language disorder affecting communication).Review of Resident #5's care plan, date initiated 08/04/22, revealed Resident #5 was dependent on staff for meeting his emotional, intellectual, physical, and social needs related to cognitive deficits and disease processes.Review of the Medication Administration Record (MAR) dated March 2026 revealed Resident #5 had an outside appointment at The Hope Center (a comprehensive cancer treatment center) on 03/13/26 at 1:00 P.M.Review of the document titled The Hope Center for Cancer Care, dated 03/13/26, revealed Resident #5 was referred to the center's hematology office for an initial visit due to anemia. Hope Center Physician (HCP) #980 wrote the resident had aphasia, chronic psychosis, was unable to give any history, was not able to answer questions, and was only able to state that his right leg hurt. HCP #980 indicated he is here with an aide from the facility, however the aide does not have any information regarding [name of resident stated] health history, status or complaints. The facility aid does not know why the patient is being seen today. All health history is obtained from medical records sent with referral. HCP #980 also noted unfortunately [Resident #5] is unable to answer any of my questions today. Labs to be drawn and sent out. If he is iron deficient, he will likely need IV repletion. Follow up in four weeks to develop a treatment plan. No questions presented by facility staff.Review of a Nurses Note dated 03/14/26 at 5:25 A.M. authored by Licensed Practical Nurse (LPN) #722 revealed STNA alerted this nurse that the resident has a large bruise and fluid filled sac on RLE [right lower extremity]. Upon assessment this nurse observed a bruise measuring approximately 11 cm [eleven centimeters] Wide and 16 cm long with a fluid filled sac measuring approximately 6 cm wide and 11cm long with a tear in the center measuring approximately 4 cm long and 1.5 cm wide with serosanguineous [clear, bloody] drainage. area drained, cleansed with NSS [normal saline solution], abd [a type of dressing] applied and covered with kerlix [gauze]. DON and R [resident] physician notified. There was no indication the resident's representative was notified. Review of the Nursing Note dated 03/14/26 at 6:10 A.M. written by the Director of Nursing (DON) revealed the DON came to the building to assess a bruise to the right lower extremity. The assistant director of nursing (ADON) stated Resident #5 had an incident on transport bus on 03/13/26. Resident #5 slid down in a chair and the left leg had pressed up against the footrest. The DON wrote this lines up with placement and injury. The DON wrote that the Nurse Practitioner was notified and a new order was obtained to cleanse right lower leg with normal saline solution, apply xeroform and DD (dry dressing) until healed. The DON wrote left message with family to notify.Review of the progress note entry dated 03/14/26 at 6:12 A.M. authored by LPN #722 revealed the entry was an SBAR (Situation, Background, Assessment and Recommendation) entry. LPN #722 documented the reported change of condition was fever (temperature 100.7 degrees Fahrenheit), relevant medical history was cancer, diabetes, the resident had pain, and the primary care provider was notified and started Resident #5 on Cephalexin 500 milligrams twice a day and Tylenol for temperature and pain. There was no indication the resident's representative was notified.Review of the progress note dated 03/14/26 at 9:31 A.M. authored by Nurse Practitioner (NP) #981 revealed the NP received a call from LPN #722 reporting bruise to RLE with fluid filled center. The blister opened and pus expressed. Nurse concerned it might be cellulitis. Temperature 100.7. There was no indication the resident's representative was notified.Review of a progress note dated 03/15/26 at 2:52 A.M. authored by LPN #722 revealed Resident #5 was sent out to the emergency room after being found with slurred speech, shaking and eyes rolling back in his head by a certified nursing assistant. Family notified. DON notified.An interview on 04/14/26 at 8:27 A.M. with LPN #722 revealed Resident #5's son was his representative and emergency contact and was very involved with Resident #5's care. LPN #722 stated she did not notify the son of the leg injury on 03/13/26, but did notify the son on 03/15/26 when Resident #5 was sent to the hospital and it was during that conversation the son told her that the DON had not called him at all nor left a voice mail to notify him about Resident #5's change of condition on 03/13/26. LPN #722 stated the son reported he was not told about Resident #5's appointment at the cancer center on 03/13/26 either because if he had known he would have gone to that appointment with Resident #5. LPN #722 confirmed the DON entered a note in the medical record stating she notified Resident #5's family on 03/14/26 of a bruise. An interview on 04/14/26 at 8:46 A.M. with Ombudsman #801 revealed their agency was investigating an incident involving Resident #5 and a staff member during transport to The Hope Center on 03/13/26 and during the investigation Resident #5's representative (son) stated to the Ombudsman he was not notified regarding any incident on the van during transportation to The Hope Center appointment or any appointment at The Hope Center.An interview on 04/14/26 at 12:35 P.M. with Resident #5's representative (son) confirmed that he was not notified of the bruise, fever or pus on his father's leg until he was hospitalized on [DATE], nor was he informed that his father had been sent out to an initial doctor's appointment at The Hope Center on 03/13/26. Resident #05's representative stated he was the primary contact and should be told when his dad was hurt or had to see the doctor. He stated he attended all of his dad's physician appointments and accompanied his dad on the ride to the facility. Resident #5's son stated the nursing home told me they must have dialed the wrong number.An interview on 04/15/26 at 9:54 A.M. with the DON confirmed that she did not notify Resident #5's representative when the bruise was found on 03/14/26 because it was early in the morning and stated she might have left a message, and did not remember speaking with Resident #5's representative on that occasion and verified Resident #5's representative was involved with Resident #5's care. The DON stated I must have called the wrong number Review of facility policy titled Change in a Resident's Condition or Status, revised February 2021, revealed the facility would promptly notify the resident, his or her attending physician, and the representative of changes in the resident's medical condition and/or status. The nurse will notify the resident representative when the resident is involved in any incident that results in injury including injuries of unknown source.This deficiency represents non-compliance investigated under Complaint Number 2978911.

Based on record review, and interview the facility failed to demonstrate effective leadership of the overall facility operations to ensure each resident attained/maintained their highest practicable physical, mental, and psychosocial well-being. This affected five residents (#3, #28, #41, #43, and #68) and had the potential to affect all residents in the facility. The facility census was 67.Findings include:Review of the job description for the position of Administrator revealed it was signed by the facility Administrator on 09/13/24. The position summary included leading and directing the overall operation of the facility in accordance with resident needs, government regulations, and company policies to maintain quality of care for the residents while achieving the facility's business directives. Administrative duties included but were not limited to maintaining working knowledge and ensuring compliance with all governmental regulations, monitoring employee relations practices of key staff to ensure compliance with employment laws and company policies, promoting practices that maintain high morale and staff retention including effective communication, prompt problem resolution and positive reinforcement. Role responsibilities included interpersonal skills such as interacting with residents, family members, co-workers, ancillary staff in a non-judgmental, supportive calm manner. Addresses family satisfaction issues and assists in resolving the matter in a professional manner; Is aware of the Resident Abuse Reporting Law. Resident care responsibilities for resident dignity include ensures understanding of, and compliance with, all rules regarding resident rights, addresses residents in a respectful manner, and discuss confidential resident information in appropriate area only.Review of the job description for the position of Director of Nursing revealed it was signed by the DON on 10/02/25. The position summary included under the supervision of the administrator, has authority, responsibility, and accountability for functions, activities and training for the nursing services staff, in addition to the Therapy Department and its functions within the facility. In the absence of the Administrator, assumes responsibility for the facility. Is responsible for the overall management of resident care 24 hours a day, seven days a week. Conducts periodic reviews that the facility and personnel are in compliance with state code requirements. Meets with all licensed staff on a routine basis to review nursing and facility issues. Ensure plans are in place to correct employee concerns. Is aware of resident abuse reporting law. During the onsite investigation, the following concerns related to the Administrators' and DONs' role responsibilities were identified: a. An interview was conducted on 03/24/26 at 8:10 A.M. with the state Ombudsman who revealed the Director of Nursing (DON) was informed on 03/05/26 of a resident concern related to alleged staff misappropriation of resident medications which involved Resident #28 and #41. The Ombudsman stated the DON stated this is so out in left field when the Ombudsman told her who the licensed practical nurse (LPN #816) was that the residents suspected of misappropriation. The Ombudsman stated she had also brought the concerns to the Administrators attention about the alleged staff misappropriation of resident medications which involved Resident #28 and #41. The Administrator stated to the Ombudsman unless the police are called, I won't be doing anything about it, he stated it did not matter and stated I don't know what to say about it. The Ombudsman stated it was not until the Regional Director of Operations (RDO) was contacted by the Ombudsman's office that a Self-Reported Incident (SRI) investigation was opened (SRI 271810). (See findings under F602). An interview on 03/24/25 at 2:45 P.M. with the Director of Nursing (DON) revealed she was unsure how to complete a thorough investigation as there was no written policy on how to investigate incidents/SRIs. The DON stated the Administrator was the Abuse Coordinator and there were multiple staff members who helped with each SRI. The DON confirmed she was directly involved with narcotic misappropriation investigations including SRI 271810. (See findings under F610).Confidential interview with a staff member revealed they were aware the DON was informed of concerns with misappropriation of resident's narcotics and did not do anything about it and did not take concerns seriously. There was no investigation started. The confidential interview also revealed staff felt when concerns were brought to the DONs attention nothing gets done and things are just ignored or brushed under the rug. When asked if staff and residents are interviewed for SRI investigations, the staff member stated that the questions asked to staff and residents are generic and vague, and the questions do not get to the real issue.An interview on 03/11/26 at 2:39 P.M. with the Director of Nursing (DON) revealed LPN #810 had been working at the facility for approximately one month after her LPN license was suspended related to narcotic diversion. The DON stated she was informed by Human Resource Supervisor (HRS) #813 but could not recall when she found out. The DON stated LPN #810 was suspended but was unsure if she had been terminated. When asked whose responsibility it was to check the nurses' professional licenses she stated she believed it was HRS #813's job. The DON verified LPN #810 worked full time on nightshift from 6:30 P.M. to 7:00 A.M. and worked on both the [NAME] and [NAME] units. The DON verified LPN #810 worked 13 shifts with a suspended license at the facility. (See Findings under F726).Interview on 03/11/26 at 3:34 P.M. with the Administrator and HRS #813 revealed the facility had a policy in place that nursing licenses were to be checked and verified as active on hire, quarterly and annually but this was not being completed until LPN #810 was terminated on 02/25/26. (See Findings under F726).b. An interview on 03/24/26 at 11:30 A.M. with Resident #68 revealed he did not feel he could bring his concerns to the Administrator because the Administrator was intimidating and would not take his concerns seriously nor do anything about them. A confidential interview with a staff member revealed when concerns were brought to the Administrator about incidents in the facility the staff member felt frightened to report to him because the Administrator raised his voice over what the staff member had reported to him in the past as if he did not want to hear it.c. Review of the Self-Reported Incident (SRI) 271526 filed with the Ohio Department of Health (ODH) on 02/28/26 at 9:24 A.M. revealed the facility reported an allegation of physical abuse between Resident #3 and Resident #43 that was unwitnessed. However, three staff (CNA #820, #940 and #941) were identified as staff Resident #43 reported to about the incident. The narrative summary of incident investigation indicated Resident #43 told these staff that Resident #3 placed his hands in the vicinity near Resident #43's neck. However, no one saw it. The residents were separated and found without injury. Both residents denied the incident occurred and stated they felt safe. Other staff and residents were interviewed and residents were interviewed. The facility unsubstantiated that abuse had occurred. The investigation was closed on 03/06/26. Review of the facility SRI investigation revealed there were no written witness statements by CNA #820, #941 and #940 in the file. There were three staff interviews from CNA #820, #940 and #941 which were typed out and signed only by the Administrator. An interview on 03/24/26 at approximately 12:00 P.M. with the Regional Director of Clinical Operations (RDCO) verified no written witness statements by staff were in the SRI investigation file. The RDCO stated she would go check with the Administrator.An interview on 03/24/25 at approximately 3:00 P.M. with the RDCO revealed the Administrator had dumped a box out onto the floor in his office and found the handwritten witness statements from CNA #820, #940 and #941. Review of the handwritten witness statements revealed the Administrator had omitted several details from CNA #820's written statement dated 02/28/26. CNA #820 wrote that Resident #43 told her Resident #3 yelled an expletive at him, threatened him, approached him with a tray table and he was scared. The typed staff interview version signed only by the Administrator stated Resident #3 told him to shut up and placed something over his neck. Interviews on 03/25/26 between 11:00 A.M. and 11:30 A.M. by the state surveyor with Resident #3 and #43 revealed both residents reported feeling safe in the facility and neither reported abuse. Neither resident could recall the incident from 02/28/26. An interview was conducted on 03/24/26 at 4:00 P.M. with the Administrator, RDCO, RDO and the Corporate Risk Nurse (CRN) to discuss the discrepancies in the content of SRI 271526 witness statements. Both versions were read aloud to the group by the surveyor. When asked to explain the discrepancies, the Administrator stated you can't understand what they write anyway because they write how they speak. The Administrator stated he preferred to type out his own interviews to use as statements for the SRI investigations because he thought he was adding depth to what the employees were writing. The Administrator stated he was on vacation when the incident occurred and when asked when he was on vacation he stated I don't know. At the end of the interview the Administrator was observed walking out of the room down the hall and could be heard loudly and clearly stating you can't fix stupid from approximately 10 feet down the hall. It was observed that there was office doors open in this hallway with staff sitting in the offices. This deficiency is an incidental finding identified during investigation of Complaint Number 2801908, 270855 and 2721344.

Based on interviews, review of personnel files and review of the facility corrective action, the facility failed to ensure that all nursing staff were competent and legally licensed to provide nursing care and services to residents. This had the potential to affect all residents residing in the facility. The facility census was 67.Findings include:Review of the Ohio Board of Nursing (OBN) document Order, Suspension of License, revealed on 01/22/26 Licensed Practical Nurse (LPN) #810's professional license was suspended due to narcotic diversion.Review of LPN #810's employee file revealed a hire date of 02/25/25 and a termination date of 02/25/26. There was no evidence in the file of a quarterly licensure verification completed by the facility on LPN #810's license.A confidential interview on 03/10/26 at 4:43 P.M. revealed concerns regarding LPN #810's professional license being suspended due to issues with narcotics and concern that LPN #810 continued to work without a license as a nurse providing nursing care to residents at the facility.Interview on 03/11/26 at 2:39 P.M. with the Director of Nursing (DON) revealed LPN #810 had been working at the facility for approximately one month after her LPN license was suspended by the OBN. The DON stated she was informed by Human Resource Supervisor (HRS) #813 but could not recall when she found out. The DON stated LPN #810 was suspended immediately but was unsure if she had been terminated. When asked whose responsibility it was to check the nurses' professional licenses, the DON stated she believed it was HRS #813's job. The DON verified LPN #810 worked full-time on nightshift from 6:30 P.M. to 7:00 A.M. and worked on both the [NAME] and [NAME] units. The DON verified LPN #810 worked 13 shifts with a suspended license at the facility and completed all nursing duties which included passing medications to residents.Interview on 03/11/26 at 3:34 P.M. with the Administrator and the HRS #813 revealed the Administrator received an anonymous phone call on 02/25/26 stating LPN #810 was working with a suspended license. The Administrator immediately informed HRS #813 and an investigation was started with the suspension/termination of LPN #810. The Administrator stated through the investigative process it was discovered nursing licenses were to be checked and verified as active on hire, quarterly and annually. The Administrator stated this was not being completed. When asked whose responsibility this was, he stated it was the DONs and HR Supervisors responsibility.Review of the facility binder of corrective action, date initiated 02/25/26, revealed the facility implemented corrective action due to LPN #810 working in the facility with a suspended license which had the potential to affect all residents. The medical director and OBN were notified. All residents were assessed, narcotic reconciliation was done on all medication carts, psychosocial assessments were done on all residents and licensure verification was done for all nurses. Staff education was completed on 02/25/26 and length of education was 15 minutes on the facility hiring process/procedure including verification of licensure for nurses upon hire, quarterly and annually by the Administrator/designee to the Human Resources Manager. The Administrator/designee educated all staff on the facility misappropriation policy. The DON/designee educated all nurses on OBN licensure requirements for nurses and the facility policy/procedure for licensure verification and narcotic reconciliation policy. However, upon review of the sign-in attendance documentation records revealed incomplete evidence of staff signatures that included only 20 staff signatures of 84 staff listed on the records for education on Misappropriation and/or Licensure Requirements. The teaching method was listed as verbal explanation, on-line text learning or via phone. For the records of education of OBN Licensure Requirements and Narcotic Reconciliation presented by the DON/designee on 02/25/26, the records revealed incomplete evidence of staff signatures that included only five nurse signatures of 16 nurses listed on the records for education. The teaching method was explanation. The nurses who did not provide a signature were educated verbally on 02/25/26. There was no evidence of post-education competency testing.Further review of the corrective Controlled Substance Reconciliation QI Tool documents revealed audits began on 02/26/26 for narcotic medications administered timely and documented correctly, and delivery reconciled and documented. There was no evidence of a look back period being assessed for discrepancies in administration of narcotics.Interview on 03/24/26 at 3:07 P.M. with the DON confirmed the contents of the corrective actions and stated most of the staff education was completed verbally by phone or through a text messaging system and staff signatures were not obtained. The DON stated the text messaging system did not provide receipt that staff acknowledged looking at the message, she thought there was a way to see who looked at the message, but could not provide any evidence. The DON verified additional audits had not been completed to look for discrepancies in narcotic administration other than what was in the corrective action binder. This deficiency represents noncompliance investigated under Complaint Number 2801908.

Based on closed record review, staff interviews, and policy review, the facility failed to provide basic life support (BLS), including Cardiopulmonary Resuscitation (CPR) to Resident #61 per the residents advanced directive for a full code status, when the resident was found unresponsive and absent of vital signs. This resulted in Immediate Jeopardy and serious life-threatening harm and the subsequent of death of Resident #61 beginning on [DATE] when Certified Nursing Assistant (CNA) #135 alerted Registered Nurse (RN) #142 Resident #61was absent of vital signs. Instead of providing immediate care (i.e. CPR) RN #142 assessed the resident to be absent of vital signs and contacted Licensed Practical Nurse (LPN) #136 who was working another unit to verify the resident ' s death. RN #142 pronounced the resident ' s time of death of 4:50 P.M. RN #142 notified the physician without indicating CPR was not initiated, and Physician #187 gave orders to release the resident to the funeral home. Resident #61 ' s family was notified of the resident's death but not of the fact CPR was never initiated. This affected one resident (#61) of 11 residents reviewed for death in the facility.On [DATE] at 3:54 P.M. the Administrator, Regional Director of Clinical Services (RDCS), Regional Director of Operations (DO) and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 4:50 A.M. when staff failed to provide basic life saving measures/CPR to Resident #61. Upon entering the resident ' s room CNA #135 observed Resident #61 to be absent of vital signs and not breathing. CNA #135 alerted RN #142 who assessed Resident #61 and found the resident was absent of vital signs and asked LPN #136 who was working on another unit to come and verify time of the resident ' s death and absence of vital signs. RN #142 did not notify LPN #136 or CNA #135 Resident #61 was a full code not was CPR attempted/provided. RN #142 notified Physician #187 of time of death but did not notify Physician #187 that CPR was not initiated.The immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 8:15 A.M. the Director of Nursing (DON) notified the Medical Director of the incident involving Resident #61. On [DATE] at 11:00 A.M. the facility implemented a plan for the DON to perform CPR Mock Code Evaluations via hands on demonstration with verbal discussion on day shiftand night shift on [DATE], [DATE], [DATE]. Additional mock code scheduled for [DATE], [DATE] and [DATE]. The DON/ADON then would perform random mockcodes for one week to capture all facility staff nurses to evaluate effectiveness and ensure competency. Once the random mock codes for one week were conducted by or on[DATE] the facility DON will audit the Mock CPR codes comparing an all-facility nurse staff roster to confirm all staff nurses have participated in a Mock CPR drill. If anurse was on vacation or unable to attend the drills, additional Ad Hoc Mock CPR drills will be provided prior to their next shift. On [DATE] at 11:48 A.M., Human Resources Employee audited all 16 facility nurses (4 RNs, 12 LPNs) and 11 agency nurses (3 RNs and 8 LPNs) files to ensure a valid CPRcard was on file. For additional measure the facility had an American Heart Association (AHA) CPR class scheduled to be completed in house on [DATE]. The facility wantedto offer a hands-on CPR class to include return demonstration that adheres to the AHA guidelines for all in-house licensed personnel due to facility policy and procedureguidance promotes/notes the AHA guidelines. On [DATE] the DON audited the facilities two crash carts to ensure proper supplies and equipment were available. Crash cart audits would be monitored for completion five toseven days a week by DON/ADON for four weeks. On [DATE] the DON re-audited 60/60 in-house resident records for code status according to residents ' preference/physicians ' orders. The review included care plans,DNR forms, PCC demographic bar on every resident and compared the advanced directives to the physician order for accuracy. On [DATE] an Ad Hoc QAPI meeting was held with the IDT including medical director, DON, Infection Preventionist, Administrator, Activities, BOM, Maintenance Director,Housekeeping Supervisor, Admissions Director, and the Therapy Director. Topics discussed included the CPR policy titled Emergency Procedure CardiopulmonaryResuscitation and Basic Life Support. The DON and/or ADON would audit new admissions to verify the advanced directives were as preferred/ordered. On [DATE] at 6:10 P.M. the DON re-educated all 16 licensed staff nurses (4 RNs, 12 LPNs) and identified 11 frequent agency nurses (3 RNs and 8 LPNs) to educate.Education provided included the facility ' s CPR policy titled Emergency Procedure Cardiopulmonary Resuscitation and Basic Life Support and the procedure for initiatingCPR. Licensed nurses were not permitted to work a shift until education was completed. On [DATE] per facility CPR policy all licensed staff nurses in any given shift were identified as part of the CPR team per policy. Reminder postings were placed by the timeclock, in the break room, and at the nurses ' stations by the DON and RDCS after receiving approval from the Administrator. The facility implemented a plan for the DON to audit new admissions to compare the residents ' advanced directives to the physician orders for accuracy. This audit wouldcontinue for all new admissions for three months. Findings would be reviewed at the monthly QAPI Committee meeting. The above would be discussed at the next QuarterlyQuality Assurance meetings.Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:Review of the closed medical record for Resident #61 revealed an initial admission date of [DATE] with diagnoses including atrial fibrillation, acute pulmonary edema, atherosclerotic heart disease, hypertension, malignant neoplasm of the pharynx, sepsis, and pleural effusion. Resident #61 was discharged to the hospital on [DATE] then readmitted to the facility on [DATE] with readmission diagnoses of aspiration pneumonia and acute respiratory failure with hypoxia. The resident expired in the facility on [DATE].Resident #61 was listed as his own responsible party and his sister was listed as the emergency contact. Resident #61 ' s code status in the event of cardiopulmonary arrest was a full code indicating he wanted all life sustaining measures provided to him if his heart stopped and he would stop breathing.Review of Resident #61 ' s care plan initiated on [DATE] revealed the Resident/Responsible Party wished for the resident to be a Full Code for their Advanced Directives. Care plan goals indicated the resident ' s wishes would be honored. Interventions included the facility would adhere to desired code status, they were to inform the resident ' s physician if code status changed, and the facility would review code status quarterly or as needed.Review of Resident #61 ' s physician orders dated [DATE] revealed the resident was a full code and desired basic life saving measures including CPR.Review of Physician and Nurse Practitioner (NP) assessments in the medical record revealed on [DATE] NP #189 assessed Resident #61 and documented Resident #61 was a full code.Review of Resident #61 ' s Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had some cognitive impairment, was to have nothing by mouth, required substantial (staff) assistance for oral hygiene and upper body dressing, required partial to moderate (staff) assistance with bed mobility, and was dependent on staff for toileting hygiene,showers, lower body dressing, personal hygiene and transfers with the use of a mechanical lift when not in therapy.Review of Resident #61 ' s Medication Administration Record (MAR) date [DATE] revealed on [DATE] at 4:00 A.M. RN #142 documented the administration of Levothyroxine Sodium tablet 125 micrograms (mcg) via peg tube to Resident #61.Review of Resident #61 ' s progress notes dated [DATE] at 4:50 A.M. authored by RN #142 stated CNA called RN #142 into Resident #61 ' s room, upon entering the room resident appeared to be deceased . Upon assessment it was confirmed that the resident had passed away. Other nurse came to verify time of death, family, Dr. and DON were notified. Waiting on call back from family message was left. There were no other details in RN #142 ' s note on [DATE] regarding Resident #61 coughing up phlegm or giving him a cup to spit into (as noted in the statement obtained as part of the facility investigation).Review of the facility investigation provided by Regional Director of Clinical Operations (RDCO) revealed the following incident reports and witness statements:Review of the facility document titled #152 (other) dated [DATE], timed 8:30 A.M. and authored by the DON revealed an incident description stating at approximately 4:50 A.M. on [DATE] the CNA called the resident ' s nurse into residents ' room. Upon entering the room the nurse documented resident appeared to be deceased . Upon assessment it was confirmed the resident has passed away. Residents ' nurse called for another nurse to verify resident was absent of vital signs. Nurse charted time of death 4:50 A.M. Family and on-call doctor (Physician #187) notified. DON notified via text message. The above incident was noted to be unwitnessed.Review of the facility document titled Employee Memorandum, dated [DATE] and signed by the DON and RN #142 revealed RN #142 violated a code of conduct rule by failure to follow doctor ' s orders and conduct self in a professional and ethical manner. The date of the violation was [DATE]. The corrective action was listed as follow doctor ' s orders. No further details werelisted on the form.Review of a typed witness statement, dated [DATE] with the first and last name of RN #142 typed and without signature, revealed the following typed statement STNA notified this nurse at approximately 0450 to come to resident room. Upon entering the room I observed resident to have passed away. Vitals taken and there were no respirations or pulse. Resident was cold to the touch and pale, fingertips gray and bluish tent to lips and face cold and stiff. Rigor mortis was starting to take place. Resident appeared to have been deceased for some time. Nurse from the other unit came over to assess resident and confirmed time of death. Resident was last seen by this nurse at 0230. Resident was coughing and trying to bring up phylum (that had been present upon admission to the facility). This nurse elevated bed and gave resident a cup and he was able to expectorate in the cup. He stated he felt better and went to sleep.Review of a handwritten witness statement dated [DATE] authored by LPN #136 revealed LPN #136 was asked by RN #142 to confirm death of Resident #61 the morning of [DATE] at 4:45 A.M. with a CNA present in the room for assessment. Upon entering the room, the resident appeared cyanotic (blue) and cold to touch. No signs of life or respiratory effort. No palpable carotid pulse, heart or respiratory sounds for five minutes. Death confirmed at 5:00 A.M. and rigamortis was starting to set in.There was no witness statement from CNA #135 in the investigation.An interview on [DATE] at 10:40 A.M. with RN #142 revealed (on [DATE]) Resident #61 was last seen around 2:00 A.M. when CNA #135 came and got her due to the resident coughing up phlegm. In response, RN #142 went to check Resident #61 and gave him a cup to spit in and had him sitting up. RN #142 stated that it helped the cough, the resident was able to clear the phlegm, and the resident was laid back down. RN #142 stated around 4:40 A.M. to 4:45 A.M. CNA #135 came and got RN #142 due to the resident not breathing. Resident #61 was found to be absent of vital signs. RN #142 stated she had another nurse come in and verify absence of vital signs, and notified the physician, family and DON of the resident ' s death. RN #142 stated she did not discuss with the CNA or other nurse that Resident #61 was a full code, and stated she made the decision on her own not to do CPR because the resident was obviously dead. RN #142 also stated she did not tell the residents ' family nor the physician that CPR was not provided (as per the resident ' s advance directives/code status).An interview on [DATE] at 1:30 P.M. with Physician #187 revealed he was notified Resident #61 was deceased , but he was not informed CPR had not been provided to Resident #61. Physician #187 stated he had concerns as to why CPR was not initiated regardless of what condition the resident was found. Physician #187 stated his nurse practitioner notified him a few days later the resident was a full code, and he then spoke with the DON to find out why CPR was not initiated at time of death as it should have been.An interview on [DATE] at 3:13 P.M. with CNA #135 revealed she was assigned to Resident #61 for her shift which began on [DATE] through [DATE]. CNA #135 stated she had been checking on the resident every two hours and when she went to check him at 4:45 A.M. he appeared to be dead. CNA #135 stated Resident #61 was cold to touch but was not stiff, and she went to get RN #142. CNA #135 stated RN #142 went to get another nurse to confirm absence of vital signs and she was unaware of any conversation between the two nurses about Resident #61 ' s full code status. CNA #135 stated she completed postmortem care on Resident #61 and described his body as cold, not stiff, and rigor mortis (stiffening of the joints and muscles within two to six hours after death) had not set in when providing his postmortem care.A follow-up interview was conducted on [DATE] at 8:21 A.M. with RN #142 who stated and verified she administered Resident #61 Levothyroxine Sodium tablet via PEG tube on [DATE] at 4:00 A.M. The RN stated Resident #61 was alive at that time. When asked why she did not provide CPR on Resident #61, RN #142 stated take it easy. In my opinion he was dead andthere was no need for CPR.An interview on [DATE] at 10:30 A.M. with the Nurse Practitioner (NP) revealed she did not have any involvement with the situation regarding Resident #61 other than being notified CPR was not done and Resident #61 expired.An interview on [DATE] at approximately 4:45 P.M. with the RDCO revealed RN #142 was disciplined for not following physician orders related to Resident #61 passing away in the facility, as part of the facility ' s response to Resident #61 expiring in the facility as a full code and not receiving CPR. The RDCO verified RN #142 was still employed as a nurse at the facility as of this time. In addition, the RDCO verified the RN had not provided a written witness statement with her signature to verify her reported account of the incident. The RDCO voiced no awareness RN #142 had documented and administered Levothyroxine Sodium to Resident #61 at 4:00 A.M. on [DATE] which contradicted the typed and unsigned witness statement with RN #142 ' s name on it indicating she last saw the resident alive around 2:30 A.M. The RDCO stated RN #142 made a decision to not provide CPR without speaking to the physician about the full code status of Resident #61 and RN #142 did not provide CPR because the resident ' s conditiondid not indicate CPR should be provided according to the facility CPR policy because he had signs of rigor mortis.An interview on [DATE] at 9:06 A.M. with LPN #136 revealed upon entering Resident #61 ' s room to verify absence of vital signs the resident was visually starting to turn blue, he was cold to touch on his hands and arms but he had no signs of body stiffness at the time she attempted to obtain the resident ' s vital signs. LPN #136 stated there was no discussion with RN #142regarding Resident #61 ' s code status and she was instructed by RN #142 to verify the absence of vital signs.Review of the facilities policy titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support, last revised on [DATE], revealed if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS was to initiate CPR unless it was known that a DNR order that specially prohibited CPR and/or external defibrillation existed for that individual or if there were obvious signs of irreversible death (e.g., rigormortis). If the resident ' s DNR status was unclear, CPR was to be initiated until it was determined that there was a DNR or a physician ' s order not to administer CPR.This deficiency represents non-compliance investigated under Complaint Number OH00167051.

Based on closed medical record review, facility policy and procedure review and interviews, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #61 that started on [DATE]. The facility failed to ensure changes in the residents ' medical condition were comprehensively assessed, the residents change in condition, including abnormal vital signs and extreme loss of balance, was communicated to the medical provider, and individualized interventions were implemented. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] when Resident #61 experienced hypotension (low blood pressure defined as a systolic pressure or top number below 90 millimeters of mercury (mm/Hg) and/or diastolic pressure or bottom number below 60 mm/Hg), dizziness, extreme loss of balance with his body going limp and eyes rolling back in his head while in physical therapy, as identified by the Physical Therapy Director (PTD) #172 who reported the incident to Licensed Practical Nurse (LPN) #132. LPN #132 did not comprehensively assess Resident #61 or notify the physician or Nurse Practitioner (NP). On [DATE] Resident #61 again presented with hypotension during physical therapy with blood pressures taken by PTD #172 noted as 82/55 millimeters of mercury (mm/Hg) and 94/59 mm/Hg while sitting and 72/50 mm/Hg and 75/48 mm/Hg while standing which was reported to Physician #187 by PTD #172 face-to-face in the facility hallway. Physician #187 failed to do a comprehensive medical assessment on Resident #61 on [DATE]. Resident #61 expired in the facility on [DATE] due to cardiopulmonary arrest. This affected one resident (#61) of eleven residents reviewed for change of condition.On [DATE] at 3:54 P.M. the Administrator, Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS) and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when therapy staff identified Resident #61 exhibited a change in condition which included abnormal vital signs, an extreme loss of balance caused by dizziness, body going limp and eyes rolling back in his head as recorded and reported by PTD #172. There was no evidence of timely or adequate interventions/medical treatment being provided. Resident #61 was not seen by Physician #187 nor by the Nurse Practitioner on [DATE]. Additionally, on [DATE] PTD #172 identified and documented Resident #61 again showed low blood pressures requiring therapy to be stopped. PTD #172 stopped Physician #187 in the hallway on [DATE] and notified him of low blood pressure. Physician #187 did not see Resident #61 on [DATE] or on [DATE]. On [DATE] Physician #187 gave verbal orders in the hallway to Registered Nurse (RN) #150 to decrease the residents Metoprolol (cardiac medication) from 25 milligrams (mg) daily to 12.5 mg daily and on [DATE] Physician #187 gave additional verbal orders to LPN #132 to discontinue the resident ' s Valsartan (cardiac medication) and to do orthostatic blood pressures every shift for three days. Resident #61 was subsequently found absent of all vital signs on [DATE] at 4:50 A.M. and pronounced deceased .The Immediate Jeopardy was removed on [DATE] when the facility implemented the followingactions: On [DATE] the Regional Director of Clinical Services (RDCS) notified the Medical Director of the Immediate Jeopardy involving quality of care for Resident #61. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held and attended by the Administrator, Medical Director, Regional Director ofClinical Services (RDCS), Director of Nursing (DON), Therapy Director, Infection Preventionist, Activities Director, Business Office Manager (BOM), MaintenanceDirector, Housekeeping Supervisor, and Admissions Director (AD) to discuss the incident involving Resident #61. On [DATE] the DON, RDCS and LPNs interviewed/assessed 60 of 60 in house residents to identify any unreported changes in condition. Skin sweeps were done for 16 residentswho were unable to be interviewed due to cognitive deficits. 44 residents were interviewed related to unreported changes in their health status. On [DATE] the DON educated 16 of 16 licensed facility nurses, 11of 11 frequently used agency nurses, 14 of 14 therapy staff and 32 of 32 nurse aides on the facility ' s change incondition policy titled Change in a Resident ' s Condition or Status which included physician notification and documentation requirements. Staff members were notpermitted to work a shift until education was completed [DATE]. Newly hired (licensed nurses and nurse aides) would be educated on the change of condition policy includingphysician notification regulations during orientation by the DON/ADON. Beginning [DATE] the facility implemented a plan for the DON and Assistant Director of Nursing (ADON) to review the 24-hour report to identify documented changes inconditions to ensure any change of condition identified is properly reported to the resident, physician and the family/resident representative per policy/procedure. Thiswould occur for five to seven days a week for five weeks then randomly thereafter. The reviews would be discussed at the next QAPI meeting.Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not ImmediateJeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include: Review of the closed medical record for Resident #61 revealed an initial admission date of [DATE] with diagnoses including atrial fibrillation, acute pulmonary edema, atherosclerotic heart disease, hypertension, malignant neoplasm of the pharynx, sepsis, and pleural effusion. Resident #61 was discharged to the hospital on [DATE] then re-admitted to the facility on [DATE] with a readmission diagnosis of aspiration pneumonia and acute respiratory failure with hypoxia. The resident expired in the facility on [DATE].Record review revealed Resident #61 was listed as his own responsible party and his sister was listed as the emergency contact. Resident #61 ' s code status in the event of cardiopulmonary arrest was a full code indicating he wanted all life sustaining measures provided to him if his heart stopped and he would stop breathing. There was no evidence in the medical record to indicate a change in the full code status at any time during the stay.Review of Resident #61 ' s care plan initiated on [DATE] revealed the resident/responsible party wished for the resident to be a full code for their advanced directives. Care plan goals indicated the resident's wishes would be honored. Interventions included the facility would adhere to desired code status, they were to inform the resident ' s physician if code status changed, and thefacility would review code status quarterly or as needed.Further review of Resident #61's care plan revealed a plan for the resident ' s desire to return home with home health care when able.Review of physician orders revealed on [DATE] there was an order for Metoprolol Succinate Extended Release (ER) 25 milligrams (mg) daily via peg tube and an order dated for Valsartan 40 mg via peg tube daily for hypertension.Record review revealed Resident #61 had a plan of care initiated on [DATE] regarding the diagnosis of hypertension (high blood pressure) with goals and interventions including the resident would remain free from signs and symptoms of hypertension. Interventions included nursing staff to administer hypertensive medications per physician orders and monitor for side effects such as orthostatic hypotension (low blood pressure) and increased heart rate, monitor for and document any edema (swelling), and staff were to report any significant changes to the physician.Review of Resident #61 ' s Physician and Nurse Practitioner assessments revealed the last assessment was completed on [DATE] by Nurse Practitioner (NP) #189 indicating Resident #61 had an improvement in conditions since last visit. The resident denied any issues or concerns at the time of the visit. Active issues included hypertension managed with Metoprolol ER (a medication used to decrease blood pressure) 25 milligrams (mg) daily, Lasix (diuretic) 20 mg daily, Valsartan (a medication used to decrease blood pressure) 40 mg daily and Spironolactone (diuretic) 12.5 mg daily. The resident was seen for a stabilization visit after being hospitalized for pneumonia and paroxysmal atrial fibrillation (abnormal heart rhythm). The resident was noted to be a full code. The note included the resident appeared chronically ill, received continuous oxygen and was alert and oriented to person, place and time with forgetfulness. There was no evidence in the assessment to indicate hypotension/low blood pressure was an expected or normal baseline finding for Resident #61.Vital signs were noted as within normal limits for the resident and were noted as vital signs reviewed from the date of [DATE] at 2:47 P.M. which included a blood pressure of 127/75 millimeters of mercury (mm/Hg).Review of Resident #61's Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had some cognitive impairment, was to have nothing by mouth, required substantial assistance for oral hygiene and upper body dressing, required partial to moderate assistance with bed mobility, and was dependent on staff for toileting hygiene, showers, lower body dressing, personal hygiene and transfers with the use of a mechanical lift when not in therapy.Review of Resident #61's Physical Therapy Daily Treatment Note authored by Physical Therapy Director (PTD) #172 dated [DATE] revealed Resident #61 performed sit to stand and stand pivot transfers from bed to wheelchair with minimal assist to contact guard assist, Resident #61 also performed Pressure Releaving Exercises (PREs) to lower extremities with verbal and visual cues for technique. An additional remark by PTD #172 stated the resident experienced extreme loss of balance (LOB) on first and only ambulation attempt caused by dizziness, the resident's body went limp with eyes rolling back requiring maximal assistance to prevent fall. Resident was immediately taken to the nurses ' station; nursing reported a low blood pressure and then resident was assisted to bed.Further review of Resident #61 ' s medical record revealed the Medication Administration Record, Treatment Administration Record and record of blood pressures for [DATE] showed no bloodpressures had been recorded by nursing on [DATE] and not since [DATE]. Additionally, review of the nursing progress notes and assessments showed no evidence the nurse documented the change of condition which was brought to nursing ' s attention by PTD #172 on [DATE] and there were no notes or assessments from the physician or NP to indicate Resident #61 had been assessed on [DATE]. The last nursing assessment completed on Resident #61 was a skin assessment on [DATE].Review of a Physical Therapy note dated [DATE] authored by PTD #172 and signed at 1:51 P.M. revealed Resident #61 ambulated approximately 50 feet using a front wheeled walker with minimal assistance along with pre-gait standing task. Resident #61 experienced a drop in blood pressure with each attempt. PTD. #172 spoke with Physician #187 regarding this situation. Gait training was paused for the remainder of the day. Noted under the additional remarks sections were Resident #61 ' s blood pressure readings ranging from 82/55 mm/Hg to 94/59 mm/Hg sitting to 72/50 mm/Hg to 75/48 mm/Hg standing which were obtained in therapy. Standing task was put on hold on this date.Review of Resident #61's nursing progress note dated [DATE] at 10:59 A.M. authored by Registered Nurse (RN) #150 revealed RN #150 was given a verbal order from the physician to decrease Resident #61 ' s Metoprolol to 12.5 mg every day. Additionally, on [DATE] at 2:48 P.M. a progress note authored by Licensed Practical Nurse (LPN) #128 revealed the physician gave a verbal order to discontinue Resident #61 ' s Valsartan and to do orthostatic blood pressures (blood pressure conducted lying, sitting, and standing) every shift for three days.Review of physician orders dated [DATE] revealed new orders for Metoprolol 12.5 mg daily, Valsartan was discontinued and the physician ordered orthostatic blood pressures every shift forthree days.Review of documented vital signs dated [DATE] for Resident #61 revealed RN #142 recorded the following blood pressures: 108/64 mm/Hg while lying at 8:31 P.M., 101/60 mm/Hg whilesitting at 8:32 P.M. and 84/57 mm/Hg while standing at 8:33 P.M.Further review of Resident #61 ' s progress notes revealed there were no additional progress notes authored after [DATE] at 2:48 P.M. until the resident ' s death on [DATE] at 4:50 A.M.An interview on [DATE] at 1:30 P.M. with Physician #187 revealed he had not been notified of any concerns with Resident #61 on [DATE], but on [DATE] he was caught in the hallway byPhysical Therapy Director (PTD) #172 who indicated during treatments Resident #61 became hypotensive and dizzy when standing. Physician #187 stated he did not see the resident to physically assess him but did review his medications to address the symptoms reported by PTD #172. Physician #187 stated he decreased Resident #61 ' s Metoprolol to 12.5 mg daily. Physician #187 stated he then made additional changes to discontinue the residents Valsartan that day and ordered orthostatic blood pressures every shift for three days. Physician #187 stated he was not notified by the facility of the orthostatic blood pressures taken on [DATE] between 8:31 P.M. to 8:33 P.M. Physician #187 stated he was notified Resident #61 expired but stated he was not informed that no CPR was initiated. Physician #187 stated he had concerns as to why CPR was not initiated, and regardless of what condition the resident was found in the nurses should have performed CPR on the resident as he was a full code resident. Physician #187 stated his Nurse Practitioner notified him a few days later that the resident was a full code yet no CPR was initiated. Physician #187 stated he brought it to the attention of the Director of Nursing (DON) his concerns with CPR not being initiated at time of death for Resident #61.An interview on [DATE] at 1:48 P.M. with PTD #172 confirmed PTD #172 spoke to Physician #187 in the hallway on [DATE] regarding Resident #61 becoming orthostatic in therapy and would complain of dizziness with standing. PTD #172 stated this also occurred on [DATE] and verified he witnessed Resident #61 have an extreme loss of balance with dizziness and body went limp with eyes rolled back in his head. PTD #172 stated Resident #61 had to be held to prevent a fall at that time. PTD #172 stated it was not abnormal for Resident #61 to feel dizzy when standing, but it was not Resident #61's norm or baseline to go limp as if he was going to pass out. PTD #172 stated he had told LPN #132 about Resident #61 ' s symptoms in therapy on [DATE]. PTD #172 stated he thought that was the nurse assigned to Resident #61 on that day.An interview on [DATE] at 2:26 P.M. with RN #150 revealed on [DATE] the RN was assigned to be the float nurse in the facility and Physician #187 stopped him in the hallway and gave averbal order to decrease Resident #61 ' s Metoprolol from 25 milligrams (mg) daily to Metoprolol 12.5 mg daily.An interview on [DATE] at 10:30 A.M. with the Nurse Practitioner (NP) revealed she did not have any involvement with the situation regarding Resident #61 (on [DATE] or [DATE]) othe than being notified CPR was not done on [DATE] and Resident #61 expired. The NP stated she was unaware of the change in condition the resident had on [DATE] during therapy and the day prior to his death.An interview on [DATE] at 11:36 A.M. with LPN #132 revealed the LPN was on orientation and RN #150 was teaching him. LPN #132 stated therapy indicated Resident #61 became dizzy, had an extreme loss of balance, complained of being dizzy, and had moderated changes in blood pressure. Therapy staff indicated the resident went limp and eyes rolled back in head. LPN #132stated they assisted the resident to his room and to bed but did not complete an assessment and did not notify the physician or NP.An interview on [DATE] at 11:51 A.M. with RN #150 revealed on [DATE] the RN was at the nurses ' station on the [NAME] unit when PTD #172 brought Resident #61 to him. RN #150 stated PTD #172 said Resident #61 was done in therapy due to weakness, dizziness and almost falling during therapy. RN #150 stated the resident appeared tired but was alert and oriented per baseline. RN #150 stated his actions included taking the resident to his room, checking vital signs and blood sugar, and assisted the resident to bed. RN #150 stated he did not notify Physician #187 nor a Nurse Practitioner of Resident #61 ' s acute change in condition in therapy because RN #150 felt the symptoms described were not lingering. RN #150 verified he did not document the vitals he took, what was reported by PTD #172 nor complete a change of condition assessment in the medical record.Review of the facility policy titled Change in a Resident ' s Condition or Status, last revised February 2021, revealed it was the policy of the facility to promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and /or status. The policy included the facility must inform the resident, consult with the resident ' s medical practitioner and/or notify the resident ' s representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification included but were not limited to significant change in the resident ' s physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including but not limited to life threatening conditions or clinical complications.This deficiency represents non-compliance investigated under Complaint Number OH00167051.

Based on closed record review, facility policy review and interview the facility failed to ensure routine assessment/skin monitoring was completed and failed to prevent the development of an avoidable pressure ulcer injury for Resident #68. Following the development of the pressure ulcer, the facility failed to ensure treatments were completed as ordered. Actual Harm occurred on 07/19/23 when Resident #68, who was assessed to be at risk for pressure ulcer development was found to have an open wound (to the left lateral foot) with no evidence of any type of treatment being initiated. On 07/20/23 the area was assessed to be unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. This affected one resident (#68) of three reviewed for wounds. The facility census was 61. Finding include: Review of the medical record for Resident #68 revealed an admitted [DATE] with diagnoses including chronic kidney disease, type II diabetes, adult failure to thrive, and neuromuscular dysfunction of the bladder. Record review revealed the resident was transferred to the hospital on 09/18/23. The resident did not return to the facility. Review of the weekly skin computer assessments from 06/01/23 through 07/20/23 revealed only one weekly skin check was completed on 06/01/23. Review of the Treatment Administration Record (TAR) for June 2023 revealed weekly skin checks were documented as completed on 06/07/23, 06/14/23, 06/21/23 and 06/27/23. Review of the TAR for July 2023 revealed weekly skin assessments were documented as being completed on 07/05/23, 07/12/23, and 07/19/23. Review of the shower sheets for July 2023 revealed there was no shower documented as completed on scheduled shower days 07/04/23, 07/08/23, 07/11/23, 07/15/23, 07/18/23, 07/25/23, 07/25/23, and 07/29/23. Showers were refused on 07/12/23 and 07/19/23. The resident received a shower on 07/22/23. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. The assessment revealed the resident required limited assistance with toilet use and hygiene. The resident was continent of bowel and bladder. The assessment indicated the resident was at risk for pressure ulcers. Review of the care plan dated 07/18/23 revealed Resident #68 was at risk for pressure injury, rash, cellulitis, and skin tears due to limited mobility. Interventions included weekly skin assessments to report irregularities, protect skin from moisture, and to elevate heels off the bed as tolerated. The care plan stated the resident was resistive to care related to failure to thrive. The care plan documented the resident refused showers. Review of the pressure ulcer risk assessment dated [DATE] revealed the resident was at moderate risk for the development of pressure ulcers. Review of the skilled charting documentation dated 07/19/23 at 1:59 A.M. revealed a left lateral wound was identified with scant drainage and granulated, healing, tissue. There was no evidence that a treatment was put in place. Review of the wound physician assessment report dated 07/20/23 revealed the resident had a left lateral foot unstageable pressure wound that measured 4.5-centimeter (cm) length by 4.5 cm width and depth unable to be determined. The wound had 50 percent (%) to 74% slough, a mass of dead tissue, and 1% to 24% eschar, dried dead tissue, with a moderate amount of drainage. A new treatment order was put in place at this time. A treatment was ordered to cleanse the wound with normal saline, apply hydrogel (promotes the removal of infected or necrotic tissue), calcium alginate (highly absorbent dressing), abdominal (ABD) pad, and wrap with Kerlix rolled gauze daily and as needed. Review of the July 2023 physician's orders revealed orders dated 07/28/23 for an ultrasound to bilateral lower extremities and change the dressing to the left lateral foot to cleanse with normal saline solution, pat dry, apply adaptic oil emulsion dressing (non-adherent dressing) cut to fit exposed bone/tendon, pack wound with Dakin's (antiseptic) saturated four by four gauze, cover with an ABD pad and secure with Kerlix rolled gauze, change twice daily and as needed. Review of the July 2023 TAR revealed the treatments to the left lateral foot were not documented as completed as ordered on 07/28/23, 07/29/23, and 07/30/23. Review of the medical record revealed ultrasound results dated 08/02/23 revealed no occlusion, and the resident received an order for an antibiotic, Doxycycline. Review of the medical record revealed an order dated 08/25/23 to send the resident to the local hospital on Monday, 08/28/23, for a MRI (magnetic resonance imaging) to rule out worsening wound. On 08/28/23, the resident was diagnosed with cellulitis and osteomyelitis (infection of the bone) and was ordered to continue Doxycycline and begin Keflex (antibiotic) for 14 days. Review of the medical record revealed the resident was sent to the local hospital on 09/18/23 and admitted with a diagnosis of osteomyelitis. Interview on 10/04/23 at 7:00 A.M. with Licensed Practical Nurse (LPN) #272 revealed on 07/19/23 she was orientating with another nurse who identified the wound. The wound was about the size of a quarter. She could not recall if a dressing was put into place. The nurse would not allow her to document the assessment. Interview on 10/04/23 at 12:45 P.M. with the Director of Nursing (DON) verified Resident #68's weekly skin assessments and showers were not completed. There was no evidence a wound treatment was administered on 07/19/23 when the wound initially identified. The DON also verified treatments to the left lateral foot were not documented as completed per physician's orders on 07/28/23, 07/29/23, and 07/30/23. Interview on 10/04/23 at 3:30 P.M. with State tested Nursing assistant (STNA) #281 stated the resident refused showers but would wash up in his room. Resident #68 was able to wash the upper portion of his body but needed assistance with his legs and feet. STNA #281 stated he was always wearing socks and she would just wash his legs. STNA #281 stated she never took off his socks to look at his feet. STNA #281 stated when she provided a shower, she does not do a thorough skin check or check the bottom of feet. Interview on 10/04/23 at 3:57 P.M. with Registered Nurse (RN) #215 stated the computer program does not always prompt to complete weekly skin assessments. RN #215 kept a list of residents and days they were scheduled to receive weekly skin checks to ensure they were completed. Review of the facility policy titled Pressure Ulcers and Skin Breakdown, revised April 2018, revealed the nurse shall describe and document a full assessment of a pressure sore including location, stage, length, width and dept, presence of exudate or necrotic tissue. Review of the facility policy titled Bath, Shower or Tub, revised February 2018, revealed the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This deficiency represents non-compliance investigated under Master Complaint Number OH00146836.

Based on record review and interview, the facility failed to consistently complete skin assessments for residents at risk for pressure ulcer developement. This resulted in actual harm to Resident #31, who developed an unstageable pressure ulcer (unable to determine depth of tissue destruction) on the right hip. The deficient practice affected two (Resident #31, Resident #47) of four residents reviewed for pressure ulcer development. The facility census was 46. Findings include: 1. Review of the medical record for Resident #31 revealed an admitted to the facility of July 2013 and [DIAGNOSES REDACTED]. A review of the nursing admission assessment dated [DATE] documented Resident #31 had a rash on the right hip, a boil on the left side and no other skin impairments. The admission assessment also indicated Resident #31 needed the assistance of staff for bed mobility and transfer due to right sided paralysis and weakness of the lower extremities. Resident #31 was assessed to be incontinent of urine and requireed staff assistance with incontinence skin care. Review of the plan of care developed revealed a pressure ulcer prevention plan initiated on 07/25/13. Review of a physician order [REDACTED]. The current care plan for Resident #31 included a problem of pressure area to the right hip and venous stasis ulcers of the right foot. Nursing interventions on the plan of care included nurses to complete a full skin evaluation weekly with bath or shower, and resident non-compliance with turning and repositioning, especially off of the right side. Review of the weekly skin assessment revealed skin assessments were completed from admission through 09/18/13 but did not identify a skin concern with the right hip. A review of the assessment for 09/18/13 read "No new areas of skin impairment". The next completed assessment was dated 10/07/13 and read "See nursing documentation". A review of nursing progress notes and the medical record did not identify additional documentation for the skin status between 09/10/13 and 10/01/13 or staff ability to maintain compliance with repositioning. Further review of the medical record revealed a skin grid (documents wound status) created 10/01/13 and identified an unstageable pressure ulcer (unable to determine depth of underlying tissue destruction) to the right hip and buttocks region measuring 4.0 centimeters (cm) in length and 2.8 cm in depth. Orders were obtained 10/01/13 to cleanse the right hip with normal saline and apply [MEDICATION NAME] (dressing to help clear wound debris) every three days. Resident #31 continued to have treatments three times a week for the pressure ulcer of the right hip. On 12/03/13 at 7:10 A.M. an interview with the Assistant Director of Nursing (ADON) verified the facility had no evidence to indicate weekly skin assessments were completed between 09/18/13 and the development of an unstageable pressure ulcer on 10/01/13. At 9:00 A.M. the Director of Nursing (DON) verified weekly skin assessments were to be completed weekly on the weekly skin assessment document because during bathing and showers skin was not always observed by the nurse. 2. A review of the medical record for Resident #47 revealed [DIAGNOSES REDACTED]. Resident #47 was identified on admission (July 2013) as a pressure ulcer risk and a care plan was developed. Review of the care plan nursing interventions and physician orders [REDACTED]. A review of the weekly skin assessment dated [DATE] revealed "No areas of impairment". The next documented assessment dated [DATE] read "See skin grid". Review of a skin grid (documents wound status) dated 10/14/13 revealed the resident had a stage two (partial loss of top layers of skin) on the inner buttocks measuring 1.3 cm length, 1.0 cm width and 0.2 cm depth. Physician orders [REDACTED]. A review of nursing progress notes and the medical record did not identify additional documentation for the skin status between 09/19/13 and 10/14/13. On 12/03/13 at 9:00 A.M. an interview with the DON verified the facility did not have evidence to indicate weekly skin assessments were completed as required.

Based on observation, interview and record review, the facility failed to ensure Residents #15 and #81 were monitored regarding pain management and that interventions for pain were effective. Residents #15 and #81 experienced unresolved pain that restricted their activities and quality of life. This affected two of three residents reviewed regarding pain management of 12 sampled residents. The census was 53 residents. Findings include: 1. Resident #15 had [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].M. and off at 6:00 P.M. The medication administration records for July, August and September, 2011 revealed the resident did not receive the [MEDICATION NAME]es for pain. The resident frequently received the [MEDICATION NAME], but there was no monitoring of the effectiveness and no documentation regarding the resident's pain management. A Resident/Patient Summary dated 06/10/11, 07/04/11, 08/06/11 and 09/09/11 indicated the resident had moderate pain daily. Pain Data Collection and Assessment indicated Resident #15 had chronic daily pain in his shoulders and legs that was intermittent due to arthritis. It was documented that [MEDICATION NAME] relieved the pain. The assessment was updated quarterly with the most recent assessments dated 06/22/11 and 09/18/11. The assessment indicated the resident required pain management with a focus on chronic pain management. The assessment revealed the resident was able to participate in setting goals for pain management. There was no documentation that there was any pain management or new interventions attempted to address the daily pain the resident experienced. The care plan dated 09/14/11 regarding pain revealed the resident expressed chronic pain by facial grimacing and verbal complaints. Interventions included provide diversion and assist to activity of preference, notify the doctor if resident does not express relief of pain, educate about comfort measures, reposition for comfort, assess pain management every shift, monitor for non-verbal signs/symptoms of pain, use non-pharmacological interventions when possible and assess pain and record every shift. There was no documentation that indicated the interventions on the care plan had been implemented. The resident was observed sitting up in bed on 09/26/11 at 11:32 A.M. and 3:20 P.M. During an interview with the resident at 3:20 P.M., he revealed that he had leg and shoulder pain that was not relieved by the pain medication. He stated he did not do much due to the pain. The resident was observed on 09/27/11 at 2:35 P.M. in bed in his room. An interview with State tested Nurse Aide (STNA) #9 on 09/27/11 at 2:35 P.M. revealed the resident told her he needed to rest due to the pain. On 09/28/11 at 10:10 A.M. the resident was observed lying in bed. He stated he had constant left shoulder pain that was sharp "like a knife". He stated the pain medication decreased the pain, but did not relieve the pain. An interview with the director of nursing (DON) on 09/28/11 at 1:45 P.M. verified there was no monitoring or tracking regarding pain. The policy regarding pain management dated 05/01/11 indicated the plan of care team would re-evaluate pain management interventions until the pain was managed. There was no documentation of any evaluation of pain management or new interventions attempted to alleviate the resident's pain. 2. Resident #81 had [DIAGNOSES REDACTED]. The Pain Data Collection dated 07/26/11 indicated the resident was taking [MEDICATION NAME] medications-[MEDICATION NAME] Patch and [MEDICATION NAME] and to see the plan of care for Chronic Pain Management. The plan of care regarding chronic pain management dated 07/26/11 had interventions that included the administration of pain medications, positioning and encourage exercise. There was no documentation regarding the resident's pain or the implementation of any interventions other than the administration of pain medication. The physician orders [REDACTED]. There was no documentation of any monitoring of the effectiveness of the pain medications. The resident was observed in the wheelchair in his room on 09/26/11 at 11:29 A.M. and at 2:35 P.M. The resident was interviewed in his room while he was in bed on 09/26/11 at 3:40 P.M. He stated he had pain that was not relieved by his pain medications. The resident was observed on 09/27/11 at 2:40 P.M. in bed. An interview with the resident on 09/28/11 at 10:05 A.M. while he was in his room in the wheelchair verified he continued to have constant aching hip pain. He stated the pain was not as bad at night when he was in bed. There was no documentation regarding any monitoring of the resident's complaints of pain or new interventions initiated to address the pain. An interview with the DON on 09/28/11 at 1:45 P.M. verified there was no monitoring or tracking regarding pain. The policy regarding pain management dated 05/01/11 indicated the plan of care team would re-evaluate pain management interventions until the pain was managed. There was no documentation of any evaluation of pain management or new interventions attempted to alleviate the resident's pain.

Based on record review and interview, the facility failed to ensure adequate monitoring of Resident #55's physical condition and status to ensure appropriate care and treatment were provided to the resident in a timely manner. This affected one resident (Resident #55) of three residents reviewed who no longer resided at the facility. The facility census was 53 residents. Findings include: Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had physician orders for routine aerosol treatments and oxygen via nasal cannula. Review of a nurse's note, dated 08/16/11 at 12:00 P.M., revealed the resident was lethargic and staff could not obtain a blood pressure or oxygen saturation. The note indicated an aerosol treatment was given, his oxygen was increased from two liters to four liters nasal cannula, and an intravenous (IV) line with fluids was initiated. The note indicated the resident was responsive to painful stimuli. The physician and family were consulted and the decision was made by the family not to have the resident transferred to the hospital, but that family would come to the facility and decide if he should be sent. The next entry in the nurse's notes, dated 08/16/11 at 2:45 P.M., revealed the family was at the bedside and decided to have the resident transferred to the emergency room . The resident left the facility at 2:50 P.M. Record review revealed no written documentation of an assessment or monitoring of the resident's condition following the note written on 08/16/11 at 12:00 P.M. Review of hospital discharge summary documentation, revealed the resident was hospitalized from [DATE] through 08/18/11. Discharge [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. Re-admission physician orders included oxygen at two liters by nasal cannula continuously and aerosol treatments every six hours. Review of nurse's notes revealed an entry dated 08/18/11 related to the resident's readmission. Additional nurse's notes were reviewed, dated 08/19/11 at 6:00 A.M., 2:30 P.M., and 4:00 P.M. which reflected the resident was resting quietly. A nurse's note, dated 08/20/11 (with no time noted) revealed, "resting at present", no complaint voiced. Review of a physician progress notes [REDACTED]. Staff were to follow the orders from hospital. The note did not reflect a physical assessment had been completed or if the resident's lung sounds/respiratory status had been assessed. The next entry in the nurse's, dated 08/20/11 at 12:30 P.M., revealed respiratory rate was 28 (per minute). The resident's oxygen saturation was 94 percent on five liters of oxygen and the resident's lungs were assessed to be diminished with congestion bilaterally. The note indicated the physician was notified and an order was obtained for a chest x-ray. There was no indication related to when or why the resident's oxygen had been increased from two liters as ordered to five liters, and no physician order to increase the oxygen to five liters. The next entry in the nurse's notes, dated 08/20/11 at 2:30 P.M., revealed the resident's wife called to check the status of the chest x-ray. The wife insisted the resident be sent out to the hospital at that time. The next entry in the nurse's notes, dated 08/20/11 at 3:20 P.M., revealed the ambulance company was on-site to pick the resident up. Record review revealed no written assessment or documentation of the resident's condition/status following the note written on 08/20/11 at 12:30 P.M. On 09/13/11 at 3:00 P.M., review of ambulance transport documentation revealed emergency personnel received a call from the facility at 3:06 P.M. and arrived to the facility at 3:12 P.M. The facility staff informed the emergency personnel that the resident was congested and not responding appropriately, and the family was concerned as to why the resident had not arrived at the hospital yet. The resident was transferred to the hospital at 3:20 P.M. On 09/13/11 at 10:19 A.M., interview with the director of nursing (DON) verified the lack of written documentation to determine that Resident #55 was being monitored and/or assessed on 08/16/11 from 12:00 P.M. until being transferred to the hospital at 2:50 P.M. and then again on 08/20/11 from 12:30 P.M. until 3:20 P.M. when being transferred to the hospital both times following changes in condition. The DON also verified she recalled Resident #55 being transferred to the hospital because the resident's wife insisted he be sent on 08/20/11 and not related to any type of change in condition. However, review of the ambulance company documentation revealed a significant change in condition for the resident. This deficiency substantiates Complaint Number OH 086.