Does Woodstock Valley Health and Rehabilitation have any serious inspection findings?

Yes, Woodstock Valley Health and Rehabilitation has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 114 total deficiencies from recent inspections.

What are the staffing levels at Woodstock Valley Health and Rehabilitation?

Woodstock Valley Health and Rehabilitation has a one-star staffing rating from CMS with 0.22 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Woodstock Valley Health and Rehabilitation located?

Woodstock Valley Health and Rehabilitation is located in WOODSTOCK, VA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Woodstock Valley Health and Rehabilitation have?

Woodstock Valley Health and Rehabilitation has 88 certified beds.

Who owns Woodstock Valley Health and Rehabilitation?

Woodstock Valley Health and Rehabilitation is a for profit - corporation facility and is part of the CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE chain.

Woodstock Valley Health and Rehabilitation

Q: What is Woodstock Valley Health and Rehabilitation's CMS rating?

Woodstock Valley Health and Rehabilitation has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Do nurses at Woodstock Valley Health and Rehabilitation stick around?

Woodstock Valley Health and Rehabilitation has high staff turnover at 65%. High turnover can mean less continuity of care as staff change frequently.

Q: Was Woodstock Valley Health and Rehabilitation ever fined?

Yes, Woodstock Valley Health and Rehabilitation has been fined $99,827 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

803 SOUTH MAIN ST, WOODSTOCK, VA 22664 · (540) 459-5676

For profit - Corporation 88 Beds CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#285 of 285 in VA

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Last Inspection: May 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Woodstock Valley Health and Rehabilitation has received a Trust Grade of F, indicating significant concerns regarding the quality of care. Ranking #285 out of 285 facilities in Virginia, this means it is in the bottom tier of nursing homes in the state. Although the facility's trend shows some improvement, reducing issues from 39 in 2024 to 29 in 2025, it still faces serious challenges. Staffing is a major concern, with a rating of 1 out of 5 stars and a turnover rate of 65%, much higher than the Virginia average of 48%. Additionally, the facility has incurred $99,827 in fines, which is higher than 97% of Virginia facilities, reflecting ongoing compliance problems. Specific incidents include a failure to adequately supervise residents, leading to critical safety risks; for example, one resident was allowed to leave the facility unsupervised multiple times despite their cognitive impairments. Another incident involved a resident expressing suicidal thoughts without appropriate assessments or interventions being implemented, which resulted in a serious self-harm situation. While the facility does have average quality measures, the significant issues with safety and staffing raise considerable concerns for families considering this home for their loved ones.

Trust Score: F
In Virginia: #285/285
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 65% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $99,827 in fines. Higher than 59% of Virginia facilities. Some compliance issues.
Skilled Nurses: Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 114 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 39 issues

2025: 29 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Virginia average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 65%

19pts above Virginia avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $99,827

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: CONSULATE HEALTH CARE/INDEPENDENCE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (65%)

17 points above Virginia average of 48%

The Ugly 114 deficiencies on record

3 life-threatening 2 actual harm

Sept 2025 29 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision, monitoring, use of safety devices, and fully implement their smoking policy to ensure safety for two of 16 current residents, resident #10 (R10) and R11. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, isolated. Also, the facility staff failed to provide interventions for adequate supervision for one of 16 residents in the survey sample, Resident #7. The findings include:1. For R10, the facility staff failed to provide a smoking apron and monitor to ensure a cigarette lighter was not kept on his person. R10 was admitted to the facility with diagnosis that included but not limited to nicotine dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/23/2025, R10 scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating the R10 was moderately impaired of cognition for making daily decisions. On 09/23/2025 at approximately 10:18 a.m. an observation of R10 was conducted on the locked Dogwood unit. R10 was in a wheelchair, carrying a “Fanny Pak” and observed going outside to the enclosed patio area on the locked Dogwood unit independently. Further observations revealed R10 removing a lighter from the “Fanny Pak, lighting a cigarette, then lighting R11's cigarette. Further observations failed to evidence cigarette butt receptacles on the patio area and a smoking apron for R10. The facility's “Smoking Evaluation” dated 04/10/2025 for R10 documented in part, “Does resident smoke? Yes. Has fine motor skills needed to securely hold cigarette Yes. Observations: 1. Resident is able to communicate why oxygen must be removed prior to going to the smoking area? Yes. 2. Resident is able to communicate the risks associated with smoking. Yes. 3. Resident does not allow ashes or lit material to fall while smoking, inhaling, or holding smoking item? Yes. 4. Resident does not endanger self or others while smoking, (i.e. burn furniture, wheelchair, clothing, skin, self, or others). Yes. 5. Resident smokes only in designated area? Yes. 6. Resident is able to extinguish cigarette safely when finished smoking. Yes. Resident is determined to be: Safe Smoker. Comments/Adaptive equipment needed (if applicable): Utilize an apron while smoking.” The comprehensive care plan for R10 dated 07/19/2023 documented in part, “Focus. Mr. [NAME] is a smoker. Date Initiated: 07/19/2023.” Under “Interventions” it documented in part, “Observe clothing, use smoking apron and skin for signs of cigarette burns. Date Initiated: 07/19/2023; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 07/19/2023.” On 09/23/2025 at approximately 10:25 a.m. an interview was conducted with R10 in his room. When asked where he obtained the lighter he used to light his and R11's cigarettes, R10 stated the light was in his “Fanny Pak” and that he has it all the time. R10 then opened the “Fanny Pak” and showed the surveyor the cigarette lighter. On 9/23/25 at 3:16 p.m., an interview was conducted with CNA #1 who stated that the smoking at the facility was supervised by staff. She stated that there were designated times, and they were posted at the nurse's station and were the same on both units. She stated that activities normally came over to get the locked unit residents at the smoking times and took the residents over to the other unit for smoke breaks but if they did not come over, the unit CNAs took them out. CNA #1 stated that they kept cigarettes at the desk and the residents came and asked and then went out with them. She stated that everything tobacco related was stored in a drawer behind the nurse's station on the locked unit but it did not have a lock on it. CNA #1 stated that there were only two smokers on their unit currently. CNA #1 stated that R11 was not a smoker but went outside in the courtyard and picked up cigarette butts. CNA #1 stated that R11 would pick them up, not knowing who's they were and smoke them, always asked everyone for cigarettes and lighters. CNA #1 stated that R10 was out in the courtyard this morning with R11 and would provide cigarettes to R11 at times. She stated that R10 would sometimes hide cigarettes, and they were supposed to report them to activities, and they were supposed to confiscate them. CNA #1 stated that she did not give R10 the cigarette he smoked this morning, and she was not sure where R11 got her cigarette from. She stated that they allowed residents to smoke over on the locked unit but did not have any ashtrays to dispose of the cigarette butts, so they threw them on the ground. She stated that they tried to watch R11 to make sure she did not bring the cigarette butts back in the facility, but she probably was. CNA #1 stated that they had a list of residents who required smoking aprons on the other unit. She stated that the residents on the locked unit were allowed to go out to the courtyard as they pleased but were not allowed to smoke whenever they wanted. She stated that they will try to go out to smoke every hour but had to smoke at the designated times with staff supervising them. The facility's smoking sign listing smoking times and location documented, “Woodstock Valley Health & (and) Rehab (Rehabilitation). Smoking Times for Rosewood Courtyard ONLY. O600 (6:00 a.m.), 10:00 a.m., 1:30 p.m., 4:00 p.m., 8:00 p.m.” A review of the facility's smoking policy documented in part, “The Center will have safety equipment available in designated smoking areas including smoking blankets, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays, the center will establish and post designated smoking areas and times. Further review of the policy failed to evidence the secured storage of smoking implements, supervision and safety of residents who smoke on the locked unit. On 9/23/25 at 5:15 p.m. ASM (administrative staff member) #1, the executive director, ASM #2, director of nursing, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, ASM #10, traveling director of nursing, LPN (licensed practical nurse) #1, staff development coordinator, LPN #2, unit manager, and OSM (other staff member) #9, regional director of human resources and staffing, were made aware of the observations on the Dogwood unit and were notified of immediate jeopardy (IJ) and substandard quality of care. The facility presented the following IJ plan which was accepted on 09/23/2025 at 9:26 p.m. “Woodstock Valley Health and Rehabilitation 9/23/2025. The following plan is being submitted in response to the Immediate Jeopardy citation at F689 for non-compliance with the facility's smoking policy, the lack of supervision, and the lack of smoking safety interventions, all facility residents are likely at risk for serious injury, serious harm, serious impairment or death. Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials. The responsible party for both Resident #10 and Resident #11 were notified of the incidents on 9/23/2025. The current smoking area on the locked dogwood unit is no longer designated as a smoking area. Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit. If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.]. A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit. The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container. Current residents will be re-educated on the facility smoking policy. Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy. If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy. The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record. Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times. Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking. The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents. All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift. A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke. This was initiated 9/23/2025 at approximately 1815 and remains in place until the screamer alarm is installed. Monitoring § The Executive Director or designee will make visual observations of the smoking times on Rosewood 2x daily x 2 weeks and then 3x/week x 4 weeks, to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol. § The Executive Director or designee will make daily observations of the courtyard on the locked Dogwood unit x 2 weeks and then 3x/week x 4 weeks to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area. § Findings of the daily observations will be monitored weekly by the RVPO or RDCS weekly x 6 weeks. The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance. Findings of the above audits will be reported to the QAPI Committee for additional oversight. Compliance Date: 9/24/2025 @ noon.” On 9/24/25, the survey team performed the following actions to verify that the removal plan had been fully implemented: *Verified the following parts of the removal plan by paper review, with no concerns noted: - Review of the education sign-in sheets for all current facility and contract staff. - Reviewed list of current residents who smoked. - Reviewed medical records of residents who smoke to verify a signed copy of the facility's smoking policy and current smoking assessment. -Reviewed resident's current smoking assessment to verify accurately it reflects any assistance/supervision and/or protective devices for safe smoking. -Reviewed the comprehensive care plan of current residents who smoke to verify that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents. *Verified by observation, with no concerns noted: - Smoking area on the locked Dogwood unit verified was no longer designated as a smoking area. - Rosewood courtyard off the dining room was verified to be equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays, present at designated smoking times. - Residents smoking during a designated smoking time, under staff supervision, and with the use of smoking safety interventions. *Verfied Staff Education by staff interviews of Nurses, CNAs, and ancillary staff, demonstrating knowledge compliant with smoking policies and procedures that promoted safety for all residents, with no concerns noted: After review of findings with state agency, it was confirmed that the removal plan had been fully implemented by the facility. On 09/24/2025 at 2:00 p.m., ASM #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, was informed that the removal plan had been verified and the IJ had been abated. No further information was provided prior to exit. 2. For R11, the facility staff failed to provide supervision, a smoking apron and monitor to ensure cigarettes were not kept on her person. R11 was admitted to the facility with diagnosis that included but not limited to dementia (1) and hearing loss. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/23/2025, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the R11 was severely impaired of cognition for making daily decisions. On 09/23/2025 at approximately 9:53 a.m. an observation of R11 was conducted on the locked unit. R11 was observed in the dayroom sitting in a rocking chair with an unlit cigarette in her right hand up to her mouth. At approximately 9:55 a.m. continued observations of R11 revealed she was holding a plastic cup in her lap. Upon closer observation of the contents of the plastic cup revealed two, unlit, partially smoked cigarettes. At approximately 10:18 a.m. an observation revealed R11 going outside to the enclosed patio area independently followed by R10. Further observations revealed CNA (certified nursing assistant) #1 going out to the patio area after R11 had gone out. Observations also revealed R10 taking a cigarette lighter from his “Fanny Pak”, lighting R10's cigarette while CNA #1 was standing and talking to R10 and R11. Further observations failed to evidence cigarette butt receptacles on the patio area and smoking aprons for R11. On 9/23/25 at 11:28 a.m. Resident #11 (R11) was observed outside in the courtyard sitting in a chair with a walker and personal belongings in front of her. R11 took a partially smoked cigarette out of a bag with personal belongings and began peeling off the paper from the cigarette and throwing it onto the sidewalk. At 11:29 a.m., a staff member went outside to speak with the resident but did not take the cigarette. At 11:33 a.m., another staff member was observed to take the cigarette from R11. At 11:36 a.m., Resident #10 (R10) was observed outside, at 11:37 a.m., R10 was observed taking a cigarette out and lighting it with a lighter that was on his person. R11 ambulated with her rolling walker over to R10 who proceeded to light a cigarette for her. Both residents proceeded to smoke unsupervised with no staff present in the courtyard area. R11 was observed lighting a second partially smoked cigarette with the first cigarette and then proceeded to throw the first cigarette butt behind her into a mulched area with fallen dried leaves present. R11 proceeded to smoke some of the second cigarette and extinguish it into a plastic spoon and store the partially smoked cigarette into the storage pocket of the rolling walker with overflowing personal belongings. Further observations failed to evidence cigarette butt receptacles on the patio area and smoking aprons for R10 and R11. The comprehensive care plan for R11 dated 08/20/2024 documented in part, “Focus. (R11) is an unsafe smoker. Date Initiated: 08/20/2024.” Under “Interventions” it documented in part, “Her smoking supplies are stored with staff in a lock box. Date Initiated: 08/20/2024, She requires a smoking apron while smoking. Date Initiated: 08/20/2024, She requires direct SUPERVISION while smoking. Date Initiated: 08/20/2024.” The facility's “Smoking Evaluation” dated 06/19/2025 for R11 documented in part, “Does resident smoke? Yes. Observations: 1. Resident is able to communicate why oxygen must be removed prior to going to the smoking area? No. 2. Resident is able to communicate the risks associated with smoking. Yes. 3. Resident does not allow ashes or lit material to fall while smoking, inhaling, or holding smoking item? No. 4. Resident does not endanger self or others while smoking, (ie burn furniture, wheelchair, clothing, skin, self, or others). No. 5. Resident smokes only in designated area? No. 6. Resident is able to extinguish cigarette safely when finished smoking. No. Resident is determined to be: Unsafe Smoker. Comments/Adaptive equipment needed (if applicable): Direct supervision at all times and smoking apron.” On 09/23/2025 at approximately 3:45 p.m. an interview was attempted with R10 regarding how she obtained cigarettes. Due to R10's low cognition and hearing difficulty, R10 could not adequately hear and comprehend the questions. On 9/23/25 at 3:16 p.m., an interview was conducted with CNA #1 who stated that the smoking at the facility was supervised by staff. She stated that there were designated times, and they were posted at the nurse's station and were the same on both units. She stated that activities normally came over to get the locked unit residents at the smoking times and took the residents over to the other unit for smoke breaks but if they did not come over, the unit CNAs took them out. CNA #1 stated that they kept cigarettes at the desk and the residents came and asked and then went out with them. She stated that everything tobacco related was stored in a drawer behind the nurse's station on the locked unit but it did not have a lock on it. CNA #1 stated that there were only two smokers on their unit currently. CNA #1 stated that R11 was not a smoker but went outside in the courtyard and picked up cigarette butts. CNA #1 stated that R11 would pick them up, not knowing who's they were and smoke them, always asked everyone for cigarettes and lighters. CNA #1 stated that R10 was out in the courtyard this morning with R11 and would provide cigarettes to R11 at times. She stated that R10 would sometimes hide cigarettes, and they were supposed to report them to activities, and they were supposed to confiscate them. CNA #1 stated that she did not give R10 the cigarette he smoked this morning, and she was not sure where R11 got her cigarette from. She stated that they allowed residents to smoke over on the locked unit but did not have any ashtrays to dispose of the cigarette butts, so they threw them on the ground. She stated that they tried to watch R11 to make sure she did not bring the cigarette butts back in the facility, but she probably was. CNA #1 stated that they had a list of residents who required smoking aprons on the other unit. She stated that the residents on the locked unit were allowed to go out to the courtyard as they pleased but were not allowed to smoke whenever they wanted. She stated that they will try to go out to smoke every hour but had to smoke at the designated times with staff supervising them. The facility's smoking sign listing smoking times and location documented, “Woodstock Valley Health & (and) Rehab (Rehabilitation). Smoking Times for Rosewood Courtyard ONLY. O600 (6:00 a.m.), 10:00 a.m., 1:30 p.m., 4:00 p.m., 8:00 p.m.” A review of the facility's smoking policy documented in part, “The Center will have safety equipment available in designated smoking areas including smoking blankets, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays, the center will establish and post designated smoking areas and times. Further review of the policy failed to evidence the secured storage of smoking implements, supervision and safety of residents who smoke on the locked unit. On 9/23/25 at 5:15 p.m. ASM (administrative staff member) #1, the executive director, ASM #2, director of nursing, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, ASM #10, traveling director of nursing, LPN (licensed practical nurse) #1, staff development coordinator, LPN #2, unit manager, and OSM (other staff member) #9, regional director of human resources and staffing, were made aware of the observations on the Dogwood unit and were notified of immediate jeopardy (IJ) and substandard quality of care. The facility presented the following IJ plan which was accepted on 09/23/2025 at 9:26 p.m. “Woodstock Valley Health and Rehabilitation 9/23/2025. The following plan is being submitted in response to the Immediate Jeopardy citation at F689 for non-compliance with the facility's smoking policy, the lack of supervision, and the lack of smoking safety interventions, all facility residents are likely at risk for serious injury, serious harm, serious impairment or death. Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials. The responsible party for both Resident #10 and Resident #11 were notified of the incidents on 9/23/2025. The current smoking area on the locked dogwood unit is no longer designated as a smoking area. Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit. If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.]. A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit. The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container. Current residents will be re-educated on the facility smoking policy. Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy. If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy. The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record. Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times. Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking. The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents. All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift. A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke. This was initiated 9/23/2025 at approximately 1815 and remains in place until the screamer alarm is installed. Monitoring § The Executive Director or designee will make visual observations of the smoking times on Rosewood 2x daily x 2 weeks and then 3x/week x 4 weeks, to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol. § The Executive Director or designee will make daily observations of the courtyard on the locked Dogwood unit x 2 weeks and then 3x/week x 4 weeks to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area. § Findings of the daily observations will be monitored weekly by the RVPO or RDCS weekly x 6 weeks. The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance. Findings of the above audits will be reported to the QAPI Committee for additional oversight. Compliance Date: 9/24/2025 @ noon.” On 09/24/2025 the survey team, through observations, interviews and documentation review, verified the removal plan had been fully implemented by the facility. On 09/24/2025 at 2:00 p.m., ASM #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, was informed the removal plan had been verified and the IJ had been abated. No further information was provided prior to exit. References: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. For Resident #7 (R7), a resident assessed as being at risk of elopement, the facility staff failed to maintain interventions to promote adequate supervision. A review of R7's clinical record revealed a nurse's note dated 2/2/25 that documented, [R7's name redacted] found on grounds of facility attempting to go to the store to buy a lighter. Housekeeping manager returned resident to this facility. [R7's name redacted] eloped out of the building and this is an issue because he must have codes to the doors. [R7's name redacted] was a resident on Alzheimer's unit in the past and monitored for elopement risk. An elopement risk evaluation dated 2/2/25 documented R7 was at risk for elopement. The evaluation further documented that R7 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors, wandered oblivious to safety needs, had a history of elopement, and had the ability to exit the facility. A review of R7's physician's orders revealed an order dated 2/3/25 for a WanderGuard (a bracelet and door controller system used to prevent at-risk residents from exiting the facility) to be applied to the resident's ankle and checked every shift R7's comprehensive care plan dated 2/2/25 documented, [R7's name redacted] is an elopement risk r/t [related to] impairment in cognitive functions and awareness: attempted to leave facility. The interventions included: 2/3/25-Assess for elopement risk. 2/3/25-Monitor location every 15 minutes (resolved/discontinued on 2/4/25). 2/4/25-Wanderguard placement every shift (resolved/discontinued on 2/6/25). Further review of R7's clinical record failed to reveal any further elopement risk evaluation since 2/2/25, revealed the physician's order for a WanderGuard was discontinued on 2/6/25, and failed to reveal any documentation why the WanderGuard was discontinued or documentation of any further interventions to prevent elopement. On 9/23/25 at 2:09 p.m., an observation of R7 was conducted. The resident was observed ambulating with a walker in the hall and was not wearing a WanderGuard. Also, the resident's room was not located on the locked Alzheimer's unit. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated if a resident is at risk for elopement, the nurse should discuss this with the physician, social services, administrator, and minimum data set coordinator to determine if the resident is suitable for a WanderGuard and update the resident's care plan. LPN #2 stated an additional elopement risk assessment should be done before discontinuing an elopement intervention such as a WanderGuard to make sure the resident truly is no longer at risk for elopement. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Elopements and Wandering Residents documented, 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The IDT (Interdisciplinary Team) will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. No further information was presented prior to exit.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 16 residents in the survey sample, Resident #2, was free from mental abuse resulting in psychosocial harm on 3/29/25. The findings include: For Resident #2 (R2) the facility staff failed to ensure the resident was free from mental and verbal abuse resulting in psychosocial harm when the facility staff threatened to have the resident sent out of the facility with a temporary detention order.The resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to: diabetes, obesity, high blood pressure, sleep terrors, insomnia, depressive disorder, anxiety disorder, osteoarthritis, post-traumatic stress disorder, and pain.On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, the resident was not coded as having any behaviors during the lookback period.The MDS assessment, a quarterly assessment, with an ARD of 1/17/25, completed prior to 3/29/25, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, the resident was coded as having verbal behavioral symptom directed towards others four to six days of the lookback period but not daily.The nurse's note dated 3/29/25 at 3:29 p.m. documented, Resident has been agitated and verbally inappropriate to staff this shift. Resident came up to med (medication) cart crying and stated that she was going through withdrawal, and she felt like she was dying and couldn't do this anymore. DON (director of nursing), NP (nurse practitioner), Police and EMS (emergency medical services) notified. Resident refused to cooperate with all party's (sic) involved.The physician order dated 3/5/25, documented, Fentanyl Transdermal Patch (1) 72 Hours 75 MCG/HR (micrograms per hour); apply 1 patch every 3 days for chronic pain replace after 3 days and remove per schedule. The March 2025 MAR (medication administration record) documented the above order. The MAR documented the medication was administered on 3/17/25. For 3/20/25 it was documented the patch was removed but for the administration it was documented a 9 which indicates, Other/See Nurse Notes. For 3/23/25, there were 9 document for the removal and administration of the Fentanyl. For 3/26/25, there was a 9 documented for the removal and administration of the Fentanyl.The nurse's note dated 3/20/25 at 3:36 p.m. documented in part, Fentanyl.none acaaiable (sic)(applicable), np (nurse practitioner) to write script.The nurse's note dated 3/23/25 at 5:04 p.m. documented in part, Fentanyl .dc/d (discontinued) new order placed.There was no nurse's note dated 3/26/25 related to the Fentanyl.The narcotic sign-off sheet dated 3/4/25, documented the administration of the Fentanyl patch on 3/17/25. The narcotic sheet was dated 3/29/25, documented the administration of the Fentanyl on 3/29/25. There was no record of administration of Fentanyl on a narcotic sheet between 3/17/25 and 3/29/25, a period of 12 days.The Clinical Opioid Withdrawal Score (COWS) dated 3/29/25 at 6:10 p.m., documented the resident scored a 0 on the assessment. A score greater than eight requires treatment in the emergency room.The nurse's note dated 3/29/25 at 7:33 p.m. documented, LATE ENTRY: Resident in NAD/[NAME] (no acute distress/no acute respiratory distress). Sitting in w/c (wheelchair) conversing other residents. Vital signs obtained. 100/64 (blood pressure), 80 (heart rate), 98.1 (temperature), 96% (oxygen saturation rate) RA (room air), 16 (respirations) even and unlabored, 0/10 (no pain on a scale of 0 - 10 ten being the worse pain ever in) pain. Resident assessed for Opiate withdrawal (COWS). Residents (sic) total score = 0. She is cooperative with assessment. Affect congruent.The social services note dated, 3/29/25 at 8:00 p.m. documented, LATE ENTRY: f/u (follow up) with resident after recent incident. Resident says she is fine but not happy. Offered AG (assisted living) grant and let her know it is an option to be in an assisted living vs (versus) nursing home. She stated she ‘will think about it.The comprehensive care plan dated, 8/2/24, and revised on 11/6/24, documented in part, Focus: (R2) reports episodes of having night terrors. Interventions: Administer medications per order. Observe for objective and subjective for increase in night terrors and report to MD/NP (medical doctor/nurse practitioner). Psych (psychological) consult as needed. 4/4/25 - Focus: (R2) has the potential for altered psychosocial well-being r/t PTSD. She has voiced c/o night terrors r/t (related to) traumatic hospitalization resulting in coma. She is followed by house psych and (name of community service board - CCB) outside of the facility. She has exercised her right to not allow facility to have visit notes and information from the CCB. Interventions: Counseling as indicated. If conflict arises, remove resident to calm quiet place and allow resident to vent. Non-pharmacological interventions such as cognitive stimulation, music therapy, outdoor activities, meaningful activities per resident preference. Social services to follow up with resident r/t incident to ensure no lingering effects. 8/22/24 - Focus: (R2) has behaviors of making false accusations, calls 911, makes comments about suicide and suicidal ideations to manipulate her family and staff, throw/drop food trays, tells others not to eat their food, tells others to not be nice to staff and other residents, refusal of medications, threatens staff not to have their jobs. Interventions: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate locations as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.The facility synopsis of event dated 4/3/25, documented in part, Resident stated to ombudsman she felt intimidated and threatened by employee.The facility synopsis of event dated 4/10/25 documented, Final (facility synopsis of event) for allegation of abuse. (R2) is a [AGE] year-old female, who was admitted to (name of facility) on 7/11/24. Her diagnoses include but are not limited to: COPD (chronic obstructive pulmonary disorder), chronic respiratory failure, H/O (history of) suicidal ideation, CVA (cerebral vascular accident) (stroke), restless leg syndrome, major moderate depressive disorder, PTSD (post traumatic stress disorder), major depressive disorder and generalized anxiety disorder. She uses a wheelchair of mobility, and her BIMS score is 15. It was reported that (R2) on March 29th, the Director of Nursing (ASM -administrative staff member #3), was intimidating and threatening to her. (R2) needed her fentanyl patch to be replaced and was complaining of being in pain and experiencing withdrawal symptoms. During the discussion, (R2)'s behaviors escalated, and EMS and the local police department were notified due to the complaints. While the police and EMS were at the facility, an ECO (emergency containment order) was discussed between (ASM #3) and the police. (R2) heard this conversation and reported that she felt scared and felt (ASM #3) was making false allegations against her. (R2) did not want to leave the facility due to the fear of losing her rights. The police asked (R2) if she wanted to go to the hospital for an evaluation, (R2) refused, and the police and EMS left the facility. (ASM #3) was suspended effective immediately pending this investigation. Staff interviews conducted and statements received from (ASM #3), (ASM #8, the PA - physician assistant), (OSM - other staff member #2), the staffing coordinator, (ASM #5) psychiatrist; and (LPN -licensed practical nurse #4). Statement was received from (R2). Interviewed other residents with a BIMS score of 8 or higher to determine if resident had experienced any abuse or felt unsafe in the facility - none were identified. There were no other residents involved in this incident. This investigation will be unsubstantiated as the statement received from the staff and (R2) are contradicting (sic). (R2) will be monitored weekly x4 for any signs of psychosocial distress by the facility social worker and findings will be documented in the resident's medical record. Any new grievance from (R2) will be comprehensively investigated. The facility team will continue to work collaboratively with APS (adult protective services) and the Ombudsman, both of whom have been involved with this investigation.The Ombudsman Report dated 4/29/25 documented in part, Escalation/Mental Abuse per APS assessment and definition: The DON reportedly aggressively ripped the resident's personal signs from her door, without her consent (according to resident and other staff present), while the police were present in the resident's room. This escalation served to agitate the resident and exacerbate her PTSD symptoms related to medical treatment, causing mental anguish. Resident Rights Violations: Residents have the right to complain. When this resident complained, rightfully, about not receiving her medication in a timely manner, the DON and Provider (ASM #8) moved to discuss an ECO for her despite the medication being on its way to the facility. Both the resident's complaint and any withdrawal symptoms could have been easily handled by getting an emergency prescription to (name of pharmacy) for the resident's medication and administering said medication. There was no need to escalate this matter and in doing so the resident was punished for exercising her right to complain. Additionally, the rationale for this DON's behavior, from her own statement, is based on the resident making reports to other organizations against the facility, making this action appear to be a retaliation. (quotes from the regulations). Residents have the right to informed consent. At no time was this resident given the option to decide how she wanted the issue addressed before EMS/police were called. The DON did not assess the resident, nor did she have a conversation with several other staff about the resident without ever actually speaking to the resident directly. She presented ‘facts' about the resident to the provider and psychiatrist without ever assessing the resident directly. Every staff member who interacted directly with the resident that day reported her behavior to be well within her baseline, which the DON would have know if she had taken time to speak with the resident and the staff who were present with her during her complaints.(quotes from the regulations) Residents have the right to refuse care or treatment. The DON's statement also claims that the resident threatened anyone who tried to remove her patch. The resident has the right to maintain bodily autonomy and refuse care or treatment of any kind, including removing a patch that no longer had any medication in it and was not harming her in any way. Additionally, the resident refused transport to the hospital, and instead of honoring this request he Provider and DON moved forward with discussions of an ECO to force her into this decision even though EMS deemed her capable of making rational decisions at the time of her refusal. (quotes from the regulations). Residents have the right to be assessed by skilled medical professionals. In her own statement, the DON stated that the resident's ‘bipolar disorder (DON is NOT a mental health practitioner of any kind) would result in ‘rapid mood changes,' using this rationale to continue pursuing drastic measures against a resident who had been assessed and was found to not be reactive or out of control. This is not accurate to bipolar disorder and is a harmful assumption to make without a licensed mental health professional assessing the resident in person and making such a claim. Additionally, this resident has not been diagnoses with bipolar disorder and her chart was not consulted to determine her current diagnoses. (quotes from the regulations). Residents have the right to be treated with dignity and respect. This resident was not spoken to by this staff member or the provider until the police were already present in her room. The resident does not recall this DON ever introducing herself to her prior to entering her room with officers, and the DON reported to APS and myself that she felt bad that ‘this is how they met for the first time.' Additionally, the DON removed the resident's personal signs from her door without her permission, and they were not an immediate harm to anyone. This bot violated her right to maintain her personal possessions and escalated the mental anguish of the resident during this interaction . (quotes from regulations). Residents have the right to person-centered care. This requires all staff to address each resident individually, according to their needs and preferences. This resident has a history of medical abuse and PTSD, which would indicate the need for calm, clear interactions where she had agency to decide what treatment she would like to pursue. This did not happen. (quotes from the regulations).The facility final synopsis of event dated, 5/7/29, documented, Final (synopsis of event) for allegation of abuse sent 4/10/25 regarding resident (R2). This report serves as an addendum to final FRI for allegation of abuse sent on 4/10/25 regarding resident (R2). Based on the facility's further investigation, it was determined that the root cause of the behavior exhibited on 3/29/25 by (R2) could have been due to the Fentanyl patch not being administered as ordered. The Fentanyl patch is documented as not available on 3/20 and 3/23. This trigger was not recognized or de-escalated by the DON or PA on 3/29/25 resulting in a call to the EMS/police for an ECO. The Fentanyl patch is documented as administered on 3/29 and has been administered timely I April and May. (R2) also has orders for Oxycodone 10 mg 1 tab (tablet) every 4 hrs. (hours) for chronic severe pain while awake and receives routinely every 4 hrs. As a result of the facility's continued investigation and the report received from the Ombudsman on 4/29/25, the facility substantiates that (R2)'s rights were violated and the allegation of neglect regarding timely medication administration was substantiated. Based on the actions that represent a concern for resident rights, the DON (ASM #3)'s employment was terminated on 5/1/25. (license #xxxxxxxxx). The provider group (name of PA's employer) was given a 30-day termination notice on 4/1/25. The facility administrator (ASM #1) was educated on investigation and responding to incidents and received a written counseling regarding conducting timely and comprehensive investigations and responding to incidents on 5/6/25. An audit of all residents on pain medication to ensure meds are available was completed on 5/7/25. Any concerns identified were immediately addressed. The facility identified opportunity for improvement in the following areas and has initiated education on the following topics: Virginia resident rights, HIPPA (health insurance portability act) compliance, Code of Ethics, De-escalation techniques, Responding to need of TDO (temporary detaining order)/ECO, Grievance, Abuse, Neglect, Exploitation and Misappropriation, Mandated reporter, Medication unavailable, Completing a comprehensive investigation to include FRI, Investigating and Responding to Incidents. (R2) has been assessed by her new provider on 5/6/25 with no new concerns identified. (R2) was interviewed by (ASM #2), the DON on 5/3/25 and states that she is in good spirits with no complaints of pain. (R2)'s care plan has been updated to include behavioral/PTSD triggers, behavior monitoring, and resident specific non-pharmacological interventions to minimize triggers. Social Services will follow with resident weekly for 4 weeks to provide psycho-social support and follow-up with any concerns. The facility is working in collaboration with APS (adult protective services) and the Ombudsman to ensure compliance with resident rights. The facility has implemented a process for additional oversight through QAPI (quality assurance plan improvement) to ensure that all allegations regarding care and resident rights are thoroughly investigated with appropriate interventions in place.The physician assistant notes dated 3/29/25, documented in part, Patient was seen today as she is in need of a refill for her fentanyl patches. She has been threatening staff all morning with calls to the state, replace, etc. Pending other current potential legal issues with (R2), a referral to pain management will be considered. Negative for nausea, vomiting, diarrhea, fever, chills, shortness of breath, chest pain.Review of systems: Psychiatric: Normal affect is appropriate. There is no agitation.The psychiatry initial consult dated, 5/22/25, documented in part, She reports a history of abuse, including a verified case involving Adult Protective Services (APS). She experiences night terrors related to her coma and nightmares stemming from the abuse incident. She feels that she has been mistreated and ignored by some staff members, leading to a lack of trust in her care providers. Despite these challenges, she is an advocate for herself and others, working with outside sources to improve conditions.An interview was conducted with R2 on 9/23/25 at 10:00 a.m. The resident stated on 3/29/25 she was feeling not well, sick to her stomach and had diarrhea. She stated her daughter had come in on 3/28/25 and looked at her pain patch (fentanyl) and it was dated 3/17/25. The next morning, she said she started complaining about her pain patch having not been changed as ordered. She stated she told the DON that she needed her pain patch, and the solution was to get a prescription to (local pharmacy) and get it delivered. The DON told the resident that We don't do that. She told the DON that yes, they can do that. The resident explained to the DON that that has been done in the past. R2 stated she went back down the hallway to her room. R2 stated the DON was yelling at her for taking videos of people and violating HIPPA. She thought her glucose monitor was a bodycam. The resident gave the DON the finger and yelled (explicative). The next thing the resident could recall was the police came to her and said she was being hostile. The police asked her if she understood why they were there. The police followed her everywhere she went in the facility. At first the resident was told they were going to ECO her and then changed it to a TDO. The psychiatrist that they called stated she was in a manic phase of her Bipolar disease. R2 stated she doesn't have a diagnosis of bipolar disorder. R2 stated she has PTSD related to being in a coma in 2013. She stated she was embarrassed as there were multiple people in the hallways, staff members, residents, housekeeping and activities. There were multiple kinds of people from different departments. The nurses and aides were watching them watch her. R2 stated she felt like she was dying inside, she felt so sick. R2 stated if the DON had listened to her, she would have understood what the real situation was. R2 stated the DON never wrote anything down and no medical personnel ever assessed her. The rescue squad, when they arrived, did my vital signs. They kept on telling her she was going to be taken TDO. R2 stated they were going to take her to a detox place. They caused this to her, not me being detoxed. She stated the DON had only been here for nine to ten days. R2 stated no one saw the DON oriented to any of the residents. The police told her that she was not appropriate for a TDO, but the DON kept on pressing the issue. The police left. The police told her to stay in her room until they got this figured out. R2 stated she felt the DON was on a power trip. R2 stated she felt the DON should have been more educated on who she was dealing with. (LPN #1) and (LPN #2) came in and did an assessment of her, they talked to her. (LPN #1) got her pain patch and an hour later she wasn't sick anymore. R2 stated she was so scared, they would put her away someplace beyond her control and have no choice in what she was doing, losing her rights. She stated she was petrified. R2 stated the event has left a lasting impression on her. If she sees police officers in the building, she feels like they are coming for her, and her heart starts racing. Her night terrors are about police taking her away and herself and her family don't know where she is. She had trust issues with medical people before but now her trust in medical people is down to nothing. She stated she does have a few people here that she does trust.On 9/23/25 at 12:25 p.m., an interview was conducted with ASM (administrative staff member) #3 (the medical director). ASM #3 stated symptoms of Fentanyl withdrawal could include tachycardia (an increased heart rate), agitation, itching, and seizures if the patient is on a pretty high dose of the medication.An interview was conducted with OSM (other staff member) #1, the social worker, on 9/24/25 at approximately at 9:30 a.m. OSM #1 stated on 3/29/25 she was not here at the time of the incident but (LPN #1 called her and stated the DON and (ASM #8, PA) was trying to TDO (R2). (LPN #1) explained to her that the resident was upset about her medications. I came in to check on her psychosocial wellbeing. OSM#1 stated she sat with the resident in the courtyard. The resident explained to OSM #1 and LPN #1 what was going on, she was in tears and was visibly upset. OSM #1 stated they comforted the resident and made sure she was okay. OSM #1 and LPN #1 explained to the resident they couldn't send her out by TDO because the resident was upset about her medications. When asked if she was made aware of an allegation of abuse, what steps should be taken, OSM #1 stated first is to separate the resident and/or staff member involved. The report it immediately to the DON and (ASM #1), the executive director. The executive director would need to report to the state and start an investigation.An interview was conducted with ASM #4, the former DON, on 9/24/25 at 10:22 a.m. ASM #4 stated she had only been the DON for a short period of time. The supervisor on duty called her and sent her picture of the signs the resident was posting on her door, person and wheelchair. The supervisor on duty stated the resident was complaining of withdrawal symptoms and posting signs that her rights were being violated, the food is bad, and she was not getting her medications. The resident was saying she didn't get her Fentanyl as ordered. ASM #4 stated she was not aware of any concern of the resident not getting her medications. ASM #4 stated she did not know (R2). ASM #4 contacted (ASM #8). The nurse on duty (LPN #4), spoke with ASM #8 and explained that (R2) was complaining of withdrawal symptoms. ASM #4 stated there was apparently a problem with ASM #8's electronic prescription processing and ASM #8 told ASM #4 that she thought the problem was taken care of. ASM #8 sent another order to the pharmacy. ASM #4 stated she called the pharmacy and they didn't have the prescription from ASM #8. ASM #4 stated when she spoke with ASM #8 they both agreed that if the resident was in withdrawal, then the resident's needs could not be met at the facility and the resident needed to be transferred out to the hospital. ASM #4 stated that R2 was still complaining so she called EMS and explained the situation. Dispatch for EMS sent police to accompany EMS in this situation. R2 refused to go. ASM #4 spoke with the police officer, and he stated he was well versed with R2. The police officer told ASM #4 that the resident has the right to refuse to go to the hospital. ASM #4 stated that she and the EMS waited around the corner while the police officer went to talk to R2. ASM #4 stated she entered the resident's room and introduced herself while the officer was in the room. ASM #4 stated she did not request the police. ASM #4 stated that upon entrance to the resident's room the resident asked if she had her pain patch. ASM #4 stated the resident was hostile and stating that she was in withdrawal. ASM #4 stated the resident refused any vital signs be taken. The resident refused to let anyone touch her until they put her patch on. ASM #4 stated she wanted to accurately take care of her symptoms and send the resident out to the emergency room. ASM #4 stated she did look at the patch on the resident and explained it should have been taken off a few days before. ASM #4 stated the resident clenched her fist at her and told ASM #4 that is she came any closer, but the police officer was able to calm the resident down. ASM #4 stated she stepped out of the resident's room. The police said they would have to get her detained in order to get her out of the facility. ASM #4 stated EMS came to her and stated that the resident is alert and oriented and has made the decision to refuse to go to the hospital. ASM #4 stated she spoke with the police officer and ASM #8 and ASM #8 stated she didn't think the resident needed to be sent out via a TDO. ASM #4 stated she contacted ASM #11, the interim chief nursing officer. ASM #11 instructed ASM #4 to get a psychiatrist to do a virtual assessment of the resident. ASM #4 stated she spoke with ASM #5, the psychiatrist, and he stated he didn't need to do a virtual assessment as he knew the resident well. He told ASM #4 that he knew the resident and the resident had bipolar disorder and was in a manic episode. ASM #4 stated she instructed LPN #1 to set up the virtual assessment. ASM #4 stated she was not a doctor and could not diagnose a resident. ASM #4 stated that ASM #8 was not comfortable in pursuing a TDO. ASM #4 stated by 6:00 p.m. the resident had calmed down. ASM #4 stated she had gone to the police station and spoke with the non-emergency phone line and wanted information of how to do a TDO if needed through the night. The police department stated the facility would have to go before the magistrate in the morning to [NAME]. When asked if she raised her voice at the resident, ASM #4 stated no, she was very nice to her. ASM #4 stated she explained to the resident that she understood that the resident was videotaping other residents and the current situation, and she explained to the resident that that was a HIPPA violation. When asked if she removed the resident's handmade signs off the door or walls, ASM #4 stated she did remove them as they were a health department violation due to infection control concerns.An interview was conducted with LPN #1, the staff development coordinator, on 9/24/25 at 11:47 a.m. LPN #1 stated she was not in the building at same time as ASM #4, they were sort of in passing. She stated her assessment of R2 revealed the resident was very upset about her Fentanyl patch. The patch on the resident was dated 3/17/25. LPN #1 stated she explained to ASM #4 that they could get the medications from the local pharmacy, as they have done in the past. LPN #1 stated most of her information was from the resident and she needed to report it to ASM #1, the executive director and ASM #6, the vice president of operations.An interview was conducted with LPN #4, the nurse caring for the resident on 3/29/25, on 9/24/25 at 1:03 p.m. LPN #4 stated R2 was upset about her Fentanyl patch. LPN #4 stated she doesn't normally work that hall very often. LPN #4 stated the resident refused to take off the old patch until the new one was applied. She stated at one point the resident was threatening someone but wasn't sure who it was. LPN #4 stated they contacted the physician assistant, and she came in. ASM #8 ordered the Fentanyl patch. LPN #4 stated she was on the phone with the pharmacy when the police and EMS came, she had no idea who called them. LPN #4 stated she went to the resident's room. She observed ASM #4 and the resident in a kind of an argument. She stated R2 was calm during the whole thing. ASM #4 was trying to get the resident to go to the hospital, but the resident refused to go. R2 was saying she was going through withdrawal as she didn't have her patch. ASM #4 stated the facility was not capable of handling a resident going through withdrawal. LPN #4 stated the police stated the resident didn't have to go. ASM #4 did not agree with that. LPN #4 stated that ASM #4 just wouldn't let it go. LPN #4 stated at some point, a TDO was mentioned, she wasn't sure who brought that up. She stated that R2 wasn't being a harm to herself or others. The resident wasn't yelling or anything like that. The resident didn't want to go to the hospital and just wanted her Fentanyl patch. The resident had posters on her door and clothing stating that she was being mistreated and wasn't getting her medications. ASM #4 ripped the signs off the door. LPN #4 stated she didn't hear ASM #4 ask permission to remove them off the door, stating it was a fire hazard. She further stated that ASM #4 just wouldn't let it go. The police told ASM #4 to go somewhere else as she was making the situation worse and not better. After that, ASM #4 left. LPN #4 stated R2 was fine after everything settled down.An interview was conducted with ASM # 5, the psychiatrist, on 9/24/25 at 2:47 p.m. He recalled receiving a call from ASM #4. He stated he knew the resident and she was difficult at time and had ongoing behavior related to not being satisfied with her care. He stated she can get agitated, but she is not psychotic or has any psychiatric condition. ASM #5 stated he told ASM #4 that if the resident was out of control and a danger to herself or others, then a TDO was appropriate but if she wasn't then a TDO was not needed.An interview was conducted with ASM #1, the executive director, on 9/24/25 at 2:53 p.m. ASM #1 stated she was not in the building on 3/29/25. She stated that when the Ombudsman came to her and stated that the R2 stated her rights were violated. ASM #1 stated that ASM #4 was the aggressor in this situation. ASM #4 had threatened to TDO the resident. The police and EMS were involved. The day after the incident she received calls from her boss asking about the commotion over the weekend. She spoke with R2, and resident informed her that the police were there on 3/29/25 and ASM #4 was trying to TDO her. The resident informed ASM #1 that she could hear the conversation between the police and ASM #4 and her anxiety and PTSD were affected. It was only after the Ombudsman's visit and report that the investigation was reopened. ASM #4 was suspended, brought back for a short period of time and then terminated on the grounds of violation of resident rights and mental abuse.An interview was conducted on 9/24/25 at 3:09 p.m. with ASM #6, the vice president of operations. ASM #6 stated she was not in the building at the time of the incident. She stated when Ombudsman's report came, we investigated it further and found that the conclusion was that there was a concern for violating R2 rights and neglect. When asked if psychosocial harm was found, ASM #6 stated, It could have been also.An interview was conducted with ASM #7, the psychiatric nurse practitioner, that saw the resident on 5/22/25. ASM #7 reviewed her notes and stated the resident told her about the case with APS and it was when the facility tried to TDO her. The resident explained to her that she was afraid of police coming into the building after the 3/29/25 incident.The facility policy, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means 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 and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physic

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview and clinical record review, it was determined that facility staff failed to promote a resident's dignity for one of 16 current residents in the survey sample, Residents #8 (R8). The findings include:For R8, facility staff stood while providing feeding assistance. R8 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 08/13/2025, R8 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating R8 was severely impaired of cognition for making daily decisions. GG0130 Self-Care coded R8 as being dependent for eating. 09/23/2025 at approximately 8:08 a.m., an observation revealed R9 in bed being fed by CNA (certified nursing assistant) #2. Further observations revealed CNA #2 standing next to the bed while feeding R8. Observation of R9's meal tray revealed food was p[placed in bowls. The comprehensive care plan for R8 dated 10/29/2018 documented in part, Focus. (R8) has an ADL self-care performance deficit r/t (related to) Vascular dementia (1), history of CVA (cerebral vascular accident) (2), and impaired cognition. Date Initiated: 10/29/2018. Under Interventions it documented in part, EATING: (R8) is dependent on staff for feeding Date Initiated: 10/29/2018. On 09/24/2025 at approximately 4:35 p.m. an interview was conducted with CNA (certified nursing assistant) #2. When asked to describe how she positioned herself when she fed R8 on 09/23/2025 during breakfast CNA #2 stated she was standing next to R8 while feeding her. She further stated that it was not dignified to be standing while assisting a resident with eating/feeding. The facility's policy Resident Rights documented in part, 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References:(1) A gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. Vascular dementia (VaD) is caused by a series of small strokes over a long period. This information was obtained from the website: https://medlineplus.gov/ency/article/000746.htm.(2) A stroke. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, facility document review and clinical record review, the facility staff failed to maintain a resident's right to be treated with respect and dignity, including the right to retain their personal belongings for one of 16 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to maintain the resident's right to display her personal belongings.The resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to: diabetes, obesity, high blood pressure, sleep terrors, insomnia, depressive disorder, anxiety disorder, osteoarthritis, post-traumatic stress disorder, and pain. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, the resident was not coded as having any behaviors during the lookback period. The nurse's note dated 3/29/25 at 3:29 p.m. documented, Resident has been agitated and verbally inappropriate to staff this shift. Resident came up to med (medication) cart crying and stated that she was going through withdrawal, and she felt like she was dying and couldn't do this anymore. DON (director of nursing), NP (nurse practitioner), Police and EMS (emergency medical services) notified. Resident refused to cooperate with all party's (sic) involved.The Ombudsman's report dated 4/29/25, documented in part, Additionally, the DON removed the resident's personal signs from her door without her permission, and they were not an immediate harm to anyone. This both violated her right to maintain her personal possessions and escalated the mental anguish of the resident during this interaction. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. The resident stated on 3/29/25, the DON at that time removed her signs, that she had made, from her door without her permission. R2 stated she just ripped them off the door stating it was a health department violation. R2 stated she didn't ask my permission to do so. When asked how that made her feel, R2 stated she was angry that she did that, they were her belongings. An interview was conducted with OSM (other staff member) #1, the social worker, on 9/24/25 at approximately 9:30 a.m. OSM #1 stated the resident was very upset that ASM (administrative staff member) #4 removed her signs off her door. She stated the resident was angry that ASM #4 did that. An interview was conducted with ASM #4, the former DON, on 9/24/25 at 10:22 a.m. When asked if she removed the resident's handmade signs off the door or walls, ASM #4 stated she did remove them as they were a health department violation due to infection control concerns.An interview was conducted with LPN #4 on 9/24/25 at 9:03 a.m. She stated the resident had posters on her door and clothing stating that she was being mistreated and wasn't getting her medications. ASM #4 ripped the signs off the door. LPN #4 stated she didn't hear ASM #4 ask permission to remove them off the door, stating it was a fire hazard. The facility policy, Resident Rights documented in part, Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Respect and dignity. The resident has a right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. ASM #1, the executive director and ASM # 6, the vice president of operations, were made aware of the above concern on 9/25/25 at 5:32 p.m. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on staff interview, and facility document review, the facility staff failed to secure confidential resident clinical records for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to maintain confidentiality of a document from the resident's clinical record. An email from LPN (licensed practical nurse) #5 to ASM (administrative staff member) #1 (the executive director) dated 8/22/25 documented, This morning I was standing at my cart getting ready to start morning Med [sic] pass. A CNA (certified nursing assistant) came to me and stated that (LPN #6) wanted me to print off a progress note for her. I asked what progress note and CNA said something about (R1). I asked where she was, and she said in (OSM [other staff member] #2's [the former staffing coordinator's]) office. By the time I went to (OSM #2's) office (LPN #6) had left. I needed to speak to (OSM #2) about my schedule. And that's what we did. At the end of our conversation I asked where (LPN #6) was and if she was coming back in because she wanted me to print something. (OSM #2) then stated what (LPN #6) was needing/wanting to be printed. (OSM #2) stated she did not have access to it and (LPN #6) could not print it either. I did feel hesitant to print this but felt as though I didn't have an out. I printed it and gave it to (LPN #6) immediately. Who also wanted a copy to give to HR (human resources). As I was walking back down the hallway away from (LPN #6), she stated that she was covering her butt and that there was an open investigation and how people were sweeping things under the rug. I did not know about any of this at that time. Or that (R1) was no longer our resident. Had I been aware of the severity of the situation I would not have printed this. The only time I had the progress notes on [sic] my possession was to walk from the nurses [sic] station down to Rosewood (unit) to (LPN #6's) cart where note was handed to her. LPN #6 was not available for interview during the survey. On 9/24/25 at 5:22 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she was made aware that LPN #5 had printed out documents from R1's clinical record and gave them to LPN #6. ASM #2 stated she confronted LPN #6 on that same day and LPN #6 stated she did not have any of R1's documents but she (ASM #2) later heard that LPN #6 was at the nurses' station saying the documents, were not in her shoe, implying they were. ASM #2 stated LPN #6 text her after she left the facility and stated she did have a copy of a document from R1's record printed out by another nurse. A printed copy of a text message from LPN #6 to ASM #2 (no date) documented, (ASM #2) i [sic] did have a paper that (LPN #5) printed out but I had tore [sic] it up and threw it away hours before yall [sic] had asked me about it. I am guilty of that. On 9/25/25 at 12:49 p.m., an interview was conducted with LPN #5. LPN #5 stated OSM (other staff member) #2 instructed her to print a specific progress note regarding backdated medication orders for R1. LPN #5 stated the orders were dated 8/10/25 but were created in the system several days later and could not recall the exact date the orders were created. LPN #5 stated OSM #2 told her LPN #6 needed the note to take to human resources, OSM #2 could not print the note because she no longer had access to the record since the new company took over, and it was fine for LPN #5 to print the note and give it to LPN #6. LPN #5 stated she printed the note and immediately gave it to LPN #6. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM #1. ASM #1 stated that on 8/22/25, it was brought to her attention that LPN #6 asked LPN #5 to print out a progress note or order regarding R1. ASM #1 stated she was confused because LPN #6 could print the document out herself. ASM #1 stated LPN #5 admitted she printed the document out and gave it to LPN #6. ASM #1 stated LPN #6 stated she did not ask LPN #5 to print out the document but then later texted ASM #2 stating she did have the document but destroyed it. On 9/25/25 at 4:59 p.m., ASM #1 (the executive director) was made aware of the above concern. The facility document titled, Resident Rights documented, b. The resident has a right to secure and confidential personal and medical records. No further information was presented prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

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Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure discharge needs were met for one of 16 residents in the survey sample, Resident #4.The findings include:For Resident #4 (R4), the facility staff failed to evidence 1) that written discharge instructions were given to the resident, 2) that home medications were arranged prior to discharge and 3) that the resident was given provider information that included standardized patient assessment data, and information on quality measures and resource use (where that data is available) to choose a home health provider prior to discharge.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/29/2024, the resident was assessed as being cognitively intact for making daily decisions.The resident admission demographic information documented R4 being their own responsible party with contact information listed for their spouse under contacts. The demographic information documented the discharge date of 8/12/2024.The progress notes for R4 documented in part, 07/12/2024 11:27 Note Text: Care Plan held in person with spouse and patient. Reviewed by IDT (interdisciplinary team) team. Patient will discharge back home with spouse. Spouse has no questions or concerns. Patient is a full code. 08/02/2024 11:36 Note Text: ABN/NOMNC (Advance Beneficiary Notice of non-coverage/Notice of Medicare non-coverage) issued for OT (occupational therapy). He is min (minimal) assist for ADLs (activities of daily living) and last cover day is 8/5. 08/12/2024 14:58 (2:58 p.m.) Note Text: Rec'd (received) denial notification from [Name of insurance]- patient LCD (last covered day) was 8/9/24. Spoke with spouse- she states she will be picking him up this evening. Referral has been made for therapies/aide/SN (skilled nursing). 08/13/2024 08:51 Note Text: [Name of home health] accepted patient for PT (physical therapy), OT (occupational therapy), SN, Aide. They will contact him/spouse for SOC (start of care). Meds to be sent today to [Name of pharmacy]. 08/13/2024 10:48 Note Text: Called to follow up. Left a VM (voice mail) regarding [Name of home health] accepting to continue therapies and medications faxed to [Name and location of pharmacy].Review of the progress notes failed to evidence a note documenting the discharge from the facility, a review of the discharge instructions or review of the home medications with R4 or their family on 8/12/2024.Review of the clinical record documented a discharge plan and instructions with an effective date of 8/12/2024 electronically signed on 8/13/2024. The Nursing Discharge Summary was observed to be blank. The Social Services Discharge Summary documented, Patient discharging home with wife. [Name of home health] to follow up to continue therapies at the home. Medications to be sent to [Name and location of pharmacy]. Wife to make a follow up appointment with PCP (primary care provider). The discharge plan and instructions failed to evidence review with R4 or their family on 8/12/2024 or a copy provided to the resident at discharge. The discharge instructions included a fax confirmation with a referral sent to the home health agency on 8/12/24 at 2:57 p.m. Attached pre-printed prescriptions hand-signed by the nurse practitioner documented an order date of 8/12/2024.On 9/24/2025 at 3:38 p.m., an interview was conducted with OSM (other staff member) #5, the interim director of rehab who stated that discharge planning was ongoing with social services, the resident and the family for the skilled residents. She stated that after the initial evaluation, it depended on the resident and the family how often they communicated with them, but they did it at least weekly to discuss progress and the potential discharge from services. OSM #5 stated that during morning meetings they discussed discharge plans with social services who involved the family to make sure they were safe at home. She stated that when the resident was discharged from therapy they always referred them to home health, and they gave social services an estimated discharge date but did not wait for the meeting to start the discharge planning. She stated that social services handled all of the referrals for home health, and she thought it was done prior to discharge.On 9/24/2025 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing, who stated that nursing completed a portion of the discharge instructions and at the time of discharge the nurse printed off the instructions, reviewed them with the resident and had them sign it. She stated that they kept a copy of the signed discharge instructions, and she assumed it was scanned in the medical record after discharge. ASM #2 stated that the discharging nurse should make a note in the clinical record documenting that they reviewed the discharge instructions and provided education on the home medications. On 9/25/2025 at 8:49 a.m., an interview was conducted with OSM #1, the director of social services. OSM #1 stated that she recalled having a conversation with R4's spouse during a care plan meeting about the discharge plan. She stated that she had set up home health for R4 on 8/12/2024 and had tried to contact them after discharge but was not able to reach them. She stated that prior to discharge she talked to therapy, the physician and nursing to determine the needs and she always set up PT/OT and a home health aide and skilled nursing if needed. OSM #1 stated that this was normally set up two to three days prior to the discharge date that was pre-arranged with the family. She stated that she no longer used the home health agency that she had set up for R4 due to a lack of response from them. OSM #1 stated that the home health agency was set up based on the residents insurance coverage and their location. She stated that if the resident or family mentions a home health agency they have used in the past they will set up with them, but they do not generally give out a selection of home health agencies to residents to select from. She stated that the physician normally escribes or hand-signs the prescriptions to fax to the pharmacy. OSM #1 stated that the prescriptions are sent prior to discharge. She stated that when a resident gets their NOMNC they have two days to set up the discharge because if they lose the appeal they will still be discharging, and they should still be working on the discharge to have it set up. OSM #1 stated that they stay in contact with the family when they are appealing a NOMNC and when they decide on a discharge date and time they should sign the discharge instructions. She stated that R4's discharge may have been on the weekend and may not have been done properly.On 9/25/2025 at 10:23 a.m., an interview was conducted with OSM #6, the director of sales and marketing. OSM #6 stated that she did not recall R4's discharge. She stated that if the insurance company denied the appeal they called the family to notify them and let them decide the next step. OSM #6 stated that if the family wanted to pick the resident up that day they normally ordered home health and sent prescriptions to the pharmacy. She stated that it looked like R4's prescriptions were not sent the day of discharge because the provider had not signed them or was not there to send them. She stated that she would expect nursing to contact the physician to give the resident enough medication to take home to get them through the next day if the prescriptions were not completed at the time of discharge. On 9/25/2025 at 2:23 p.m., an interview was conducted with ASM #1, the administrator, who stated that there should be a process in place to have the physician or nurse practitioner electronically sign the prescriptions to ensure they are sent to the pharmacy prior to discharge. On 9/25/2025 at 3:41 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that nursing completed a portion of the discharge instructions, printed them off along with the home medications and reviewed them with the resident and the family. She stated that she educated the resident and family on how to take the medications, where they were discharging to and any special care needed. LPN #2 stated that the resident signed a copy of the discharge instructions, and they kept a copy. She stated that the social worker printed out the prescriptions and had the physician sign them before they faxed them to the residents pharmacy. LPN #2 stated that she had only given residents medications that they had brought in on admission to take home with them and she was not sure of the process if the prescriptions had not been signed or sent prior to discharge to ensure that medications were available when the resident got home.On 9/25/2025 at 4:05 p.m., an interview was conducted with LPN #1 who stated that the social worker notified them when a resident was being discharged . She stated that nursing filled out three sections of the discharge instructions, reviewed the medications and set up any follow up appointments as needed. LPN #1 stated that the discharging nurse should perform a skin assessment, check the vital signs and go over the discharge instructions, educating the resident on any needs and the medications. She stated that they had the resident sign the discharge instructions and copied them for their records and sent a copy with the resident. LPN #1 stated that the nurse should write a note documenting the discharge in the clinical record and this process was for continuity of care.The facility policy Discharge Planning Progress dated 6/1/25 documented in part, . The facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e., another SNF (skilled nursing facility), HHA (home health agency), IRF (inpatient rehab facility), or LTCH (long term care hospital)) that will meet the resident's needs, goals, and preferences. The Social Services Director, or designee, shall compile available data on other post-acute care options to present to the resident, including, but not limited to: Data on providers within the resident's desired geographic area, where available. Quality measure data, based on standardized patient assessment data, publicly available on the CMS Care Compare website. Data on resource use to the extent the data is available, such as number of residents/patients are discharged to the community, and rates of potentially preventable hospital readmissions. The facility will ensure that the data used is relevant and applicable to the resident's goals of care and treatment preferences. The facility will present provider information to the resident and resident representative, if applicable, in an accessible and understandable format, and will answer any questions to assist in the resident's/representative's understanding. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.On 9/25/2025 at 4:58 p.m., ASM #1, the administrator was made aware of the concern.No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop a baseline care plan for one of 16 residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to develop a baseline care plan.The nursing admission assessment for R3 dated 1/23/2025 documented the resident admitted with a PICC (peripherally inserted central catheter) access, always being incontinent of bowel and bladder, having multiple wounds present on admission, a colostomy, and taking insulin.Review of the clinical record failed to evidence a baseline care plan developed within 48 hours of R3's admission of 1/23/2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the baseline care plan was developed by the admitting nurse. She stated that the purpose of the care plan was to give them a place to go to see how to take care of the residents. She stated that the admitting nurse would put things in the care plan like diet, ability to move, behaviors, catheters, and colostomy. LPN #2 stated that she was not sure if the PICC line would be on the baseline care plan or not, but it should be a quick overview of what they need to take care of the resident. On 9/25/2025 at approximately 9:25 a.m., ASM (administrative staff member) #1, the administrator, stated that they did not have a baseline care plan for R3 to provide.The facility policy Baseline Care Plan dated 6/1/2025 documented in part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders. Physician orders. Dietary orders.On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 16 residents in the survey sample, Residents #1, and #3. The findings include:1. For Resident #1 (R1), the facility staff failed to obtain the physician's authorization to transcribe orders for tramadol and oxycodone. Back dated orders were written on 8/19/25 for 8/10/25 and the physician was unaware of this. A review of R1's clinical record revealed the following physician's orders: 5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain. 6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. R1 was transferred to the hospital on 7/29/25. R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. and one tablet of oxycodone 5mg on 8/10/25 at 11:30 a.m. A review of R1's August 2025 physician's orders and August 2025 MAR (medication administration record) revealed there were no orders on 8/10/25 for tramadol or oxycodone (until back dated orders were created in the computer system on 8/19/25). A physician's order dated 8/10/25 and created on 8/19/25 by RN (registered nurse) #1 documented an order for oxycodone 5mg by mouth as needed for pain. Give a one-time dose. The order documented the medication was ordered by ASM (administrative staff member) #3 (R1's physician). A physician's order dated 8/10/25 and created on 8/19/25 by RN #1 documented an order for tramadol 50mg as needed by mouth times one dose. The order documented the medication was ordered by ASM (administrative staff member) #3 (R1's physician). A nurse's note with an effective date of 8/10/25 and created by RN #1 on 8/19/25 documented, Received order to give resident 50 mg po (by mouth) tramadol x (times) 1 dose, if ineffective give oxycodone 5 mg x 1 dose, VTO (verbal telephone order) (name of ASM #3). On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 8/10/25, there were no tramadol or oxycodone orders for R1 in the computer system but there were tramadol and oxycodone medication cards with R1's name in the medication cart. RN #1 stated she incorrectly assumed the medications were prescribed for R1, so she administered the medications. RN #1 stated she did not directly talk to ASM #3 about this matter. RN #1 stated she entered the back dated orders into the computer system because someone from nursing management told her they spoke with ASM #3 who said he approved and to go ahead and enter the orders into the system. On 9/23/25 at 12:25 p.m., an interview was conducted with ASM #3. ASM #3 stated he did not remember anyone asking, or him approving orders for R1 to be administered one-time doses of tramadol or oxycodone for when the resident was administered the medications on 8/10/25. On 9/24/25 at 4:58 p.m., an interview was conducted with LPN #1 (the staff development coordinator). LPN #1 stated she talked to ASM #3 about R1 but did not remember the conversation or recall information regarding late tramadol or oxycodone orders put into the computer system. On 9/24/25 at 5:22 p.m., an interview was conducted with ASM #2 (the director of nursing). ASM #2 stated she was not involved in R1's late tramadol or oxycodone orders being put into the computer system. On 9/25/25 at 4:59 p.m., ASM #1 (the executive director) was made aware of the above concern. The facility policy titled, Physician Orders documented, The center will ensure that Physician orders are appropriately and timely documented in the medical record .The ordering physician or physician extender will review and confirm orders. No further information was presented prior to exit. 2) For Resident #3 (R3), the facility staff failed to follow professional standards of practice of medication administration for administration of Carvedilol (to treat heart failure and high blood pressure) (1) and Entresto (to treat heart failure) (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as being cognitively intact for making daily decisions. It documented no behaviors, no refusals of care and diagnoses that included but were not limited to hypertension, diabetes, and heart failure. Review of the eMAR (electronic medication administration record) for R3 dated 3/1/25-3/31/25 failed to evidence administration of the following medication on the dates listed below: Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. On 3/30/25 at 5:00 p.m. the eMAR documented a code “7”, the eMAR chart codes documented “7=sleeping.” It failed to evidence additional attempts to administer the medication or notification of the physician of the medication not administered. Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for DMT2 (diabetes mellitus type 2). On 3/30/25 at 5:00 p.m. the eMAR documented a code “7”, the eMAR chart codes documented “7=sleeping.” It failed to evidence additional attempts to administer the medication or notification of the physician of the medication not administered. Review of the physician orders documented orders for the medications listed above. The orders failed to evidence guidance to hold the medication if the resident was sleeping. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR. LPN #2 stated that if a resident was sleeping when she came in with their medications she would come back at the end of her med pass to try again. She stated that for medications like Entresto and Coreg she would wake the resident up because they were important unless there was a physician order to hold them when sleeping. LPN #2 stated that the physician should be notified when medications are held. According to Fundamentals of Nursing, 8th edition, [NAME] & [NAME], pg. 589 documented in part, .In promoting or maintaining a patient's health, the nurse identifies factors that improve or diminish well-being . Several nursing interventions promote adherence to the medication regimen and foster independence. Teach the patient and family about the benefit of a medication and the knowledge needed to take it correctly and integrate the patient's health beliefs and cultural practices into the treatment plan .Patients need to know how to take medications properly and the risks associated with failing to do so . On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. Reference: (1) Carvedilol: MedlinePlus Drug Information (2) Valsartan and Sacubitril: MedlinePlus Drug Information

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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For Resident #2 (R2), the facility staff failed to administer pain medications per the physician order to manage the resident's pain. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. R2 stated on 3/29/25, she was going into withdrawal symptoms related to not getting her pain patch (Fentanyl - an opioid used to treat severe pain) (1) as prescribed. She stated she was sick to her stomach, diarrhea and just didn't feel well. She stated her daughter had been in the facility on 3/28/25 and noticed that her pain patch was dated 3/17/25. R2 stated that it has happened again that she didn't get her patch as prescribed. The physician order dated 3/5/25, documented, Fentanyl Transdermal Patch 72 Hours 75 MCG/HR (micrograms per hour); apply 1 patch every 3 days for chronic pain replace after 3 days and remove per schedule. The March 2025 MAR (medication administration record) documented the above order. The MAR documented the medication was administered on 3/17/25. For 3/20/25 it was documented the patch was removed but for the administration it was documented a 9 which indicates, Other/See Nurse Notes. For 3/23/25, there were 9 document for the removal and administration of the Fentanyl. For 3/26/25, there was a 9 documented for the removal and administration of the Fentanyl. The nurse's note dated 3/20/25 at 3:36 p.m. documented in part, Fentanyl.none acaaiable (sic)(available), np (nurse practitioner) to write script. The nurse's note dated 3/23/25 at 5:04 p.m. documented in part, Fentanyl .dc/d (discontinued) new order placed. There was no nurse's note dated 3/26/25 related to the Fentanyl. The narcotic sign-off sheet dated 3/4/25, documented the administration of the Fentanyl patch on 3/17/25. The narcotic sheet was dated 3/29/25, documented the administration of the Fentanyl on 3/29/25. There was no record of administration of Fentanyl on a narcotic sheet between 3/17/25 and 3/29/25, a period of 12 days. The physician order dated, 8/15/25, documented, Fentanyl Transdermal Patch 72-hour 25 MCG/HR; apply 1 patch transdermally every 72 hours for chronic pain for 21 days and remove per schedule. The September 2025 MAR documented the above order. The last documented dose of Fentanyl administration was on 9/2/25. For the scheduled dose for 9/5/25, the box was blank. Review of the nurse's note failed to evidence documentation related to the Fentanyl on 9/5/25. The physician order dated, 9/9/25, documented, Fentanyl Transdermal Patch 72-Hour 25 MCG/HR; apply 1 patch transdermally one time a day every 3 day(s) for pain and remove per schedule. The September 2025 MAR documented the above order. On 9/9/25, a 9 was documented in the box for administration.The nurse's note dated 9/9/25 at 10:15 a.m. documented, Was applied yesterday. Review of the narcotic sing-off sheets dated 8/22/25, documented the Fentanyl was administered on 9/2/25 and 9/12/25. The narcotic sign-off sheet dated 9/8/25, documented the Fentanyl was administered on 9/8/25 and 9/15/25. This indicates the resident received the patch on 9/2/25, no patch was administered on 9/5/25. Fentanyl was administered on 9/8/25, no administration, per the physician order on 9/11/25, and then administered on 9/12/25. The resident missed two doses, one on 9/5/25 and 9/11/25, going six days between doses. The comprehensive care plan dated, 11/6/24, documented in part, Focus: (R2) is on pain medication therapy r/t (related to) chronic arthritis. Interventions: Administer ANALGESIC medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift). On 9/23/25 at 12:25 p.m., an interview was conducted with ASM (administrative staff member) #3 (the medical director). ASM #3 stated symptoms of Fentanyl withdrawal could include tachycardia (an increased heart rate), agitation, itching, and seizures if the patient is on a pretty high dose of the medication.An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated nurse evidence she's given a medication by checking it off on the MAR. The above MARs, narcotic sheet and nurse's notes were reviewed with LPN #1. She verified that the resident did not receive her Fentanyl patch for 12 days in March and missed doses of Fentanyl in September per the documentation. The facility policy, Pain Management documented in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References:. 1. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601202.html

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary medications for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to obtain and/or ensure a physician's order was in place prior to administering tramadol and oxycodone to the resident on 8/10/25. A review of R1's clinical record revealed the following physician's orders:5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain.6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. R1 was transferred to the hospital on 7/29/25. R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. and one tablet of oxycodone 5mg on 8/10/25 at 11:30 a.m. A review of R1's August 2025 physician's orders and August 2025 MAR (medication administration record) revealed there were no orders on 8/10/25 for tramadol or oxycodone (until back dated orders were created in the computer system on 8/19/25). On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 8/10/25, there were no tramadol or oxycodone orders for R1 in the computer system but there were tramadol and oxycodone medication cards with R1's name in the medication cart. RN #1 stated she incorrectly assumed the medications were prescribed for R1, so she administered the medications. RN #1 stated she made a mistake and should have verified active orders before administering the tramadol and oxycodone to R1. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Medication Administration documented, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .11. Review MAR to identify medication to be administered. No further information was presented prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

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Based on staff interview, and clinical record review, the facility staff failed to provide services in compliance with State code for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to obtain a physician's order for tramadol and oxycodone prior to administering the medications on 8/10/25. The Virginia Administrative Code 12VAC5-371-300 (E). Pharmaceutical services. documents, Excluding cannabidiol oil and THC-A oil, no drug or medication shall be administered to any resident without a valid verbal order or a written, dated and signed order from a physician, dentist, podiatrist, nurse practitioner, or physician assistant, licensed in Virginia. A review of R1's clinical record revealed the following physician's orders:5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain.6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. R1 was transferred to the hospital on 7/29/25. R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. and one tablet of oxycodone 5mg on 8/10/25 at 11:30 a.m. A review of R1's August 2025 physician's orders and August 2025 MAR (medication administration record) revealed there were no orders on 8/10/25 for tramadol or oxycodone (until back dated orders were created in the computer system on 8/19/25). A physician's order dated 8/10/25 and created on 8/19/25 by RN (registered nurse) #1 documented an order for oxycodone 5mg by mouth as needed for pain. Give a one-time dose. The order documented the medication was ordered by ASM (administrative staff member) #3 (R1's physician). A physician's order dated 8/10/25 and created on 8/19/25 by RN #1 documented an order for tramadol 50mg as needed by mouth times one dose. The order documented the medication was ordered by ASM (administrative staff member) #3 (R1's physician). A nurse's note with an effective date of 8/10/25 and created by RN #1 on 8/19/25 documented, Received order to give resident 50 mg po (by mouth) tramadol x (times) 1 dose, if ineffective give oxycodone 5 mg x 1 dose, VTO (verbal telephone order) (name of ASM #3). On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 8/10/25, there were no tramadol or oxycodone orders for R1 in the computer system but there were tramadol and oxycodone medication cards with R1's name in the medication cart. RN #1 stated she incorrectly assumed the medications were prescribed for R1, so she administered the medications. RN #1 stated she did not directly talk to ASM #3 about this matter. RN #1 stated she entered the back dated orders into the computer system because someone from nursing management told her they spoke with ASM #3 who said he approved and to go ahead and enter the orders into the system. On 9/23/25 at 12:25 p.m., an interview was conducted with ASM #3. ASM #3 stated he did not remember anyone asking, or him approving orders for R1 to be administered one-time doses of tramadol or oxycodone for when the resident was administered the medications on 8/10/25. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses definitely should obtain a physician's order prior to administering medications to a resident. On 9/24/25 at 4:58 p.m., an interview was conducted with LPN #1 (the staff development coordinator). LPN #1 stated she talked to ASM #3 about R1 but did not remember the conversation or recall information regarding late tramadol or oxycodone orders put into the computer system. On 9/24/25 at 5:22 p.m., an interview was conducted with ASM #2 (the director of nursing). ASM #2 stated she was not involved in R1's late tramadol or oxycodone orders being put into the computer system. On 9/25/25 at 4:59 p.m., ASM #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for three of 16 residents in the survey sample, Residents #3, #2, and #1.The findings include:1) For Resident #3 (R3), the facility staff failed to maintain a complete and accurate medical record. The resident admission demographics for R3 documented a discharge date of 4/8/2025. The resident census information documented a stop billing date of 4/8/2025. Review of the clinical record documented a fall risk evaluation, Braden scale for predicting pressure sore risk and elopement risk evaluation for R3 completed and dated 4/30/2025. On 9/25/2025 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that assessments should be documented for the date that they are done and the assessments for R3 dated 4/30/2025 probably should have been late entries because the resident no longer resided at the facility at that time. She stated that the medical record was not accurate because R3 was not in the building on 4/30/2025. The facility policy “Documentation in Medical Record” dated 6/1/2025 documented in part, “Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation… Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred… When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as “late entry”…” On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern. No further information was provided prior to exit. 2. For Resident #2, the facility staff failed to document correctly the administration of Fentanyl. The physician order dated 3/5/25, documented, “Fentanyl Transdermal Patch 72 Hours 75 MCG/HR (micrograms per hour); apply 1 patch every 3 days for chronic pain replace after 3 days and remove per schedule.” The March 2025 MAR (medication administration record) documented the above order. For 3/20/25 it was documented the patch was removed but for the administration it was documented a “9” which indicates, “Other/See Nurse Notes.” The nurse's note dated 3/20/25 at 3:36 p.m. documented in part, “Fentanyl…none acaaiable (sic)(available), np (nurse practitioner) to write script.” The narcotic sign-off sheet dated 3/4/25, documented the administration of the Fentanyl patch on 3/17/25. The narcotic sheet was dated 3/29/25, documented the administration of the Fentanyl on 3/29/25. There was no record of administration of Fentanyl on a narcotic sheet between 3/17/25 and 3/29/25, a period of 12 days. An interview was conducted with LPN (licensed practical nurse) #1, on 9/24/25 at 11:47 a.m. LPN #1 stated a nurse evidence that she's given a medication by checking it off on the MAR. The above MAR was reviewed with LPN #1. LPN #1 stated it is an error in documentation as the nurse signed it off and didn't give it as it wasn't in the building according to the narcotic sign off sheets. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1.This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601202.html. 3. For Resident #1 (R1), the facility staff failed to document complete and accurate information regarding the resident's change in condition and interventions that were implemented on 8/10/25. A review of R1's clinical record revealed a change in condition form dated 8/10/25 that documented R1 was non-responsive, staff called 911, and the resident was transferred to the hospital. A review of R1's nurses' notes dated 8/10/25 failed to document information regarding the resident's change in condition or interventions that were implemented. On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1 (the nurse who sent R1 to the hospital). RN #1 stated that on 8/10/25, R1 became unresponsive. RN #1 stated she had administered narcotic medication to R1 earlier that day so when the resident became unresponsive, she administered two doses of Narcan (medication used to reduce or reverse the effects of opioids) which were not effective. RN #1 stated another nurse attempted to obtain R1's vital signs. RN #1 stated R1 looked like she wasn't breathing, and the resident's oxygen saturation level did not register, so RN #1 administered oxygen via a non-rebreather mask and began chest compressions until EMS (emergency medication services) arrived. RN #1 stated she should have documented this information in R1's clinical record. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to notify the emergency contact of changes in condition and the physician of medications not administered for two of 16 residents in the survey sample, Residents #3 and #4.The findings include:1) For Resident #3 (R3), the facility staff failed to A) notify the physician of medications not administered or held during dates in February, March and April of 2025 and B) notify the emergency contact of changes in condition on 3/10/2025 and 4/8/2025.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as being moderately impaired for making daily decisions. The assessment documented R3 receiving medications including insulin, antibiotic, diuretic, opioid, antiplatelet and hypoglycemic medication.The resident admission demographic information documented R3 being their own responsible party and having two family members as emergency contacts.A) Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below:Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. (antibiotic to treat infection) (1). The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented ordered call to pharmacy. It failed to evidence notification of the physician of the medication not being administered.Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time a day every Fri for Anemia of Chronic disease. (to treat anemia) (2) On 2/14/25. The eMAR progress note documented Not available in omni cell, awaiting from pharmacy. It failed to evidence notification of the physician of the medication not being administered.Gabapentin Oral Capsule 100 MG (Gabapentin) Give 4 capsule by mouth in the morning for Neuropathy related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat seizure/diabetic neuropathy) (3) Take 2 capsules twice daily. On 2/22/25, 2/23/25 and 2/24/25. The eMAR progress note dated 2/22/25 documented on order, 2/23/25 pharmacy to send and 2/24/25 pharmacy contacted. It failed to evidence notification of the physician of the medication not being administered.Gabapentin Oral Capsule 100 MG (Gabapentin) Give 8 capsule by mouth at bedtime for neuropathy. On 2/21/25, 2/22/25 and 2/23/25. The eMAR progress note dated 2/21/25 and 2/22/25 documented on order. The eMAR progress note dated 2/23/25 documented pharmacy to send. It failed to evidence notification of the physician of the medication not being administered.Neurontin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth every morning and at bedtime for neuropathy. On 2/27/25. The eMAR progress note dated 2/27/25 documented on order. It failed to evidence notification of the physician of the medication not being administered.Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 8 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat diabetes) (4) On 2/9/25, the eMAR was observed to be blank.Pregabalin Oral Capsule 25 MG (Pregabalin) Give 25 mg by mouth every morning and at bedtime related to pain in unspecified joint. (to treat pain) (5) The 6:00 a.m. doses on 2/1-2/4/25, 2/6/25, 2/7/25, and 2/20/25 and the 9:00 p.m. doses on 2/1, 2/3, 2/5-2/9/25. The eMAR progress notes documented 2/1/25, 2/4/25, 2/6/25, 2/7/25, 2/9/25- on order, 2/2/25- ordered, 2/3/25- script needs to be wrote, 2/8/25- not available at this time and 2/20/25- new order wrote, has not arrived. It failed to evidence notification of the physician of the medication not being administered.Review of the eMAR for R3 dated 3/1/25-3/31/25 failed to evidence administration of the following medication on the dates listed below:Pregabalin Oral Capsule 300 MG (Pregabalin) Give 1 capsule by mouth every morning and at bedtime for neuropathy. On 3/8/25 at 9:00 a.m. The eMAR progress note documented, on order. On 3/20/25 at 9:00 p.m., the eMAR progress note documented, ordered. It failed to evidence notification of the physician of the medication not being administered.Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. (to treat heart failure and high blood pressure) (6) On 3/30/25 at 5:00 p.m. the eMAR documented a code 7, the eMAR chart codes documented 7=sleeping. It failed to evidence notification of the physician of the medication not being administered.Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for DMT2 (diabetes mellitus type 2). (to treat heart failure) (7) On 3/30/25 at 5:00 p.m. the eMAR documented a code 7, the eMAR chart codes documented 7=sleeping. It failed to evidence notification of the physician of the medication not being administered.Review of the eMAR for R3 dated 4/1/25-4/30/25 failed to evidence administration of the following medication on the dates listed below:Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Heart Failure. (to treat fluid retention) (8) On 4/4/25 and 4/7/25 the eMAR progress notes documented, ordered. It failed to evidence notification of the physician of the medication not being administered.Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. On 4/7/25 at 5:00 p.m. the eMAR progress note documented BP (blood pressure) was 96/67. The progress note failed to evidence notification of the physician of the low blood pressure and held medications.Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for CHF. On 4/7/25 at 5:00 p.m., the eMAR progress note documented low BP. The progress note failed to evidence notification of the physician of the low blood pressure and held medications.The physician orders for R3 documented the medications list above and orders for the following:Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. Start Date: 03/20/2025.Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for DMT2. Start Date: 03/21/2025.The physician orders failed to evidence parameters for holding the Carvedilol or Entresto or an order to hold medications when sleeping.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR. She stated that if a medication was not available on the medication cart they checked the Omnicell stock and if not there they called the pharmacy to see when it would be available. She stated that they were supposed to notify the physician when a medication was not given to let them know when the medication was going to be delivered and follow their instructions. LPN #2 stated that if a medication had parameters for holding them it would be documented in the medication order itself which instructed them when to hold the medication. She stated that if they felt that the blood pressure was too low to administer a medication and they did not have parameters in the physician orders they would call the physician and let them know that it was held and document it in the eMAR notes. LPN #2 stated that if a resident was sleeping when she came in with their medications she would come back at the end of her med pass to try again. She stated that for medications like Entresto and Coreg she would wake the resident up because they were important unless there was a physician order to hold them when sleeping. B) A Change in Condition (SBAR) (situation, background, assessment, recommendation) assessment for R3 dated 3/10/2025 documented in part, .The change in condition, symptoms, or signs observed and evaluated is/are: Res (resident) was lethargic, had labored breathing, confusion, sats (saturations) were in the 70s. This started on: 03/10/2025. Mental Status Evaluation (compared to baseline; check all changes that you observe) Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse), increased confusion or disorientation. Respiratory Evaluation: Abnormal lung sounds (rales, rhonchi, wheezing), cough, labored or rapid breathing, shortness of breath, other respiratory changes (describe), Describe cough: productive; Describe other: low O2 (oxygen) sats (saturation). Recommendation of Primary Clinician (if any): start O2, abx (antibiotic), and DuoNeb (nebulizer treatment). Name of Family/Health Care Agent Notified: res own RP (responsible party).A Change in Condition (SBAR) assessment for R3 dated 4/8/2025 documented in part, .The change in condition, symptoms, or signs observed and evaluated is/are: Resident sounds gurgled when talking, breathing is labored, pale in color. This started on: 04/08/2025. Caregiver reported to this nurse that he was pale in color and sounded gurgled when talking. She went to get PA, this nurse went to residents room he was pale in color and having a hard time breathing, started on 3l of oxygen, physician arrived assessed resident and told us to call 911. Name of Family/Health Care Agent Notified: res own RP (responsible party).The clinical record for R3 failed to evidence notification of the next of kin for the changes in condition on 3/10/25 and 4/8/25.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident has a change in condition they documented everything on the change in condition form and sent the resident to the hospital as needed. She stated that even if the resident was their own responsible party if there was an emergency, they contacted the next of kin to notify them what was happening and documented that in the medical record. LPN #2 stated that if the resident was having an emergency and a change in condition they may not be able to understand what was happening and the family needed to know. The facility policy Notification of Changes dated 6/1/2025 documented in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . Circumstances that require a need to alter treatment. Additional considerations: Competent individuals: The facility must still contact the resident's physician and notify resident's representative, if known. A family that wishes to be informed would designate a member to receive calls. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.Reference:(1) Daptomycin Injection: MedlinePlus Drug Information(2) Epoetin Alfa, Injection: MedlinePlus Drug Information(3) Gabapentin: MedlinePlus Drug Information(4) Insulin Glargine (rDNA origin) Injection: MedlinePlus Drug Information(5) Pregabalin: MedlinePlus Drug Information(6) Carvedilol: MedlinePlus Drug Information(7) Valsartan and Sacubitril: MedlinePlus Drug Information(8) Spironolactone: MedlinePlus Drug Information2) For Resident #4 (R4), the facility staff failed to notify the next of kin of a change in condition on 7/8/2024.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/29/2024, the resident was assessed as being cognitively intact for making daily decisions. The assessment documented no wandering behaviors and no wander/elopement alarm use.The resident admission demographic information documented R4 being their own responsible party with contact information listed for their spouse under contacts.A Change in Condition assessment for R4 dated 7/8/2024 documented in part, .The change in condition, symptoms, or signs observed and evaluated is/are: Resident found outside facility across from facility. This started on: 7/8/2024. Resident found outside building across the street, he stated he could not find the bathroom. Resident returned inside with staff, skin check completed, wander guard applied, and safety checks initiated. Recommendations of Primary Clinician (if any): Wanderguard. Name of Family/Health Care Agent Notified: Resident is his own RP (responsible party).The progress notes for R4 documented in part, 07/08/2024 03:47 Note Text: Resident caught outside of the front parking lot by a staff member. Resident was walked back. [Name of staff member] notified to care plan for a wander guard.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident has a change in condition they documented everything on the change in condition form and notified the physician and responsible party. She stated that even if the resident was their own responsible party if there was an emergency, they contacted the next of kin to notify them what was happening and documented that in the medical record. LPN #2 stated that if the resident was having an emergency and a change in condition they may not be able to understand what was happening and the family needed to know. She reviewed the documentation for R4 and stated that the next of kin for R4 should have been made aware of the elopement and wander guard because at the time of the elopement and need for a wander guard she would question if they would be able to be their responsible party.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain a clean, comfortable, and homelike environment for one of 16 residents in the survey sample, Resident #7, three of three reusable bed pads observed in the laundry room, and in six of 27 resident rooms observed. The findings include:1. For Resident #7 (R7), the facility staff failed to maintain a blanket on the resident's bed in a clean and homelike manner. On multiple dates, a brown stain was observed on the blanket. Also, on 9/24/25, stains were observed on three of three washed bed pads in the laundry room. On 9/22/25 at 3:34 p.m., 9/23/25 at 8:02 a.m., 9/23/25 at 3:16 p.m., and 9/24/25 at 9:01 a.m., an observation of R7's room was conducted. A white blanket was observed on the resident's bed and contained a large brown oval stain (approximately ten inches in diameter) on the left lower corner. On 9/24/25 at 4:44 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated bed linens should be changed on shower days and as needed. CNA #2 stated a lot of facility linens are stained, even when they are washed and clean. At this time, three washed and dried reusable bed pads were observed with CNA #2 in the laundry room. All three bed pads contained large light brown and yellow stains. On 9/24/25 at 5:53 p.m., an observation of the three bed pads was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated the bed pads were not clean, comfortable, or homelike, and should not be in use. On 9/25/25 at 1:38 p.m., an interview was conducted with OSM (other staff member) #3 (the account manager of environmental services). OSM #3 stated she used to have an overstock of linens in the past when the contracted environmental services company ordered linens, and the stained linens would have been thrown in the trash. OSM #3 stated the facility now orders linens and there have been issues with getting linens. OSM #3 also stated she has had issues with adding bleach to the washing machines and a representative from the washing machine company has had to come in and adjust the machines. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. The facility policy titled, Safe and Homelike Environment documented, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 4. The facility will provide and maintain bed and bath linens that are clean and in good condition. No further information was presented prior to exit. 2a. Facility staff failed to maintain the privacy curtains in a clean and sanitary manner in resident rooms 311, 313 and 338. On 09/23/2025 at approximately 9:45 a.m., observations of resident rooms [ROOM NUMBER] revealed the privacy curtains between the A-side and B-side of the rooms were dirty and stained. On 09/24/2025 at approximately 9:40 a.m., observations of resident room numbers 313, 311, and 338 revealed the privacy curtains between the A-side and B-side of the rooms were dirty and stained. On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM (other staff member) #3, account manager for environmental services. When asked about cleaning resident's privacy curtains she stated that all the privacy curtains in the resident's room are pulled down and cleaned once a month for every resident room and when they are dirty or soiled. She stated that the residents' privacy curtains are checked for cleanliness by the housekeepers during the daily cleaning and if the curtains are soiled or dirty, they are taken down and laundered. She also stated that any staff member can notify housekeeping if they find a resident's privacy curtain is dirty or soiled. At approximately 2:45 p.m. an observation of the privacy curtains between the A-side and B-side of the room in resident rooms [ROOM NUMBER] with OSM #3. She agreed with the findings of the privacy curtains described above and stated that the curtains needed to be taken down and cleaned and did not present a homelike environment. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2b. Facility staff failed to maintain resident room [ROOM NUMBER] in a clean and sanitary manner. On 09/23/2024 at approximately 9:45 a.m., an observation of resident room [ROOM NUMBER] revealed food debris and spill stains next to and under the beds on the A-side and B-side of the room. On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] revealed food debris and spill stains next to and under the beds on the A-side and B-side of the room. On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM (other staff member) #3, account manager for environmental services. When asked to describe the procedure housekeepers follow for daily cleaning of resident's room she stated that basic cleaning is done daily. She also stated the housekeeper starts in the resident's room with emptying the resident's trash, wiping down all surfaces, walls, dusting, wiping down the bathroom, dust mopping then damp mopping the bathroom and resident's room. At approximately 2:50 p.m. an observation of resident room [ROOM NUMBER] was conducted with OSM #3. Upon entering the resident room and describing the observations conducted on 09/23/2024 and 09/24/2025 as described above, she agreed with the observations and stated that she was aware of the condition of the room and stated that it was unacceptable and did not present a homelike environment. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2c. Facility staff failed to maintain resident rooms [ROOM NUMBERS] in good repair. On 09/23/2024 at approximately 9:45 a.m. an observation of resident room [ROOM NUMBER] was conducted. An observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. Observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. On 09/23/2024 at approximately 9:45 a.m., an observation of resident room [ROOM NUMBER] revealed a gouged, unpainted plaster patch on the lower portion of the wall between the resident's dresser and the bathroom door covering an area approximately two feet wide by 18 inches high. On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] was conducted. An observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. Observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] revealed a gouged , unpainted plaster patch on the lower portion of the wall between the resident's dresser and the bathroom door covering an area approximately two feet wide by 18 inches high. On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM #4, plant operator and maintenance director. When asked to describe the procedure for keeping resident rooms in good repair he stated that staff will usually tell him when something needs to be fixed in a resident's room. He also stated that each nurse's has maintenance request log that staff fill in when something in a resident's room in in need of repair. He stated he does walk-throughs checking resident rooms for repairs but that it is inconsistent. At approximately 2:55 p.m. an observation of resident rooms [ROOM NUMBERS] was conducted with OSM #4. He agreed with the findings as stated above and stated the rooms needed repair and it did not present a homelike environment. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, clinical record review and facility document review, facility staff failed implement the comprehensive care plan for six of 16 current residents in the survey sample, Residents #10 (R10), R11, #7, #2, #3 and #6. The findings include:1. For R10, facility staff failed to provide a smoking apron while smoking a cigarette on the locked Dogwood unit. R10 was admitted to the facility with diagnosis that included but not limited to nicotine dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/23/2025, R10 scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating the R10 was moderately impaired of cognition for making daily decisions. On 09/23/2025 at approximately 10:18 a.m. an observation of R10 was conducted on the locked Dogwood unit. R10 was in a wheelchair, carrying a “Fanny Pak” and observed going outside to the enclosed patio area on the locked Dogwood unit independently. Further observations revealed R10 removing a lighter from the “Fanny Pak”, lighting a cigarette then lighting R11's cigarette. Further observations failed to evidence R10 with a smoking apron while smoking a cigarette. At 11:36 a.m., Resident #10 (R10) was observed outside, at 11:37 a.m., R10 was observed taking a cigarette out and lighting it with a lighter that was on his person. R10 proceeded to smoke unsupervised with no staff present in the courtyard area. Further observations failed to evidence a smoking apron for R10. The facility's “Smoking Evaluation” dated 04/10/2025 for R10 documented in part, “Comments/Adaptive equipment needed (if applicable): Utilize an apron while smoking.” The comprehensive care plan for R10 dated 07/19/2023 documented in part, “Focus. Mr. [NAME] is a smoker. Date Initiated: 07/19/2023.” Under “Interventions” it documented in part, “Observe clothing, use smoking apron and skin for signs of cigarette burns. Date Initiated: 07/19/2023.” On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. The facility's policy “Comprehensive Care Plans” documented in part, “It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2. For R11, facility staff failed to provide a smoking apron and direct supervision while smoking a cigarette on the locked Dogwood unit. R11 was admitted to the facility with diagnosis that included but not limited to dementia (1) and hearing loss. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/23/2025, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the R11 was severely impaired of cognition for making daily decisions. On 09/23/2025 at approximately 9:53 a.m. an observation of R11 was conducted on the locked Dogwood unit. R11 was observed in the dayroom sitting in a rocking chair with an unlit cigarette in her right hand up to her mouth. At approximately 10:18 a.m. an observation revealed R11 going outside to the enclosed patio area on the locked Dogwood unit independently followed by R10. Observations also revealed R10 taking a cigarette lighter from his “Fanny Pak”, lighting R10's cigarette while CNA #1 was standing and talking to R10 and R11. Further observations failed to evidence a smoking apron for R11. On 9/23/25 at 11:28 a.m. Resident #11 (R11) was observed outside in the courtyard sitting in a chair with a walker and personal belongings in front of her. At 11:36 a.m., R10 was observed outside, at 11:37 a.m., R10 was observed taking a cigarette out and lighting it with a lighter that was on his person. R11 ambulated with her rolling walker over to R10 who proceeded to light a cigarette for her. R11 proceeded to smoke unsupervised with no staff present in the courtyard area. R11 was observed lighting a second partially smoked cigarette with the first cigarette. R11 proceeded to smoke some of the second cigarette and extinguish it into a plastic spoon and store the partially smoked cigarette into the storage pocket of the rolling walker. Further observations failed to evidence a smoking apron for R11. The comprehensive care plan for R11 dated 08/20/2024 documented in part, “Focus. (R11) is an unsafe smoker. Date Initiated: 08/20/2024.” Under “Interventions” it documented in part, “She requires a smoking apron while smoking. Date Initiated: 08/20/2024, She requires direct SUPERVISION while smoking. Date Initiated: 08/20/2024.” On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 3. For Resident #7 (R7), the facility staff failed to implement the resident's comprehensive care plan for antipsychotic medication administration. R7's comprehensive care plan dated 4/25/24 documented, (R7) is on antipsychotic therapy r/t (related to) Undifferentiated Schizophrenia. Administer antipsychotic medications as ordered by physician. A review of R7's clinical record revealed a physician's order dated 3/14/25 for Ziprasidone (an antipsychotic medication) 60mg (milligrams). One capsule by mouth every morning and at bedtime for schizophrenia. A review of R7's MARs (medication administration records) for July 2025 through September 2025 failed to reveal evidence the morning dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, and 8/11/25, and failed to reveal evidence the bedtime dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is to make sure staff have a generalized location of where they are able to go, look, and learn how to take care of residents if they are not familiar with the residents. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on the MAR. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit. 4a. For Resident #2 (R2), the facility staff failed to implement the care plan for the administration of medications. The comprehensive care plan dated, 7/23/24, documented in part, “Focus: (R2) has hypertension. Interventions: Give anti-hypertensive medications as ordered. Focus: (R2) has altered cardiovascular status r/t (relate to) HTN, HLD (high blood pressure and hyperlipidemia). Focus: (R2) has Diabetes Mellitus. Interventions: Diabetes medications as ordered by doctor. Focus: (R2) has constipation. Focus: (R2) is on pain medication therapy r/t chronic arthritis. Interventions: Administer ANALGESIC medications as ordered by physician. Focus: (R2) is on antiplatelet therapy r/t cerebrovascular disease. Interventions: Administer antiplatelet medications as ordered by physician. Focus: (R2) has potential for pain r/t arthritis, right wrist pain/muscle spasms, migraine. Interventions: Administer analgesia as per orders.” The physician order dated 7/30/25, documented: 1. Atorvastatin Calcium Oral Tablet (1) 80 MG (milligrams); Give 80 mg by mouth at bedtime related to hyperlipidemia. 2. Clopidogrel Bisulfate Oral Tablet (2) 75 MG; Give 75 mg by mouth at bedtime related to Personal history of transient ischemic attach (TIA) and cerebral infarction without residual deficit. 3. Edarbyclor Oral Tablet (3) 40-25 MG; Give 1 tablet by mouth at bedtime related to essential hypertension (high blood pressure). 4. Miralax Oral Powder (4) 17GM (grams)/scoop; Give 1 scoop by mouth one time a day for constipation. 5. Gabapentin Oral Capsule (7) 300 MG; Give 2 capsules by mouth every 12 hours for neuropathy related to type 2 diabetes mellitus with other diabetic neuropathy. 6. Insulin Lispro Injection Solution (9) inject as per sliding scale: if 151-200 = 4 units; 201-250 = 6 units; 251 -300 = 8 units; 301-350 = 10 units; 351-400 = 12 units, over 400 call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with other diabetic neurological complications. Review of the Medication Administration Record (MAR) for September 2025 documented the above order. On 9/17/25 and 9/18/25 at the 9:00 p.m. doses of the above medication orders, the MAR was blank. Review of the nurse's notes for 9/17/25 and 9/18/25, failed to evidence documentation related to the medications not being administered. An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated the purpose of the care plan is it is how we are going to care for the resident and it should be followed. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Atorvastatin is also used to decrease the amount of fatty substances such as low-density lipoprotein (LDL) cholesterol ('bad cholesterol') and triglycerides in the blood and to increase the amount of high-density lipoprotein (HDL) cholesterol ('good cholesterol') in the blood. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a60004.html 2. Clopidogrel is used alone or with aspirin to prevent serious or life-threatening problems with the heart and blood vessels in people who have had a stroke, heart attack, or severe chest pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601040.html 3. Edarbyclor is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a611028.html 4. Miralax is used to treat occasional constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603032 5. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/ a694007.html 6. Insulin lispro injection products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021 4b. For Resident #2 (R2), the facility staff failed to implement the comprehensive care plan for the administration of a wound treatment. The comprehensive care plan dated, 8/13/25, documented in part, “Focus: has a surgical wound of the abd (abdomen) from debridement and irrigation of abd tissue r/t (related to) necrotizing fasciitis. Interventions: Administer treatments as ordered.” The physician order dated, 8/31/25, documented, “Cleanse ABD (abdominal) wound with wound cleanser, apply hydrofera blue and dry drsg (dressing) every three days at bedtime every 3 days for wound care.” The September 2025 Treatment Administration Record (TAR) documented the above order. The TAR documented the treatment was administered on 9/6/25 and 9/9/25. On 9/12/25 a “9” was documented. For 9/15/25, 9/18/25 and 9/21/25, the box where the nurse documents the treatment having been done was blank. The nurse's note dated 9/12/25 at 11:09 p.m. documented in part, “Patient wants treatment done tomorrow after she gets a shower.” There was no further documentation on the TAR or nurse's notes that the treatment was done on 9/13/25. Further review of the nurse's notes failed to evidence any documentation for 9/15/25, 9/18/25 or 9/21/25. An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated the purpose of the care plan is it is how we are going to care for the resident and it should be followed. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Hydrofera Blue® creates a multifaceted, non-toxic environment for wound healing. Hydrofera Blue's unique capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from the wound bed. This information was obtained from the following website: https://hydrofera.com/why-blue/ 5) For Resident #3 (R3), the facility staff failed to A) implement the comprehensive care plan to administer medication as ordered during dates in February and April of 2025 and B) to provide treatments to pressure injuries as ordered during dates in January and February of 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as receiving medications including insulin, antibiotic, diuretic, opioid, antiplatelet and hypoglycemic medication. Section M documented R3 having three Stage 3 pressure injuries and two Stage 2 pressure injuries that were present on admission. A) The comprehensive care plan for R3 documented in part, “[Name of R3] has impaired cognitive function and/or impaired thought processes r/t (related to) recent hospitalization for sepsis, metabolic encephalopathy. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “… Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2025…” “[Name of R3] has potential for fluid deficit r/t Diuretic use, Poor intake. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2025…” “[Name of R3] has Diabetes Mellitus. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “…Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2025…” “[Name of R3] has anemia r/t iron deficiency. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “…Give medications as ordered. Monitor for side effects, effectiveness. Date Initiated: 02/03/2025…” Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented “ordered call to pharmacy.” Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time a day every Fri for Anemia of Chronic disease. On 2/14/25. The eMAR progress note documented “Not available in omni cell, awaiting from pharmacy. Gabapentin Oral Capsule 100 MG (Gabapentin) Give 4 capsule by mouth in the morning for Neuropathy related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. Take 2 capsules twice daily. On 2/22/25, 2/23/25 and 2/24/25. The eMAR progress note dated 2/22/25 documented “on order”, 2/23/25 “pharmacy to send” and 2/24/25 “pharmacy contacted.” Gabapentin Oral Capsule 100 MG (Gabapentin) Give 8 capsule by mouth at bedtime for neuropathy. On 2/21/25, 2/22/25 and 2/23/25. The eMAR progress note dated 2/21/25 and 2/22/25 documented “on order.” The eMAR progress note dated 2/23/25 documented “pharmacy to send.” Neurontin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth every morning and at bedtime for neuropathy. On 2/27/25. The eMAR progress note dated 2/27/25 documented “on order.” Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 8 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. On 2/9/25, the eMAR was observed to be blank. Review of the eMAR for R3 dated 4/1/25-4/30/25 failed to evidence administration of the following medication on the dates listed below: Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Heart Failure. (to treat fluid retention) (8) On 4/4/25 and 4/7/25 the eMAR progress notes documented, “ordered.” It failed to evidence notification of the physician of the medication not being administered. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. LPN #2 stated that medications were evidenced as given by documentation in the eMAR and if medication was not available on the medication cart they checked the Omnicell stock and if not there they called the pharmacy to see when it would be available. B) The comprehensive care plan for R3 documented in part, “[Name of R3] has pressure injury to left ischium r/t decreased mobility, occasional bladder incontinence, history of radiation and chemotherapy r/t rectal cancer, poor nutrition, Non-compliance with treatment and regimen. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “Administer treatments as ordered and monitor for effectiveness. Date Initiated: 02/03/2025…” Review of the eTAR (electronic treatment administration record) for R3 dated 1/1/25-1/31/25 failed to evidence treatments completed on the following dates: Clean all wounds on buttocks with wound cleanser, apply skin prep to outer edges of wounds. Soak gauze in Dakin's solution, put gauze into wounds, squeeze out excess liquid, cover with foam dressings every day shift every 3 day(s). On 1/27/25 the eTAR was observed to be blank. Review of the eTAR for R3 dated 2/1/25-2/28/25 failed to evidence treatments completed on the following dates: Gentamicin Sulfate External Ointment 0.1 % (Gentamicin Sulfate (Topical)) Apply to sacrum, L + R ischium topically one time a day for pseudomonas infection for 2 Weeks. On 2/4/25, 2/6/25, and 2/7/25. The dates were observed to be blank. Wound care for left ischium, right ischium, sacrum. Cleanse with wound cleanser, pat dry. Apply gentamicin 0.1% ointment to wound bed, then apply calcium alginate to wound bed. Cover with foam dressing QD (every day) and change PRN (as needed) for saturation/soilage every day shift. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. Wound care order for left heel Cleanse with wound cleanser, apply calcium alginate, cover with foam dressing QD every day shift for Wound Care. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. Wound care order for right heel Cleanse with wound cleanser, pat dry, apply skin prep QD. OFFLOAD with boot or heelz up pillow one time a day. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in January and February of 2025. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. LPN #2 stated that treatments were evidenced as completed by documentation in the eTAR. On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. 6) For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to provide treatments for a pressure injury on multiple dates in July, August and September 2025 and failed to complete weekly assessments that included measurement and description of wound progress. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/13/25, the resident was assessed as having one unstageable pressure injury that was not present on admission or reentry. The comprehensive care plan for R6 documented in part, “[Name of R6] has unstageable pressure injury to the coccyx r/t (related to) poor mobility, incontinence. Date Initiated: 08/14/2019.” Under “Interventions” it documented in part, “Administer treatments as ordered and monitor for effectiveness. Date Initiated: 05/14/2025. Assess/record/monitor wound healing. Date Initiated: 05/14/2025… Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 05/14/2025.” Review of the clinical record documented skin assessments documenting presence of the wound and continued wound treatments but failed to evidence weekly measurements of the pressure injury including width, length, depth, type of tissue and exudate described. Review of the eTAR (electronic treatment record) for R6 dated 7/1/25-7/31/25 failed to evidence treatments completed to the coccyx pressure injury on 7/3/25, 7/21/25, 7/22/25, 7/23/25, 7/24/25 and 7/25/25. The dates were observed to be blank. Review of the eTAR for R6 dated 8/1/25-8/31/25 failed to evidence treatment completed to the coccyx pressure injury on 8/23/25. The date was observed to be blank. Review of the eTAR for R6 dated 9/1/25-9/30/25 failed to evidence treatments completed to the coccyx pressure injury on 9/5/25 and 9/20/25. The dates were observed to be blank. The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in July, August and September of 2025. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. LPN #2 stated that treatments were evidenced as completed by documentation in the eTAR. She stated that the facility formerly had a wound care nurse practitioner who came in weekly and assessed residents pressure injuries, measuring them and adjusting treatments as needed but they did not come there any longer. She stated that she had been on night shift and was not sure of the current process but if a new wound was reported to her she asked a nurse trained in wounds to measure it and referred it to the physician for treatment. On 9/24/2025 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the former assistant director of nursing used to keep a log sheet where she tracked pressure injuries and measured them weekly but had stepped down from the position. She stated that there was an assessment that they could complete in the electronic medical record to record their assessments but there had been a lapse due to the assistant director stepping down, and the wound nurse practitioner leaving. She stated that she could say that after the assistant director of nursing stepped down there was a period when there was a gap in tracking and measuring but they had a new doctor who started last week to assist them. ASM #2 stated that R6 was non-compliant with repositioning and tended to lay flat on her back or on the left side. On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to administer medications and treatment per the physician's orders for three of 16 residents in the survey sample, Residents #3, #2 and #7.The findings include:1) For Resident #3 (R3), the facility staff failed to administer medication as ordered during dates in February and April of 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as receiving medications including insulin, antibiotic, diuretic, opioid, antiplatelet and hypoglycemic medication. Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 4 capsule by mouth in the morning for Neuropathy related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat seizures/nerve pain) (1). Take 2 capsules twice daily. On 2/22/25, 2/23/25 and 2/24/25. The eMAR progress note dated 2/22/25 documented “on order”, 2/23/25 documented “pharmacy to send” and 2/24/25 documented “pharmacy contacted.” Gabapentin Oral Capsule 100 MG (Gabapentin) Give 8 capsule by mouth at bedtime for neuropathy. On 2/21/25, 2/22/25 and 2/23/25. The eMAR progress note dated 2/21/25 and 2/22/25 documented “on order.” The eMAR progress note dated 2/23/25 documented “pharmacy to send.” Neurontin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth every morning and at bedtime for neuropathy. On 2/27/25., the eMAR progress note documented “on order.” Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 8 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat diabetes) (2). On 2/9/25, the eMAR was observed to be blank. Review of the eMAR for R3 dated 4/1/25-4/30/25 failed to evidence administration of the following medication on the dates listed below: Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Heart Failure. (to treat fluid retention) (3) On 4/4/25 and 4/7/25 the eMAR progress notes documented, “ordered.” On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR and if medication was not available on the medication cart they checked the Omnicell stock (in house stocked medication) to see if the medication was in there for them to pull out and administer. Review of the facility provided Omnicell inventory list dated 9/23/25, documented Gabapentin 100mg stocked with a par level of 10 capsules, Gabapentin 400mg stocked with a par level of 10 capsules, Lantus Solostar 100 unit/ml stocked with a par level of two vials, and Spironolactone 25mg stocked with a par level of 10 tablets. The facility policy “Medication Administration” dated 6/1/2025 documented in part, “Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection… Policy Explanation and Compliance Guidelines: Administer medication as ordered in accordance with manufacturer specifications .” On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. Reference: (1) Gabapentin: MedlinePlus Drug Information (2) Insulin Glargine (rDNA origin) Injection: MedlinePlus Drug Information (3) Spironolactone: MedlinePlus Drug Information 2a. For Resident #2 (R2), the facility staff failed to administer multiple medications on 9/17/25 and 9/18/25. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. R2 stated she did not get her medications as ordered. The physician order dated 7/30/25, documented: 1. Atorvastatin Calcium Oral Tablet (1) 80 MG (milligrams); Give 80 mg by mouth at bedtime related to hyperlipidemia. 2. Clopidogrel Bisulfate Oral Tablet (2) 75 MG; Give 75 mg by mouth at bedtime related to Personal history of transient ischemic attach (TIA) and cerebral infarction without residual deficit. 3. Edarbyclor Oral Tablet (3) 40-25 MG; Give 1 tablet by mouth at bedtime related to essential hypertension (high blood pressure). 4. Miralax Oral Powder (4) 17GM (grams)/scoop; Give 1 scoop by mouth one time a day for constipation. 5. Mirapex Oral Tablet (5) 1 MG; Give 1 mg by mouth at bedtime related to restless legs syndrome. 6. Montelukast Sodium Oral Tablet (6) 10 MG; Give 10 mg by mouth at bedtime related to chronic obstructive pulmonary disease. 7. Gabapentin Oral Capsule (7) 300 MG; Give 2 capsules by mouth every 12 hours for neuropathy related to type 2 diabetes mellitus with other diabetic neuropathy. 8. Magnesium Oxide Oral Tablet (8) 400 MG; Give 400 mg by mouth every 12 hours for supplement. 9. Insulin Lispro Injection Solution (9) inject as per sliding scale: if 151-200 = 4 units; 201-250 = 6 units; 251 -300 = 8 units; 301-350 = 10 units; 351-400 = 12 units, over 400 call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with other diabetic neurological complications. Review of the Medication Administration Record (MAR) for September 2025 documented the above order. On 9/17/25 and 9/18/25 at the 9:00 p.m. doses of the above medication orders, the MAR was blank. Review of the nurse's notes for 9/17/25 and 9/18/25, failed to evidence documentation related to the medications not being administered. The comprehensive care plan dated, 7/23/24, documented in part, “Focus: (R2) has hypertension. Interventions: Give anti-hypertensive medications as ordered. Focus: (R2) has altered cardiovascular status r/t (relate to) HTN, HLD (high blood pressure and hyperlipidemia). Focus: (R2) has Diabetes Mellitus. Interventions: Diabetes medications as ordered by doctor. Focus: (R2) has constipation. Focus: (R2) is on pain medication therapy r/t chronic arthritis. Interventions: Administer ANALGESIC medications as ordered by physician. Focus: (R2) is on antiplatelet therapy r/t cerebrovascular disease. Interventions: Administer antiplatelet medications as ordered by physician. Focus: (R2) has potential for pain r/t arthritis, right wrist pain/muscle spasms, migraine. Interventions: Administer analgesia as per orders.” An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated nurse evidence she's given a medication by checking it off on the MAR. The above MAR was reviewed with LPN #1. She stated it isn't documented as given. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Atorvastatin is also used to decrease the amount of fatty substances such as low-density lipoprotein (LDL) cholesterol ('bad cholesterol') and triglycerides in the blood and to increase the amount of high-density lipoprotein (HDL) cholesterol ('good cholesterol') in the blood. This information was obtained from the following website: : https://medlineplus.gov/druginfo/meds/a60004.html 2. Clopidogrel is used alone or with aspirin to prevent serious or life-threatening problems with the heart and blood vessels in people who have had a stroke, heart attack, or severe chest pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601040.html 3. Edarbyclor is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a611028.html. 4. Miralax is used to treat occasional constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/med s/a603032.html 5. Pramipexole (Mirapex) is also used to treat restless legs syndrome. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds /a697029.html 6. Montelukast is used to prevent wheezing, difficulty breathing, chest tightness, and coughing caused by asthma. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a600014.html 7. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/ a694007.html. 8. Magnesium oxide also is used as a dietary supplement when the amount of magnesium in the diet is not enough. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a601074.html. 9. Insulin lispro injection products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021 2b. For Resident #2 (R2), the facility staff failed to administer wound treatments to an abdominal wound between 9/9/25 and 9/23/25. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. The resident stated that her current wound dressing is supposed to be every three days. It hasn't been done on many occasions. The physician order dated, 8/31/25, documented, “Cleanse ABD (abdominal) wound with wound cleanser, apply hydrofera blue and dry drsg (dressing) every three days at bedtime every 3 days for wound care.” The September 2025 Treatment Administration Record (TAR) documented the above order. The TAR documented the treatment was administered on 9/6/25 and 9/9/25. On 9/12/25 a “9” was documented. For 9/15/25, 9/18/25 and 9/21/25, the box where the nurse documents the treatment having been done was blank. The nurse's note dated 9/12/25 at 11:09 p.m. documented in part, “Patient wants treatment done tomorrow after she gets a shower.” There was no further documentation on the TAR or nurse's notes that the treatment was done on 9/13/25. Further review of the nurse's notes failed to evidence any documentation for 9/15/25, 9/18/25 or 9/21/25. The comprehensive care plan dated, 8/13/25, documented in part, “Focus: has a surgical wound of the abd (abdomen) from debridement and irrigation of abd tissue r/t (related to) necrotizing fasciitis. Interventions: Administer treatments as ordered.” An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated nurse evidence she's completed a treatment by checking it off on the TAR. The above TAR was reviewed with LPN #1. She stated it isn't documented as completed. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Hydrofera Blue® creates a multifaceted, non-toxic environment for wound healing. Hydrofera Blue's unique capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from the wound bed. This information was obtained from the following website: https://hydrofera.com/why-blue/ 3. For Resident #7 (R7), the facility staff failed to administer the medication melatonin on multiple dates in July 2025 and September 2025. A review of R7's clinical record revealed a physician's order dated 3/5/25 for melatonin 5mg (milligrams). Two tablets by mouth at bedtime for insomnia. A review of R7's July 2025 and September 2025 MARs (medication administration records) failed to reveal evidence that melatonin was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/25/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25 (as evidenced by blank spaces on the MARs). A review of the in-house over-the-counter medication supply list revealed melatonin 5mg tablets were available in the facility. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on the MAR. On 9/25/25 at 3:51 p.m., another interview was conducted with LPN #2. LPN #2 stated that if a medication is not available in the medication cart, the nurse should obtain the medication from the facility stock of over-the-counter medications or Omnicell (a machine containing various medications) if the medication is available there. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury for two of 16 residents in the survey sample, Residents #3 and #6.The findings include:1) For Resident #3 (R3), the facility staff failed to provide treatments to pressure injuries (1) as ordered during dates in January and February of 2025.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as having three Stage 3 pressure injuries and two Stage 2 pressure injuries that were present on admission.Review of the eTAR (electronic treatment administration record) for R3 dated 1/1/25-1/31/25 failed to evidence treatments completed on the following dates:Clean all wounds on buttocks with wound cleanser, apply skin prep to outer edges of wounds. Soak gauze in Dakin's solution, put gauze into wounds, squeeze out excess liquid, cover with foam dressings every day shift every 3 day(s). On 1/27/25 the eTAR was observed to be blank.Review of the eTAR for R3 dated 2/1/25-2/28/25 failed to evidence treatments completed on the following dates:Gentamicin Sulfate External Ointment 0.1 % (Gentamicin Sulfate (Topical)) Apply to sacrum, L + R ischium topically one time a day for pseudomonas infection for 2 Weeks. On 2/4/25, 2/6/25, and 2/7/25. The dates were observed to be blank.Wound care for left ischium, right ischium, sacrum. Cleanse with wound cleanser, pat dry. Apply gentamicin 0.1% ointment to wound bed, then apply calcium alginate to wound bed. Cover with foam dressing QD (every day) and change PRN (as needed) for saturation/soilage every day shift. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank.Wound care order for left heel Cleanse with wound cleanser, apply calcium alginate, cover with foam dressing QD every day shift for Wound Care. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank.Wound care order for right heel Cleanse with wound cleanser, pat dry, apply skin prep QD. Offload with boot or heelz up pillow one time a day. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. The comprehensive care plan for R3 documented in part, [Name of R3] has pressure injury to left ischium r/t decreased mobility, occasional bladder incontinence, history of radiation and chemotherapy r/t rectal cancer, poor nutrition, Non-compliance with treatment and regimen. Date Initiated: 02/03/2025. The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in January and February of 2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that treatments were evidenced as completed by documentation in the eTAR.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.Reference:(1) A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.2) For Resident #6 (R6), the facility staff failed to provide treatments for a pressure injury on multiple dates in July, August and September 2025 and failed to complete weekly assessments that included measurement and description of wound progress.On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/13/25, the resident was assessed as having one unstageable pressure injury that was not present on admission or reentry.A weekly skin integrity review for R6 dated 4/9/2025 documented intact skin.A weekly skin integrity review for R6 dated 4/18/2025 documented in part, .coccyx- open area on coccyx found by CNA (certified nursing assistant) staff member.A wound physician summary for R6 dated 4/22/2025 documented in part, .Patient is seen for evaluation and management of wound(s)/skin. Staff noticed an open area at pt's buttock area and have been placing a dry dressing on the area. Pt has a hx (history) of stage 2 PI (pressure injury) to her left buttock along with previous trauma to the area. Left Buttock: (+) partial thickness ulceration that measures 1.0 x 0.5 x 0.2 cm. Wound base 100% pink/red moist tissue. reopened stage 2 PI Contributing factors to dx: poor mobility, incontinence, previous trauma to area, age, muscle weakness, previous stage 2 PI to left buttock Wound care to left buttock as follows: Cleanse with wound cleanser or NS (normal saline), pat dry. Apply zinc Q (every) shift.A wound physician summary for R6 dated 5/20/2025 documented in part, .Left buttock (+) partial thickness ulceration that measures 0.5 x 0.5 x 0.1 cm. Wound base 100% pink/red moist tissue. Edges adherent to wound base.A pressure ulcer wound round assessment for R6 dated 8/4/2025 documented in part, Units of measure: centimeters. Site: Coccyx; Type: Pressure; Length: 1.5; Width 1.5; Depth 0.3; Stage: unstageable. Wound bed: slough; Color: yellow; wound edges: rolled. Continue treatment as ordered.A wound physician summary for R6 dated 9/18/2025 documented in part, .Stage 4 Pressure Wound Sacrum Full Thickness. Wound Size (LxWxD) (length by width by depth): 1x1x1.2cm.Granulation tissue: 100% . Healing Potential: Good. Estimated Time to Heal: 2-4 months.Approach: Off-loading.Review of the clinical record documented skin assessments documenting presence of the wound and continued wound treatments but failed to evidence weekly measurements of the pressure injury including width, length, depth, type of tissue and exudate described between the measurements obtained on 5/20/25 and 8/4/25.Review of the eTAR (electronic treatment record) for R6 dated 7/1/25-7/31/25 failed to evidence treatments completed to the coccyx pressure injury on 7/3/25, 7/21/25, 7/22/25, 7/23/25, 7/24/25 and 7/25/25. The dates were observed to be blank.Review of the eTAR for R6 dated 8/1/25-8/31/25 failed to evidence treatment completed to the coccyx pressure injury on 8/23/25. The date was observed to be blank.Review of the eTAR for R6 dated 9/1/25-9/30/25 failed to evidence treatments completed to the coccyx pressure injury on 9/5/25 and 9/20/25. The dates were observed to be blank.The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in July, August and September of 2025. The comprehensive care plan for R6 documented in part, [Name of R6] has unstageable pressure injury to the coccyx r/t (related to) poor mobility, incontinence. Date Initiated: 08/14/2019. Under Interventions it documented in part, Administer treatments as ordered and monitor for effectiveness. Date Initiated: 05/14/2025. Assess/record/monitor wound healing. Date Initiated: 05/14/2025. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 05/14/2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that treatments were evidenced as completed by documentation in the eTAR. She stated that the facility formerly had a wound care nurse practitioner who came in weekly and assessed residents pressure injuries, measuring them and adjusting treatments as needed but they did not come there any longer. She stated that she had been on night shift and was not sure of the current process but if a new wound was reported to her she asked a nurse trained in wounds to measure it and referred it to the physician for treatment. On 9/24/2025 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the former assistant director of nursing used to keep a log sheet where she tracked pressure injuries and measured them weekly but had stepped down from the position. She stated that there was an assessment that they could complete in the electronic medical record to record their assessments but there had been a lapse due to the assistant director stepping down, and the wound nurse practitioner leaving. She stated that she could say that after the assistant director of nursing stepped down there was a period when there was a gap in tracking and measuring but they had a new doctor who started last week to assist them. ASM #2 stated that R6 was non-compliant with repositioning and tended to lay flat on her back or on the left side. On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on resident interview, staff interview and facility document review, the facility staff failed to maintain sufficient nursing staff to meet the resident's needs for two of two resident units, Dogwood and Rosewood units. The findings include:The facility staff failed to maintain sufficient nursing staff to provide HS (hours of sleep) snacks to residents. The Facility Assessment Tool dated 06/01/2025 documented in part, Staffing plan. Position: Nurse aides - Distribution adjusted based on resident activities and care needs per shift. Total Number Needed or Average or Range: 6-8 (six to eight) CNAs (certified nursing assistants) day shift, 4-6 (four to six) CNAs evening / nights. The facility's As worked schedules for nursing staff on the Dogwood Unit dated 06//2024 through 06/30/2025 documented one CNA (certified nursing assistant) during the 3:00 p.m. to 11:00 p.m. shift on 06/07/2025 with a facility census of 77, and 06/14/2025 with a facility census of 77; one CNA for four hours during the 3:00 p.m. to 11:00 p.m. shift on 06/04/2025 with a facility census of 76, 06/06/2025 with a facility census of 76, 06/08/2025 with a facility census of 78, 06/11/2025 with a facility census of 77, 06/13/2025 with a facility census of 79 and on 06/24/2025 with a facility census of 71. The facility's As worked schedules for nursing staff on the Rosewood Unit dated 06//2024 through 06/30/2025 documented one CNA during the 3:00 p.m. to 11:00 p.m. shift on 06/01/2025 with a facility census of 78 and on 06/08/2025 with a facility census of 78. On 09/24/2025 at approximately 10:40 a.m. an interview was conducted with Resident #2 (R2), resident council president for the Rosewood unit, with a BIMs (Brief Interview for Mental Status) of 15, being cognitively intact for making daily decisions, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks. On 09/24/2025 at approximately 10:50 a.m. an interview was conducted with R16, resident council president for the Dogwood unit, with a BIMs of 15, being cognitively intact for making daily decisions, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks. On 09/24/2025 at approximately 2:15 p.m., a telephone interview was conducted with OSM (other staff member) #2, former staffing coordinator. When asked about the number of CNAs needed for the Dogwood and Rosewood units during the 3:00 p.m. to 11:00 p.m. (3-11) shift she stated she would try to get three CNAs but usually had two CNAs for each unit during the 3-11 shift. When asked to describe the procedure she followed if there were not enough staff she stated she would reach out to staff to work another shift or call staff to 0see if they could come in and work. When asked about utilizing agency nursing staff she stated that corporate did not allowed her to use agency staff. On 09/24/2025 at approximately 4:35 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding snacks being provided to residents during the night shift. CNA #2 stated that in March and April 2025 she worked on the 7:00 p.m. to 7:00 a.m. shift and that snacks were not consistently provided to the residents because there were not enough staff. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11, district manager for dietary , regarding HS snacks for residents. She stated the HS snacks consisted of sandwiches, cookies, crackers and drinks provided by the dietary department and sent to the nurse's stations at 7:00 p.m. each evening. She further stated that it was the responsibility of the nursing staff to pass on the snacks to the residents. On 09/25/2025 at approximately 3:00 p.m. an interview was conducted with ASM #2 regarding residents receiving HS snacks. She stated that it was hit or miss that the residents received the HS snacks. On 09/25/2025 at approximately 3:15 p.m. an interview was conducted with CNA #7 regarding staffing during the 3:00 p.m. to 11:00 p.m. shift. She stated that there are times when she is the only CNA working on a unit for two to three hours. On 09/25/2025 at approximately 3:20 p.m. an interview was conducted with OSM #8, staffing coordinator for sister facility. After reviewing the As Worked schedule for the dates listed above, she agreed that the facility was short staffed on the 3-11 shift for the dates listed above. The facility's policy Nursing Services and sufficient Staff documented in part, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 3. The facility is required to provide licensed nursing staff 24 hours a day (except when waived), along with other nursing personnel, including but not limited to nurse aides. 5. Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on staff interview, and facility document review, the facility staff failed to meet RN (registered nurse) requirements for 16 of 31 days reviewed. The findings include:1. The facility staff failed to provide RN coverage for eight consecutive hours a day on 8/25/25, 8/30/25, 8/31/25, 9/13/25, and 9/14/25. A review of nursing schedules revealed there was no RN coverage for eight consecutive hours on 8/25/25, 8/30/25, 8/31/25, 9/13/25, and 9/14/25. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated there had not been eight consecutive hours of RN coverage in the facility and there was only one other RN besides her working at the facility. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Nursing Services-Registered Nurse (RN) documented, The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. No further information was presented prior to exit. 2. The facility staff failed to ensure the Director of Nursing did not serve as a charge nurse on 8/25/25, 8/27/25, 8/29/25, 9/2/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, and 9/20/25. A review of the nursing schedules revealed the Director of Nursing served as a charge nurse on 8/25/25, 8/27/25, 8/29/25, 9/2/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, and 9/20/25. A review of nurse staffing postings revealed the resident census on all of those dates was greater than 60 residents. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she was told she was not supposed to work as a nurse on the floor unless there was a crisis, but if we don't have any other choice then we don't have a choice. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern.The facility policy titled, Nursing Services-Registered Nurse (RN) documented, The Director of Nursing may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. No further information was presented prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on staff interview, and facility document review, the facility staff failed to complete an annual performance review for four of five CNA (certified nursing assistant) reviews. The findings include:For CNA #3, CNA #4, CNA #5, and CNA #6, the facility staff failed to complete an annual performance review. CNA #3 was hired on 8/22/23. CNA #3's most recent performance review was completed on 8/27/24.CNA #4 was hired on 6/13/23. CNA #4's most recent performance review was completed on 7/23/24.CNA #5 was hired on 7/20/21. CNA #5's most recent performance review was completed on 7/22/24.CNA #6 was hired on 2/15/23. CNA #6's most recent performance review was completed on 7/31/24. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she did not know who was responsible for ensuring the completion of CNA performance reviews because she had only been the director of nursing since April 2025 and had never been a director of nursing before then. ASM #2 stated she assumed CNA performance reviews should be completed every year based on the CNA's hire date. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Nurse Aide Training Program documented, 2.b. It is the responsibility of the employee to attend/complete mandatory in-service trainings to maintain employment status with the facility. A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review. No further information was presented prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on facility staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure medications were available for administration for two of 16 residents in the survey sample, Residents #3 and #7.The findings include:1) For Resident #3 (R3), the facility staff failed to ensure medications were available for administration during dates in February and March of 2025. Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. (antibiotic to treat infection) (1). The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented “ordered call to pharmacy.” Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time a day every Fri for Anemia of Chronic disease. (to treat anemia) (2) On 2/14/25. The eMAR progress note documented “Not available in omni cell, awaiting from pharmacy.” Pregabalin Oral Capsule 25 MG (Pregabalin) Give 25 mg by mouth every morning and at bedtime related to pain in unspecified joint. (to treat pain) (3) Not administered on the 6:00 a.m. doses on 2/1-2/4/25, 2/6/25, 2/7/25, and 2/20/25 and the 9:00 p.m. doses on 2/1, 2/3, 2/5-2/9/25. The eMAR progress notes on 2/1/25, 2/4/25, 2/6/25, 2/7/25, 2/9/25 documented, “on order”, 2/2/25- “ordered”, 2/3/25- “script needs to be wrote”, 2/8/25- “not available at this time” and 2/20/25- “new order wrote, has not arrived.” Review of the eMAR for R3 dated 3/1/25-3/31/25 failed to evidence administration of the following medication on the dates listed below: Pregabalin Oral Capsule 300 MG (Pregabalin) Give 1 capsule by mouth every morning and at bedtime for neuropathy. On 3/8/25 at 9:00 a.m. The eMAR progress note documented, “on order.” On 3/20/25 at 9:00 p.m., the eMAR progress note documented, “ordered.” On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR. She stated that if a medication was not available on the medication cart they checked the Omnicell (in house medication) stock and if not there they called the pharmacy to see when it would be available. She stated that they were supposed to notify the physician when a medication was not given to let them know when the medication was going to be delivered and follow their instructions. The facility policy “Medication Administration” dated 6/1/2025 documented in part, “Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection… Policy Explanation and Compliance Guidelines: Administer medication as ordered in accordance with manufacturer specifications .” On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. Reference: (1) Daptomycin Injection: MedlinePlus Drug Information (2) Epoetin Alfa, Injection: MedlinePlus Drug Information (3) Pregabalin: MedlinePlus Drug Information 2. For Resident #7 (R7), the facility staff failed to ensure the medications Ziprasidone and Flomax were available for administration on multiple dates July 2025 through September 2025. A review of R7's clinical record revealed the following physician's orders: 3/14/25-Ziprasidone 60mg (milligrams). One capsule by mouth every morning and at bedtime for schizophrenia. 5/6/25-Flomax 0.4mg. One capsule by mouth once a day for enlargement of the prostate gland. A review of R7's MARs (medication administration records) for July 2025 through September 2025 failed to reveal evidence the morning dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, and 8/11/25, failed to reveal evidence the bedtime dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25, and failed to reveal evidence the daily dose of Flomax was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/27/25, and 8/11/25. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on the MAR. On 9/25/25 at 3:51 p.m., another interview was conducted with LPN #2. LPN #2 stated that if a medication is not available in the medication cart, the nurse should obtain the medication from the Omnicell (a machine containing various medications) if the medication is available there or contact the pharmacy if the medication is not available in the Omnicell. A review of the Omnicell list revealed Ziprasidone and Flomax were not available in the Omnicell. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview and facility document review, facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 2:00 p.m. an observation in the facility's kitchen revealed OSM (other staff member) #10, acting dietary manager plating Caesar salad into bowls using a beige/ off-white handle scoop. Further observations revealed OSM #10 placing one scoop of salad into each bowl. At approximately 4:24 p.m. an observation of the facility's kitchen tray line revealed the cook plating food for the resident's dinner. Observations of the serving utensils being used by the cook to plate the food revealed he was using a grey handle scoop for serving lasagna, and a red handle scoop for sliced carrots. Continued observations revealed the cook placed one scoop of lasagna, carrots on the resident's dinner plates and one bowl of Caesar salad on each meal tray. The facility's menu for dinner on 09/22/2025 documented in part, Monday. Entree. Lasagna w/ (with) meat sauce 1 (one) square. Caesar Salad 1 Cup. Sliced Carrots 1/2 (half) Cup.The facility's Production Count dated Monday-9/22/2025 documented in part, Lasagna w/MeatSauce 8 Oz (eight ounces), Caesar Salad 1 Cup, Sliced Carrots 1/2 Cup. The kitchen's Disher Size reference sheet documented in part, SCOOP NO. (number) MENU OZ VOLUME#4 8 Oz 1 Cup#8 4 Oz 1/2 Cup#10 3 Oz 3/8 (three-eighth) Cup#16 2Oz 1/4 (quarter) Cup On 09/25/2025 at approximately 1:10 p.m. an interview was conducted with OSM #11, district manager for dietary. When asked about the serving sizes of the grey, red and beige/ off-white handle scoops, OSM #11 showed the surveyor the scoops and stated the that the grey handle scoop holds four ounces, the red handle scoop holds two ounces and the beige/ off-white handle scoop holds three ounces. After informed of the observation of the serving utensils/scoops being used for food portions as stated above for the resident's dinner on 09/22/2025 OSM #11 stated the cook should have referenced the Production Sheet and check for the correct serving utensil/scoop to serve the correct portions of food. When asked if residents received the correct amount of food for dinner on 09/22/2025 she stated no. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of two facility units, Rosewood Unit. The findings include:On 09/22/2025 at approximately 5:45 p.m., a test tray consisting of lasagna with meat sauce, sliced carrots, green beans and mash potatoes were placed on a food cart in the facility's kitchen and sent to the Rosewood Unit of the facility. The cart was followed by the surveyor, OSM (other staff member) #11, district manager for dietary. At approximately 6:05 p.m., the last dinner tray was served to a resident on the Rosewood Unit and OSM #11 was asked to remove cover from the test plate then proceeded to take the temperatures of the food. Two surveyors observed OSM #11 obtaining the food temperatures of the test tray. The lasagna with meat sauce was 127-degrees F (Fahrenheit), the green beans were 117-degrees F, sliced carrots were 113-degrees F and the potatoes were 112-degrees F. The test tray was sampled by two surveyors, OSM #11 for appropriate holding temperatures and palatable taste. When asked to describe the taste of the food OSM #11 stated the food could have been warmer. After tasting all the food on the test tray OSM #11 was asked if the food was palatable. She stated the food was not palatable and should have been 130-degree F. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

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Based on resident interview, staff interview and facility document review, facility staff failed to provide HS (hours of sleep) snacks on two of two resident units, Dogwood and Rosewood units. The findings include:The facility's Meal Delivery Schedule documented in part, Breakfast (7:30 a.m.)-8:00 (a.m.)). Rosewood (unit) 8:00. Dinner 4:30 (p.m.)-5:15 (p.m.). Rosewood 5:15. According to the Meal Delivery Schedule there are 14 hours and 15 minutes between the last full evening meal and the first full meal of the next day. On 09/24/2025 at approximately 10:40 a.m. an interview was conducted with Resident #2 (R2), resident council president for the Rosewood unit, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks and that the resident council had never agreed to allow up to 16 hours to elapse between a substantial evening meal and breakfast the following day. On 09/24/2025 at approximately 10:50 a.m. an interview was conducted with R16, resident council president for the Dogwood unit, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks and that the resident council had never agreed to allow up to 16 hours to elapse between a substantial evening meal and breakfast the following day On 09/24/2025 at approximately 4:35 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding snacks being provided to residents during the night shift. CNA #2 stated that in March and April 2025 she worked on the 7:00 p.m. to 7:00 a.m. shift and that snacks were not consistently provided to the residents because there were not enough staff. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11, district manager for dietary , regarding HS snacks for residents. She stated the HS snacks consisted of sandwiches, cookies, crackers and drinks provided by the dietary department and sent to the nurse's stations at 7:00 p.m. each evening. She further stated that it was the responsibility of the nursing staff to pass on the snacks to the residents. OSM #11 also stated that she received pictures form OSM #12, the facility's dietary account manager, showing the HS snacks from previous evenings were not passed on to residents and she had an email from OSM #12 regarding concerns of the snack not being passed on to the residents. The email dated 08/14/2025 at 9:07 a.m. from OSM #12 to OSM #11 documented in part, .So the snacks are being given out. The CNAS (certified nursing assistants) and residents are still coming to get milk because it is not being given out. I did send (Name of Administrative staff Member #1) a text message of pictures to show her. In the stand up she told me she received them and told me she would address it but said nothing at the stand up meeting. But we are doing our part for once and they are not doing theirs. On 09/25/2025 an attempt to interview OSM #12 was unsuccessful due to her being out on leave. On 09/25/2025 at approximately 2:22 p.m. an interview was conducted with ASM #1, executive director regarding HS snacks. She stated that she did recall the messages from OSM #12 and purchased two new snack carts for each unit in August (2025). She also stated that she informed the nursing managers, LPN (licensed practical nurse) #1 and ASM #2 regarding residents not receiving the HS snacks. ASM #1 stated the nurse managers were to educate the nurses and CNAs who work on the 3:00 p.m.-11:00 p.m. shift about passing HS snacks to residents. On 09/25/2025 at approximately 3:00 p.m. an interview was conducted with ASM #2 regarding residents receiving HS snacks. She stated that it was hit or miss that the residents received the HS snacks. She further stated that she did not recall the conversation with ASM #1. On 09/25/2025 at approximately 4:20 p.m. an interview was conducted with LPN #1. She stated she did not recall the conversation with ASM #1 regarding the HS snacks. She further stated that the facility's was not bringing the snacks to the unit. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations and staff interviews, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 5:30 p.m. an observation in the facility kitchen revealed OSM (other staff member) #10, acting dietary manager and OSM #11 , district manager for dietary, hand drying 20 resident meal trays, placing them on the tray line. Continuing observation revealed kitchen staff at the tray line, sliding the meal trays down the tray line, placing resident's meals on the tray and placing the tray in the food carts to be taken to the unit floors. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11. When informed of the observation as stated above OSM #11 stated that the meal trays should have been air dried to prevent contamination. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0840 (Tag F0840)

Could have caused harm · This affected multiple residents

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Based on staff interview, and facility document review, the facility staff failed to provide evidence of an updated contract with an outside provider for one of eight contracts reviewed, potentially affecting seven residents who received respiratory equipment services. The findings include:The facility staff failed to provide an updated contract for respiratory equipment. A review of facility contracts with outside service providers revealed there was no current contractual agreement with the respiratory equipment provider. The contract was between the outside provider and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal team. ASM #1 stated the new company bought approximately 48 or 49 facilities and this has been a slow process. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. No further information was presented prior to exit.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0843 (Tag F0843)

Could have caused harm · This affected most or all residents

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Based on staff interview, and facility document review, the facility staff failed to provide evidence of an updated hospital transfer agreement for one of one agreement reviewed, potentially affecting all residents, a census of 86. The findings include:The facility staff failed to provide an updated hospital transfer agreement. A review of the hospital transfer agreement revealed there was no current contractual agreement with the hospital. The agreement was between the hospital and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal team. ASM #1 stated the new company bought approximately 48 or 49 facilities and this has been a slow process. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. No further information was presented prior to exit.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

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Based on staff interview, and facility document review, the facility staff failed to ensure the required QAPI (Quality Assurance and Performance Improvement) committee members attended for three of three quarterly meeting reviews, (October 2024 through December 2024, January 2025 through March 2025, and April 2025 through June 2025). The findings include:The facility staff failed to ensure an Infection Preventionist attended QAPI meetings from October 2024 through June 2025. A review of QAPI meeting sign-in sheets for October 2024 through June 2025 failed to reveal the signature of an Infection Preventionist. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated an infection preventionist is supposed to attend the QAPI meetings and she could not show an infection preventionist attended the QAPI meetings from October 2025 through June 2025. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. 1. The facility policy titled, Quality Assurance and Performance Improvement (QAPI) documented, The QAA Committee shall be interdisciplinary and shall:a. Consist at a minimum of: i. The Infection Preventionist.b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. No further information was presented prior to exit.

MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on staff interview and facility document review, the facility staff failed to meet nurse staffing information requirements for 31 of 31 days reviewed. The findings include:The facility staff failed to ensure the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides directly responsible for resident care per shift was documented on the nurse staffing information postings from 8/25/25 through 9/24/25, and failed to ensure accurate nurse staffing information was posted on 9/23/25. A review of nurse staffing information postings from 8/25/25 through 9/24/25 failed to reveal the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides (the postings only documented the total number and the actual hours worked by licensed staff and unlicensed staff). On 9/23/25 at 4:05 p.m., an observation of the posted nurse staffing information was conducted. The posting was dated 9/19/25. At this time, ASM (administrative staff member) #1 (the executive director) stated the staffing coordinator resigned the previous day. On 9/25/25 at 10:45 a.m., an interview was conducted with OSM (other staff member) #8 (the staffing coordinator from a related facility). OSM #8 stated she used to manually complete the nurse staffing information postings but now the postings are generated from the online scheduling system and only document the total number and the actual hours worked by licensed staff and unlicensed staff. In regard to the posting of nurse staffing information, OSM #8 stated the information should be posted each morning, every day. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. The facility policy titled, Nurse Staffing Information Posting documented, The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. No further information was presented prior to exit.

May 2024 39 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident #61 (R61), the facility staff failed to assess the resident to safely leave the facility unsupervised in the community. The resident signed themselves out of the facility unsupervised on 15 occasions. R61 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1), unspecified dementia (2), and major depressive disorder (3). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/30/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented no wandering or behaviors observed. Section GG documented R61 able to ambulate 150 feet independently. The assessment failed to assess R61's ability to maneuver steps or curbs while in the community. The Release of Responsibility for Leave of Absence document for R61 documented the resident signing themselves out on the following dates 8/8, 8/19, 10/3, 10/5, 12/24, 3/5, 3/14, twice on 3/15, twice on 3/24, three times on 5/12, and 5/18. (The year was not documented on all dates). The current physician orders for R61 documented in part the following psychotropic medications ordered, - Amitriptyline HCL (4) oral tablet 50 mg (milligram) Give 1 tablet by mouth at bedtime for depression. Order Date: 07/28/2022. - Buspirone HCL (5) oral tablet 5 mg Give 1 tablet by mouth every 8 hours related to anxiety disorder, unspecified. Order Date: 05/19/2024. - Donepezil HCl (6) tablet 10 mg Give 1 tablet by mouth at bedtime for dementia. Order Date: 06/08/2022. - Lorazepam (7) oral tablet 1 mg Give 1 mg by mouth at bedtime for anxiety. Order Date: 01/16/2024. - Trazodone HCL (8) tablet 50 mg Give 1.5 tablet by mouth at bedtime for depression. Order Date: 02/10/2023. The physician orders failed to evidence an order for R61 to be allowed to leave the facility unsupervised to the community. The progress notes for R61 documented in part, - 5/11/2024 12:24 Resident takes other residents things without asking. This writer found six cigarettes and a lighter in her room this morning. Resident has a nicotine patch on and has been educated multiple time she can't smoke with the patch on . yet resident continues to sneak cigarettes. Will talk to mngt (management) Monday. Review of R61's clinical record documented an elopement risk evaluation dated 8/10/2023 which documented no risk for elopement. The assessment failed to evidence an assessment of the residents ability to safely leave the facility unsupervised in the community. A BIMS assessment dated [DATE] documented R61 being cognitively intact. The assessment failed to evidence the residents ability to safely leave the facility unsupervised in the community. The comprehensive care plan for R61 documented in part, [Name of R61] has impaired cognitive function r/t (related to) dementia. Date Initiated: 06/16/2022. The care plan further documented, [Name of R61] has behaviors of stealing other resident's and staff belongings, and leaving building without signing out, going through linen cart and going into ice cart after being educated on infection control policies. Date Initiated: 01/04/2023. On 5/21/2024 at 8:42 a.m., an interview was conducted with R61 in their room. R61 stated that there were days that they left the facility to go to the dollar store and grocery store. R61 stated that they walked to the front entrance to meet the bus and it carried them to the store where they bought what they needed and then they rode the bus back to the facility. R61 stated that they signed a paper at the nurses station when they left the building and told the nurse where they were going. R61 stated that the facility had put a bracelet on them the night before and told them that the state wanted them to track where they were and they did not think it was right and it went against their religious beliefs so they had taken it off. R61 ended the interview at that time. On 5/20/2024 at approximately 5:12 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that in order for a resident to independently leave the facility, the resident should not be at risk for wandering, be alert and oriented times four (to person, place, time and situation), be aware of their own safety, and sign out. RN #3 further stated that there was not a specific assessment regarding a resident's ability to safely and independently leave the facility. On 5/20/2024 at 5:41 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator, ASM #4, the director of sales and marketing, ASM #5, the regional director of clinical services, and ASM #6, the vice president of operations. ASM #1 stated an elopement risk assessment was completed for residents and if residents were not at risk for elopement, were alert and oriented, and know what was going on, they had the right to sign themselves out and could leave the facility. ASM #5 stated that she did not think the elopement risk assessment addressed safety, but would look into it. ASM #5 stated that the staff also looked at the residents' BIMS score and whether the resident was alert and oriented. ASM #5 was not able to describe how the BIMS assessment correlated to a residents' function at a higher level of safety awareness but stated she would find out. ASM #1, ASM #4, ASM #5, and ASM #6 were made aware of the concern for immediate jeopardy at that time. A bcat (brief cognitive assessment tool) was completed for R61 on 5/20/2024 by OSM (other staff member) #3, occupational therapist. The assessment documented a score of 23, out of a possible 50, indicating R61 presented with moderate to severe dementia. The therapy screen attached documented in part, . Comments (optional): Screen specific for cognitive using BCAT score: 23/50. Eval (evaluation) orders requested: None . On 5/21/2024 at 9:44 a.m., an interview was conducted with OSM #3, occupational therapist. OSM #3 stated the bcat was a measure of cognitive function that broke down different categories like verbal recall and executive functioning. OSM #3 stated R61's bcat score showed that they were in the dementia category. He stated that R61 was not on current therapy caseload so the only assessment completed for them was the bcat. He stated that he did not perform an assessment of R61's physical ability to leave the facility as ambulation was typically handled by physical therapy. He stated that his understanding was that administration wanted him to assess the residents requested for their cognitive ability to be safe to leave the facility alone. He stated that based on R61's bcat score he was torn to make a decision and there were different types of tests that could be done. He stated that the physical assessment still needed to be completed for R61 to make the final decision. On 5/21/2024 at 10:15 a.m., an interview was conducted with RN #1. RN #1 stated she did not have a definitive answer to say how the staff assess residents to determine if they could safely and independently leave the facility unsupervised. RN #1 stated that she had not personally seen R61 leave the facility but felt that the resident was not completely alert and oriented. She stated that if R61 left the facility unsupervised they could forget where they were going and forget how to get back and feared that R61 would take anything that anyone would offer them. She stated that R61 had a habit of stealing things that did not belong to them and snuck cigarettes into their room. She stated that there was a risk of R61 getting burned, causing a fire, getting on the bus and getting lost, getting dehydrated, falling or getting abducted. RN #1 stated there was about an 80 percent likelihood that R61 would sustain serious harm, serious injury, or a serious adverse outcome while out in the community unsupervised and it was just a matter of time. On 5/21/2024 at 10:31 a.m., ASM #1 stated that on 5/20/2024, R61 was given cognitive and physical function tests to determine if the resident could safely and independently leave the facility unsupervised. ASM #1 stated R61's mind was not as good as it should be but physically the resident was okay. ASM #1 stated R61 had not been deemed to safely and independently leave the facility unsupervised. On 5/21/2024 at 11:00 a.m., an interview was conducted with ASM #3, the nurse practitioner. ASM #3 stated that the company allows some residents to go out and take trips by themselves but she had never assessed a resident to determine if the resident could safely and independently leave the facility unsupervised. No further information was provided prior to exit. Reference: (1) chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (3) major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. (4) Amitriptyline is used to treat symptoms of depression. Amitriptyline is in a class of medications called tricyclic antidepressants. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682388.html#why (5) Buspirone is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety. Buspirone is in a class of medications called anxiolytics. It works by changing the amounts of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a688005.html#why (6) Donepezil is used to treat dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) in people who have Alzheimer's disease (AD; a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities). Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function (such as memory, attention, the ability to interact with others, speak, think clearly, and perform regular daily activities) by increasing the amount of a certain naturally occurring substance in the brain. Donepezil may improve the ability to think and remember or slow the loss of these abilities in people who have AD. However, donepezil will not cure AD or prevent the loss of mental abilities at some time in the future. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a697032.html#why (7) Lorazepam is used to relieve anxiety. Lorazepam is also used to treat insomnia caused by anxiety or temporary situational stress. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682053.html#why (8) Trazodone is used to treat depression. Trazodone is in a class of medications called serotonin modulators. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681038.html#why 6. For Resident #47 (R47), the facility staff failed to address and/or reevaluate the plan of care after falls on 3/11/24 and 3/25/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment documented R47 having two falls without injury since the previous assessment. The clinical record for R47 documented in part, - A Change in Condition dated 3/11/2024 documenting in part, .Found lying on right side of bed on the floor. No injuries. VS (vital signs) attempted several times but resident was combative, slapping and scratched this writer . Primary Care Clinician Notified: [Name of nurse practitioner] 03/11/2024 08:30 . Name of Family/Health Care Agent Notified: No family to contact . - A Change in Condition dated 3/25/2024 documenting in part, .Resident found lying on the floor to the left of her bed. No injuries noted. Resident hitting, pinching and spitting at staff while attempting to put her back to bed. Resident assisted to WC (wheelchair) . Primary Care Clinician Notified: [Name of nurse practitioner] 03/25/2024 10:00 . Name of Family/Health Care Agent Notified: No family to call . - A Change in Condition dated 3/25/2024 documenting in part, .Slid self out of WC onto floor right after being sat at nurses station post fall in resident room. No injuries noted . Primary Care Clinician Notified: [Name of nurse practitioner] 03/25/2024 10:00 . Name of Family/Health Care Agent Notified: No family to call . The comprehensive care plan for R47 documented in part, [Name of R47] is at risk for falls r/t (related to) dementia, confusion, deconditioning, gait/balance problems, unaware of safety needs. Date Initiated: 01/08/2024. Revision on: 01/10/2024. The comprehensive care plan failed to evidence a review or revision after the falls on 3/11/2024 and 3/25/2024. The clinical record failed to evidence fall investigation or a review of the plan of care after the falls on 3/11/2024 and 3/25/2024. On 5/21/2024 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator, for the fall investigations for the falls on 3/11/2024 and 3/25/2024, none were provided. On 5/21/2024 at 3:55 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that when a resident had a fall the staff should review the current fall interventions in place and initiate a new intervention if deemed necessary, review the medications for possible contributing causes, provide frequent rounding and review the falls. She stated that the nurse was responsible for making the decision on adding any intervention and updating the care plan but they had not being doing it consistently. She stated that the care plan should at least be reviewed and a fall risk assessment completed. On 5/22/2024 at 9:13 a.m., an interview was conducted with LPN (licensed practical nurse) #6, MDS coordinator. LPN #6 stated that after a fall the care plan was reviewed and revised as needed. She stated that falls were discussed daily in the team meeting and nursing did a risk assessment to determine potential contributing factors of the falls so new interventions could be put into place. On 5/23/2024 at approximately 3:15 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM (other staff member) #11, the director of social services were made aware of the findings. No further information was obtained prior to exit. 7. For Resident #25 (R25), the facility staff failed to implement interventions to prevent future injuries after experiencing a fall on 1/29/24. On 4/15/24, R25 experienced a fall and was transferred to the hospital for evaluation and treatment of an injury he sustained in a fall that evening. R25 was admitted to the facility with diagnoses including cerebral palsy and quadriplegia. A review of R25's clinical record reveals he experienced a fall on 1/29/24. A review of R25's care plan dated 5/15/24 (including a history of revisions for the past year) revealed no evidence of review or revision after the fall on 1/29/24. A review of R25's progress notes revealed the following: 4/15/24 at 6:01 p.m. This Writer was walking passed (sic) resident room and saw him sitting in his wc (wheelchair. Approximately 10 minutes later this writer was going up the hall to help another resident and he was found lying on the floor on his abdomen with his head to the right side of bodynet to his bed. He had a laceration to his scalp and a towel was placed on the floor mat .Resident does have contractures to his bles (bilateral lower extremities. This writer tried to touch his left shoulder and he cried out in pain. Resident was not moved at this time and 911 was called .Resident transferred to [name of local hospital] for evaluation of fall/laceration. 4/15/24 at 11:30 p.m. Resident returned to facility via stretcher .Dx (diagnosis): Ground level fall, abrasion of scalp. No distress noted. A review of the emergency room record for R25 dated 4/15/24 revealed, in part: EMS (emergency medical service) reports nursing home believes he slid out of his wheelchair, abrasion noted to the occipital scalp. No evidence of additional traumatic injury. CT (computed tomography) negative. Laceration/abrasion not requiring repair. On 5/15/24 at 1:33 p.m., RN (registered nurse) #1 was interviewed. When asked the process to be followed after a resident falls, she stated the staff should attempt to find out how the resident fell. She stated the electronic medical record has specific post-fall documentation that need to be completed. She stated the care plan should be reviewed, and new interventions should be put in place to prevent injuries from future falls. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated after a resident falls, the team reviews all falls the next morning in the clinical meeting. This meeting addresses all aspects of the fall, including how and where it occurred, and new interventions that should go on the resident's care plan. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. 3. For Resident #58 (R58), the facility staff failed to thoroughly assess the resident to determine if the resident could safely and independently leave the facility unsupervised. The resident left the facility unsupervised on multiple occasions. R58 was admitted to the facility on [DATE]. R58's diagnoses included but were not limited to cerebral palsy (1), suicidal ideations, bipolar disorder (2), epilepsy (3), muscle weakness, and a history of falling. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/15/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section GG documented R58 used a wheelchair and/or scooter. A review of R58's clinical record revealed the following current physician's orders for psychotropic medications: 5/25/23-divalproex sodium (4) 250 mg (milligrams), three tablets two times a day for depression. 5/25/23-sertraline (5) 100 mg, one tablet once a day for depression. 6/21/23-trazodone (6) 50 mg at bedtime for insomnia. 4/5/24-risperdal (7) 0.5 mg two times a day for agitation/aggressive behaviors. 2/7/24-buspirone (8) 10 mg, one tablet two times a day for depression/anxiety. Further review of R58's clinical record revealed a physician's order dated 5/26/23 that documented, May go out on LOA (leave of absence) with meds. The order did not specify if R58 could safely and independently leave the facility unsupervised. A nurse's note dated 5/26/23 documented, Resident propelling in w/c (wheelchair), up and down hallways. He stated he was his own POA (power of attorney), and he wanted to get out of the facility to go explore [NAME]. Was informed he could not go outside on his own. A nurse's note dated 5/27/23 documented, This patient went to [NAME] to buy tobacco products. The sheriff's office called this facility due to a passerby spotting patient. This nurse took the phone call. Patient confirmed to be a patient of our facility. Once patient returned to facility, patient stated that he had forgotten to notify staff of his LOA (leave of absence) due to being new to the facility and being new to facility protocols. A nurse's note dated 5/30/23 documented, Resident verbally expressed desire to go out by himself. Resident was educated about ShenGo (public bus) availability. Resident was educated on safety and DON (director of nursing), NP (nurse practitioner), and his Nurse expressed concerns about him going out on his own. Resident is his own RP (responsible party) and makes his own decisions; he reminded DON of this. Resident said 'I know how to cross the street. Look who you are talking to. I am (name) and I do this all the time.' Resident signed himself out and went to [NAME]; he said, 'I will be back.' DON offered for one of us to go shopping for him, he refused. Nurse, NP aware. A nurse's note dated 6/7/23 documented, Resident went to [NAME] last pm, This morning a [sic] empty bottle of [NAME] Bootlegger was found on the front porch in the mulch, this is some type of alcohol beverage sold at the [NAME] store. Resident denied that he had drank it. Educated on the effects of alcohol with the medications that he is taking. NP made aware of findings. Will monitor resident for any concerns. An elopement risk evaluation signed by a nurse on 6/21/23 documented R58 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors, wandered oblivious to safety needs, had a history of elopement, had the ability to exit the facility and was at risk for elopement. The evaluation failed to document an assessment to determine if R58 could safely and independently leave the facility unsupervised. A nurse's note dated 7/13/23 documented, Resident was going to go out for a stroll and was struggling to get around and brought back in by an employee after dispatch called reporting he was falling out of the chair. A nurse's note dated 9/27/23 documented, Staff went to change and assist resident to bed for the night. Patient reeked of alcohol had urinated on himself in the wheelchair, slurred speech, unable to assist staff to help him into bed. Patient stated to staff I have only been drinking mt dew. Three 24oz cans of 8% alcohol found in resident's room. Educated resident on the interactions that could occur with mixing alcohol with his medication. 2 staff assisted resident into bed changed his clothes and brief placed pillows under sheet to help assist resident from rolling out of bed, fall mat placed on the floor and bed put in low position. Administrator contacted about behavior. A nurse's note dated 10/14/23 documented, On 10-13-2023 resident was in bed at 7pm told nurse he wasnt [sic] feeling well and he thought he might have a seizure, nurse told him to stay in bed so he would be safe if he had a seizure, VSS (vital signs stable) WNL (within normal limits), no s/s (signs or symptoms) of seizure activity noted, nurses on north hall were giving report at the nursing station, this nurse saw the resident up in his wheelchair propelling self-down hall towards the front lobby, this nurse got a call from the rescue squad saying that the resident called 911 and wanted to go to the ER (emergency room), went to ER and told the DR (doctor) in the ER that he took 11-12 hits off a CBD (cannabidiol) vape pen and thought he was overdosing, no new orders, ER gave him a packed lunch and sent him back at 10pm, resident went to bed no further issues noted, call bell in reach. A nurse's note dated 5/2/24 documented, Resident checked himself out this am to go to the store he came back and appeared to be intoxicated unable to raise his head and slurred speech resident put back to bed at his requested [sic] np ware [sic]. A nurse's note dated 5/2/24 documented, Resident left the building without signing out and went to pizza [NAME]. A nurse's note dated 5/3/24 documented, Resident left the building without signing himself out and it was reported by the activities director that when he came back into the building his breath smelled of alcohol and he appears to have slurred speech and unable to hold his head up. A nurse's note dated 5/3/24 documented, Resident noted to be in another resident's [sic] conversing with resident and leaning heavily to the left with difficulty sitting erect. There is a noted odor of alcohol when the resident converses with this nurse. This nurse also noted alcoholic beverage 'Four Loko Sour Apple' on residents' [sic] lap. Resident reports to this nurse the 'Four Loko' is his. He reports he has already consumed #2 cans. Vitals obtained: 120/78 (blood pressure), 82 (pulse), 98.8 (temperature), 97% (oxygen level) RA (room air), 16 even and unlabored (respirations). NP notified. T/O (Telephone Order) Monitor resident. ED (Executive Director) aware. DON aware. Nursing will continue to monitor. A note signed by an advanced practice registered nurse dated 5/6/24 documented, PCC (name of computer system containing R58's clinical record) does report h/o (history of) suicidal ideations with comment of rolling into traffic in his wheelchair .PCC reports seen in ER on [DATE] for illict [sic] drug OD (overdose) when he was out of facility over the weekend . Further review of nurses' notes for the duration of R58's stay revealed documentation that R58 had presented with seizures, multiple falls, and suicidal ideations while at the facility. Further review of R58's clinical record failed to reveal an assessment to determine if the resident could safely and independently leave the facility unsupervised. A release of responsibility for leave or absence form revealed R58 signed out on 12/25, 3/1, 3/17, 3/24/24, 4/5, 4/11, 4/15, 4/28, 5/2, 5/8, 5/10, 5/11, 5/13, 5/17, and 5/18 (the year was not documented on all dates except for 3/24/24). On 5/20/24 at 5:08 p.m., R58 was observed in a manual wheelchair on the facility front porch and an interview was conducted with the resident. R58 stated he goes out of the facility by himself and leaves the property pretty much every day. R58 stated he has to sign out before he leaves, and he goes to places such as the tobacco shop and up the hill where the fast-food restaurants are. R58 stated he doesn't always wheel himself in the wheelchair when he is off the property. R58 stated that sometimes, people he doesn't know stop and assist him. On 5/20/24 at approximately 5:12 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that in order for a resident to independently leave the facility, the resident should not be at risk for wandering, be alert and oriented times four, be aware of their own safety, and sign out. RN #3 further stated that there was not a specific assessment regarding a resident's ability to safely and independently leave the facility. On 5/20/24 at 5:41 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator), ASM #4 (the director of sales and marketing), ASM #5 (the regional director of clinical services), and ASM #6 (the vice president of operations). ASM #1 stated an elopement risk assessment is completed for residents and if residents are not at risk for elopement, are alert and oriented, and know what is going on, then they need to sign themselves out and can leave the facility. ASM #5 stated she did not think the elopement risk assessment addressed safety, but she would have to look at it. ASM #5 stated staff also look at residents' BIMS and if residents are alert and oriented. ASM #5 was not able to describe how the BIMS correlates to residents' function at a higher level of safety awareness but stated she would find out. ASM #1, ASM #4, ASM #5, and ASM #6 were made aware of the above concern and immediate jeopardy. A bcat (brief cognitive assessment tool) was completed for R58 on 5/20/24. The assessment documented a score of 40, out of a possible 50, indicating R58 presented with mild cognitive impairment. An occupational therapy treatment note dated 5/20/24 documented, Pt (Patient) seen to assess use of manual wc (wheelchair) outdoors. Pt able to manipulate wc to access sidewalks and ramps. Pt had difficulty on downhill sidewalk due to sidewalk tilting side to side as well as slanted down hill. Pt able to manage using BUE (bilateral upper extremities) to propel wc up hill towards the facility. Pt able to access ramp at front of facility after crossing the street . On 5/21/24 at 9:44 a.m., an interview was conducted with OSM (other staff member) #3 (the occupational therapist who documented the 5/20/24 assessments). OSM #3 stated the bcat is a measure of cognitive function that breaks down different categories like verbal recall and executive functioning. OSM #3 stated R58's bcat score was almost perfect and R58 did pretty good on the immediate recall portion of the bcat but had poor scores on the portions of visuospatial, memory of objects, and executive functioning. OSM #3 stated R58 has gone to Walmart and [NAME] by himself and has been found in the middle of the street. OSM #3 stated he completed an assessment of R58 in the wheelchair outside of the facility. OSM #3 stated during the assessment, R58 went down the hill and up the hill towards the hospital (adjacent to the facility property), R58 propelled up the street, but did not cross a street. OSM #3 stated physically, R58 could complete most of his assessment but sometimes R58 is under the influence of alcohol and marijuana gummies, and this delays his functioning. OSM #3 stated R58 enjoys people helping him, gets strangers to push him, and asks strangers for money. OSM #3 stated there were instances where R58 had been observed out in the middle of the road. OSM #3 stated there was no issue if R58 goes to the end of the road, but the resident is going farther. On 5/21/24 at 10:15 a.m., an interview was conducted with RN #1. RN #1 stated she didn't really have a definitive answer how staff assess residents to determine if they can safely and independently leave the facility unsupervised. RN #1 stated R58 is alert, oriented, and able to make his own decisions so to her knowledge, as long as he signs out, the staff doesn't have a say in where the resident goes. RN #1 stated R58 had gotten kicked out of [NAME] because he steals, and one time, a CNA (certified nursing assistant) had to walk from the facility to 7-11 to assist R58 because he got stuck. RN #1 further stated that R58 goes to the dollar store on the other side of town, and she could not tell the number of times people from the community have brought the resident back to the facility. In regard to the risks R58 faces while out in the community unsupervised, RN #1 stated R58 could get abducted, could break a bone because of a fall, could sustain a heat stroke, could sustain sunburn, could have a seizure, or could become dehydrated. RN #1 stated R58 has been seen out in the middle of the road in the community and obtains alcohol, vape pens and marijuana while out in the community. RN #1 stated there was a 90 percent likelihood that R58 would sustain serious harm, serious injury, or a serious adverse outcome while out in the community unsupervised and it was just a

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #85 (R85), the facility staff failed to initiate treatment for pressure injuries in a timely manner. R85 was admitted to the facility on [DATE]. A weekly skin integrity review dated 5/10/24 documented R85 presented with the following pressure injuries: -an unstageable pressure injury (1) on the right elbow. -an unstageable pressure injury on the coccyx. -an unstageable pressure injury on the right buttock. -a stage three pressure injury (1) on the left buttock. Further review of R85's clinical record revealed treatment for the right elbow, coccyx, and right buttock was not initiated until 5/11/24 and treatment for the left buttocks was not initiated until 5/15/24. The physician's orders were: -5/11/24-cleanse right elbow eschar (dead skin tissue) with normal saline and cover with a dry dressing every Tuesday, Thursday, and Saturday. -5/11/24-cleanse sacrum (coccyx) with wound cleanser, pat dry, pack with 2x2 gauze moistened with 1/4 strength Dakin's (wound cleanser) and cover with dry dressing every Tuesday, Thursday, and Saturday. -5/11/24- cleanse right upper buttock wound with wound cleanser, pat dry, moisten gauze with 1/4 strength Dakin's and cover with dry dressing every Tuesday, Thursday, and Saturday. -5/15/24- cleanse left buttocks with wound cleanser, pat dry, moisten gauze with 1/4 strength Dakin's and cover with a dry dressing every Tuesday, Thursday, and Saturday. On 5/21/24 at 4:01 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that when a resident is admitted , he or she should have a skin assessment within 24 hours of admission and treatment for pressure injuries should be implemented right aware when the wounds are found. RN #4 stated the nurses should place a treatment order in the computer system based on the facility standing orders and she texts the wound care nurse practitioner for orders. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess, monitor and/or implement treatment for pressure injuries for two of 43 residents in the survey sample, Residents #45 and #85. For Resident #45, the facility staff failed to implement treatment for a pressure injury (1) and the wound became larger in size, thus causing harm to the resident. The findings include: 1.a. For Resident #45 (R45), the facility staff failed to implement treatments for a pressure injury on the left lateral thigh. The Admission/readmission Data Collection form dated 5/1/2024, documented in part, Skin: Left thigh (rear) Pressure injury 04/28/24. The Braden Scale for Predicting Pressure Sore Risk, dated 5/1/24, documented the resident scored a 16. A score of 16 indicated the resident was at risk for developing pressure injuries/sores. Review of the physician orders failed to evidence an order for the treatment of the left thigh pressure injury. The Weekly Skin Integrity Review dated, 5/14/24, documented in part, Left thigh (rear) lateral abrasion 4x3x0 (centimeters). The wound care specialist notes dated 5/15/24, documented in part, Staff noticed 2 open areas, one on pt's (patient's) left lateral thigh they think from transfer with a Hoyer due to pad rubbing .PLAN: Left lateral thigh (+) partial thickness ulceration that measures 4.0 x 3.0 x 0.2 cm. Wound base 100% pale pink moist tissue with bioform before debridement, 100% pink/red moist tissue after. Edges adherent to wound base, scant non-odorous serous drainage, peri wound without erythema, no induration or cellulitis. Patient does demonstrate evidence of pain when area is palpated, subsides with care .Wound to left lateral thigh as follows: Cleanse with wound cleanser or NS (normal saline), pat dry. Apply xeroform to wound bed. (TX (treatment) for moist wound healing and/or autolytic debridement). Cover with dry dressing. Change dressing QD (every day) and as needed for saturation or soilage. Review of the physician orders and the TAR (treatment administration record) failed to evidence the above treatment orders had been implemented. Observation was made of R45 with the wound care specialist, administrative staff member (ASM) #7 on 5/22/24 at 8:43 a.m. ASM #7 stated there was no dressing in place on the left lateral thigh and the wound was weeping onto the wheelchair. The wound measured 5.0 x 6.0 x 0.2 cm. When asked if the wound got worse since the previously week because there was no treatment order in place for this wound, ASM #7 stated, absolutely. Review of the resident's care plan failed to evidence documentation for pressure injuries. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. The thigh wound was found on 5/14/24 and the wound care specialist saw the resident on 5/15/24 and made recommendations for treatment to the thigh wound. When asked how those orders get put into the medical record, RN #4 stated she puts them in. Informed RN #4 that there were no treatment orders in place for the thigh wound. RN #4 was asked if she was the only one putting in orders, RN #4 stated, generally. The facility policy, Skin and Wound, documented in part, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries. Process: Pressure Injury Prevention: 1. Residents's skin will be evaluated upon admission/readmission and documented in the medical record. 2. Braden Risk Evaluation will be completed upon admission/readmission, weekly for 4 weeks, quarterly and with a signbificant change in condition. 3. Nurse to complete skin evaluation weekly and prior to transfer/discharge and doucment in the medical record. 4. CNA (certified nursing assistant) to complete skin observations and report changes to Nurse. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services were made aware of the concern for harm on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. 1.b. For Resident #45, the facility staff failed to implement the wound care specialist recommendations for treatment in a timely manner for the right upper back wound. There was a delay of four days to implement the treatment. The Admission/readmission Data Collection form dated 5/1/2024, failed to evidence documentation of the right upper back wound. The Weekly Skin Integrity dated 5/14/24 documented in part, Site: right upper back stage 3 (2) PI (pressure injury) 5x10x0.2 Notes: Wound care currently seeing weekly. Device associated PI. There were no weekly skin assessments completed between 5/1/24 and 5/14/24. The Pressure Ulcer Wound Rounds dated, 5/15/24, documented in part, Right upper back, pressure: length 5 cm.; width 10 cm., depth 0.2 cm. Stage III (3). The wound care specialist notes dated 5/15/24, documented in part, Staff noticed 2 open areas .a wound at pt's right upper back they think is from the back of his wheelchair .Right upper back (+) full thickness ulceration that measures 5.0 x 10.0 x 0.2 cm. Wound base 20% intact, 40% granular, 40% thin slough before debridement, 20% intact, 60% granular, 20% thin adherent slough after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration or cellulitis. Patient does demonstrate evidence of pain when area is palpated, subsides with care Wound care to right upper back as follows: Cleanse with normal saline or wound cleanser, pat dry. Apply alginate to wound bed. cover with foam dressing. (tx for moist wound healing and/or autolytic debridement). Change dressing every day and as needed for saturation or soilage. Observation was made of R45 with the wound care specialist, (ASM) #7 on 5/22/24 at 8:43 a.m. The right upper back wound measured 2 cm. x 10 cm. x 0.2 cm. ASM #7 stated that the wound did improve as demonstrated by a decrease in area. The physician orders dated 5/19/24, four days after the wound specialist treated the resident, documented, Cleanse area to right upper back with normal saline or wound cleanser, pat dry. Apply calcium alginate to wound bed, cover with foam dressing (tx for moist wound healing and/or autolytic debridement). change dressing every day and as needed for saturation or soilage one time a day for wound care. Review of the May 2024 TAR documented the above order as starting on 5/19/24. Review of the comprehensive care plan failed to evidence documentation of the right upper back wound or pressure wounds. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. The upper back wound was found on 5/14/24 and the wound care specialist saw the resident on 5/15/24 and made recommendations for treatment to the upper back wound. When asked how those orders get put into the medical record, RN #4 stated she puts them in. Informed RN #4 that the order did not get put into the physician orders until 5/19/24. When asked why they didn't get put into place, RN #4 stated, she was on the medication cart. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. References: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for one of 43 residents in the survey sample, Resident #17. The findings include: 1. For Resident #17 (R17), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/21/2024, the resident scored eight out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment coded R17 as requiring substantial/maximal assistance with toileting and bed mobility. It further documented R17 not having any impairment in the upper extremities. On 5/20/2024 at 3:40 p.m., an observation was made of R17 in their room. R17 was observed in bed, the call bell was observed lying in the recliner located to the left of R17's bed. At this time, an interview was attempted with R17. When asked if they could reach their call bell, R17 stated, I don't know. Additional observations on 5/21/2024 at 8:52 a.m. revealed the call bell located in the position described above. Observation of the call bell on 5/22/2024 at 9:18 a.m. revealed the call bell clipped to the sheet with the press button for resident use located at the top of the bed above R17's head. The comprehensive care plan for R17 documented in part, [Name of R17] has an ADL (activities of daily living) self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Limited Mobility. Date Initiated: 04/26/2024. Under Interventions it documented in part, .Encourage the resident to use bell to call for assistance. Date Initiated: 04/26/2024 . On 5/22/2024 at 9:18 a.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that the call bell should be placed within the resident's reach at all times. She stated that the purpose of this was to be where the resident could get to it to call for assistance. On 5/22/2024 at 9:55 a.m., an interview was conducted with CNA #6. CNA #6 stated that the call bell should be placed across the resident or within reach at all times. She stated that if the resident needed help they needed to be able to ring the call light at all times. She stated that she worked with R17 and the resident was able to use the call bell. On 5/22/2024 at 10:05 a.m., CNA #6 observed R17's call bell clipped to the mattress above R17's head and stated that the call bell was not within reach and should be placed down by their hand so they were able to access it and press the button if they needed anything. The facility policy, Call Light effective 11/30/2014 failed to evidence guidance on placing the call bell within reach of the resident. On 5/22/2024 at approximately 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect one of 43 residents in the survey sample, Resident #136, from verbal abuse from another resident, Resident #38. The findings include: For Resident #136, the facility staff failed to protect him from a verbal threat by Resident #38 on 4/14/24. Resident #38: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/23/24, the resident scored a 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section E - Behaviors, the resident was coded as having verbal behavioral symptoms direct toward others (e.g., threatening others, screaming at others, cursing at others). This behavior occurred one to three days during the look back period. The nurse's note dated, 4/15/24 at 12:39 a.m. documented, Staff responded to shouting in this room. This resident was in his w/c (wheelchair) at side of roommate's bed threatening to hit him with his fist drawn back. Roommate was moved to vacant room [ROOM NUMBER]A. The comprehensive care plan dated, 7/24/23 documented in part, Focus: (R38) has behaviors (verbal - yelling, swearing, threatening other residents) r/t (related to) dementia. The Interventions documented in part, Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determined underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Resident #136: On the most recent MDS assessment, an admission assessment, with an assessment reference date of 4/15/24, the resident scored a 14 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. Review of Resident #136 (R136)'s clinical record, failed to evidence the above incident. There were no revisions to the comprehensive care plan. The only indication of the incident is the room change noted in the Census tab that documented R136 moved rooms. A review of facility synopses of events submitted to the State Agency between 4/20/23 through 5/22/24, revealed no information related to Residents #136 and #38 altercation. An interview was conducted with OSM (other staff member) #11, the director of social services, on 5/22/24 at 9:38 a.m. When asked if a resident threatens to hit another resident, is that a concern, OSM #11 stated that is verbal abuse. OSM #11 further stated that is an allegation of verbal abuse and an investigation must be initiated and a report to the State Agency has to be completed. She stated the first thing is to separate the residents, offer psychological services if needed. When asked who reports these incidents to you, OSM #11 stated, anyone, the floor staff, the CNAs (certified nursing assistants), nurses, activity director, anyone that witnesses the occurrence. Were you aware of the incident between R38 and F136, OSM #11 stated she was not aware of that incident. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 5/22/24 at 11:08 a.m. When asked if she reports and investigate an allegation of verbal abuse between residents, ASM #1 stated if a resident has an argument with another resident, she doesn't report it. The above incident was reviewed with ASM #1, and asked why it wasn't reported. ASM #1 stated she would have to have knowledge of it to report it. She stated she was not aware of this incident. ASM #1 was asked if an allegation of abuse happens in the middle of the night, how is she made aware of it, ASM #1 stated they (the staff) call me. The nurse didn't call her regarding this incident. An interview was conducted with LPN (licensed practical nurse) #5 on 5/22/24 at 2:33 p.m. When asked if a resident threatens another resident with a raised fist, what do you do? LPN #5 stated, first you separate them and make sure every one is safe. When asked if she needs to notify anyone, LPN #5 stated you call the director of nursing, social services and the administrator. LPN #5 was asked if an incident such as this is reportable, LPN #5 stated, yes, that's abuse. The facility policy, Abuse, Neglect, Exploitation & Misappropriation, documented in part, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Verbal abuse may be considered a form of mental abuse. Verbal abuse included the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend or disability. Mental and Verbal abuse includes but are not limited to: Threatening residents .Protection: The resident will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment as appropriate. Increased supervision of the alleged victim and resident. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator .Provide the resident with emotional support and counseling during and after the investigation, if needed. Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately , but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not results in serious bodily injury, to the Administrator and to other officials in accordance with State law .Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. ASM #1, ASM #6, the vice president of operations, ASM #5, the regional director of clinical services, and OSM #11 were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to protect a resident from misappropriation of medication for one of 43 residents in the survey sample, Resident #64. The findings include: For Resident #64 (R64), the facility staff failed to protect him from misappropriation of his Haldol (1) when the medication was administered to another Resident #17 (R17). A review of R64's clinical record revealed the following order dated 4/3/24: Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter. Give 0.25 ml by mouth every 4 hours as needed for agitation. A review of R64's care plan dated 4/17/24 revealed, in part: The resident has behaviors .r/t (related to) terminal diagnosis .[R64] is on an antipsychotic medication r/t end of life care. Psychosis and terminal agitation. A review of a facility synopsis of events dated 5/13/24 revealed, in part: CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 stated that [R17] was the resident involved in the report, but with the investigation we have identified .[R64] .The allegation was made by a certified nursing assistant that she had knowledge that [LPN #7] was administering medications to .[R17] .to keep them calm, and she was giving them the medication without a physician's order. It was discovered during the investigation that [LPN #7] had administered a medication (Haldol) from [R64] to [R17] due to their behaviors to keep them quiet. The medication is an antipsychotic and was in liquid form. An account of the liquid revealed that 13 mls of the medication were unaccounted for .An internal investigation was started along with the assistance of APS (adult protective services). [LPN #7] (licensed practical nurse) admitted to APS that she had chemically restrained .[R64] without a physician's order .The [name of local police] is involved as well, and criminal charges pending currently .[LPN #7] will be termed from our employment. Attempts to interview LPN #7 during the survey were unsuccessful. On 5/13/24 at 10:50 a.m., OSM (other staff member) #19, an APS case worker was interviewed. He stated LPN #7 had confessed to giving another resident Haldol that belonged to R64. He stated: She said she was doing this almost every night. On 5/14/24 at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on 5/9/24 when she received an email from APS. On 5/14/24 at 1:09 p.m., ASM #2, the director of nursing (DON), was interviewed. She stated she and RN (registered nurse) #4, the former assistant DON (ADON), used R64's MAR (medication administration) to calculate how much Haldol should have been remaining in R64's supply on 5/10/24. They discovered, between two bottles of Haldol, 20 milliliters total of missing medication. On 5/21/24 at 2:54 p.m., CNA #4 was interviewed. She stated she did not recall the exact date, but she remembered standing beside the medication cart talking with LPN #7. LPN #7 was in the process of administering medications to residents on the hall. She stated R17 was yelling, Ma'am! Ma'am! LPN #7 stated something to the effect of oh, she's starting again today. CNA #4 heard LPN #7 say: I am going to take care of it. CNA stated she saw LPN #7 take out a bottle of liquid Haldol, draw some up, and squirt it into a medication cup. LPN #7 took the medication in R17's room. CNA #4 stated when LPN #7 returned to the medication cart, LPN #7 stated: You didn't see anything. On 5/23/24 at 3:15 p.m., ASM #5, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation, revealed, in part: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and/or misappropriation of property .Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident .Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. Employee Misappropriation includes but is not limited to .Diversion of resident's medication(s) including, but not limited to, controlled substances for staff use or gain. No further information was provided prior to exit. References (1) Haloperidol is used to treat psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real). Haloperidol is also used to control motor tics (uncontrollable need to repeat certain body movements) and verbal tics (uncontrollable need to repeat sounds or words) in adults and children who have Tourette's disorder (condition characterized by motor or verbal tics). Haloperidol is also used to treat severe behavioral problems such as explosive, aggressive behavior or hyperactivity in children who cannot be treated with psychotherapy or with other medications. Haloperidol is in a group of medications called conventional antipsychotics. It works by decreasing abnormal excitement in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682180.html.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to prevent a resident from being chemically restrained for one of 43 residents in the survey sample, Resident #17. The findings include: For Resident #17 (R17), the facility staff chemically restrained the resident by administering Haldol (1) from Resident #64's supply to R17 without a physician's order. A review of R17's clinical record, including April and May 2024 physician's orders and MARs (medication administration records) revealed no evidence of an order for Haldol. A review of R17's care plan dated 4/26/24 revealed no information related to the resident's receiving Haldol. A review of a facility synopsis of events dated 5/13/24 revealed, in part: CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 stated that [R17] was the resident involved in the report, but with the investigation we have identified .[R64] .The allegation was made by a certified nursing assistant that she had knowledge that [LPN #7] was administering medications to .[R17] .to keep them calm, and she was giving them the medication without a physician's order. It was discovered during the investigation that [LPN #7] had administered a medication (Haldol) from [R64] to [R17] due to their behaviors to keep them quiet. The medication is an antipsychotic and was in liquid form. An account of the liquid revealed that 13 mls of the medication were unaccounted for .An internal investigation was started along with the assistance of APS (adult protective services). [LPN #7] (licensed practical nurse) admitted to APS that she had chemically restrained .[R64] without a physician's order . Attempts to interview LPN #7 during the survey were unsuccessful. On 5/13/24 at 10:50 a.m., OSM (other staff member) #19, an APS case worker was interviewed. He stated LPN #7 had confessed to giving another resident Haldol that belonged to R64. He stated: She said she was doing this almost every night. On 5/14/24 at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on 5/9/24 when she received an email from APS. On 5/14/24 at 1:09 p.m., ASM #2, the director of nursing (DON), was interviewed. She stated she and RN (registered nurse) #4, the former assistant DON (ADON), used R64's MAR (medication administration) to calculate how much Haldol should have been remaining in R64's supply on 5/10/24. They discovered, between two bottles of Haldol, 20 milliliters total of missing medication. When asked if administering Haldol to a resident who does not have an order for it constitutes chemical restraint, she stated that it does. On 5/15/24 at 11:35 a.m., OSM #20, a member of the local police force, was interviewed. He stated that sometime after 5/3/24, LPN #7 had confessed to him that she administered Haldol to R64 without a physician's order. On 5/21/24 at 2:54 p.m., CNA #4 was interviewed. She stated she did not recall the exact date, but she remembered standing beside the medication cart talking with LPN #7. LPN #7 was in the process of administering medications to residents on the hall. She stated R17 was yelling, Ma'am! Ma'am! LPN #7 stated something to the effect of oh, she's starting again today. CNA #4 heard LPN #7 say: I am going to take care of it. CNA stated she saw LPN #7 take out a bottle of liquid Haldol, draw some up, and squirt it into a medication cup. LPN #7 took the medication in R17's room. CNA #4 stated when LPN #7 returned to the medication cart, LPN #7 stated: You didn't see anything. On 5/21/24 at 3:55 p.m., RN #4, the former ADON, was interviewed. She stated on 5/2/24, CNA #4 came in ASM #2's office to report R17's having received Haldol that was not ordered for her. She stated ASM #2 and LPN #5, the unit manager, were also present for this meeting. She stated CNA #4 reported that a week or two before, R64 was having behaviors, and LPN #7 had told her: You didn't see this. I have something for that. When asked if administering Haldol to a resident who does not have an order for it constitutes chemical restraint, she stated that it does. On 5/22/24 at 5:10 p.m., ASM #5, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. On 5/23/23 at 3:30 p.m., a policy regarding prevention of chemical restraint of residents was requested from OSM #5. No policy was provided. No further information was provided prior to exit. References (1) Haloperidol is used to treat psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real). Haloperidol is also used to control motor tics (uncontrollable need to repeat certain body movements) and verbal tics (uncontrollable need to repeat sounds or words) in adults and children who have Tourette's disorder (condition characterized by motor or verbal tics). Haloperidol is also used to treat severe behavioral problems such as explosive, aggressive behavior or hyperactivity in children who cannot be treated with psychotherapy or with other medications. Haloperidol is in a group of medications called conventional antipsychotics. It works by decreasing abnormal excitement in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682180.html.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide the receiving facility the care plan goals upon transfer for one of 43 residents in the survey sample, Resident #45. The findings include: For Resident #45 (R45), the facility staff failed to provide the receiving hospital the care plan goals upon transfer on 4/17/24. The Transfer from SNF/NF (skilled nursing facility/nursing facility) dated 4/17/24, failed to evidence documentation that the care plan goals were sent with the resident upon transfer. The nurse's notes failed to evidence documentation on 4/17/24 as to if the care plan goals were sent to the hospital with the resident. A request was made for the evidence that the care plan goals were sent with the resident on 4/17/24. ASM (administrative staff member) #1, the administrator, stated on 05/22/24 11:20 a.m. that they could not find evidence that the care plan goals were sent with the resident to the hospital on 4/17/24. An interview was conducted with LPN (licensed practical nurse) #5 on 5/22/24 at 2:33 p.m. When asked what documents are sent with a resident when they are transferring to the hospital, LPN #5 stated, the face sheet, physician orders, MAR (medication administration record), TAR (treatment administration record), transfer form, care plan, bed hold, change in condition form, immunizations, and most recent notes. LPN #5 was asked where you evidence that you sent the care plan, she stated in a chart note. The facility policy, Transfer/Discharge Notification & Right to Appeal, documented in part, Information provided to the receiving provider must include but is not limited to: Comprehensive care plan goals. ASM #1, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #336 (R336), the facility staff failed to implement the resident's baseline care plan. A review of R336's hospital Discharge summary dated [DATE] revealed, in part: Discharge Diagnoses: Acute hypoxic respiratory failure, Acute diastolic heart failure, Pulmonary edema, Pulmonary hypertension .Patient has history of 40 pack per year smoking .She will be discharged home on .fluid restriction, recommendation for daily weight monitoring. A review of R336's baseline care plan dated 4/26/24 revealed, in part: Dietary Orders/Instructions .1500 (milliliter) fluid restrictions. A review of R336's clinical record, including physician orders, April and May 2024 MARs (medication administration records) and TARs (treatment administration records), and progress notes, failed to reveal evidence that R336 was placed on a fluid restriction or daily weights at any time during her stay at the facility. On 5/21/24 at 3:55 p.m., RN (registered nurse) #4 was interviewed. She stated that the care plan drives all the care for each resident. She stated it is up to the whole team to implement the care plan. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the baseline care plan for two of 43 residents in the survey sample, Resident #235, and Resident #336. The findings include: 1. a. For Resident #235 (R235), the facility staff failed to develop, on the baseline care plan, the care for the resident's right foot wounds. The admission assessment completed on 5/8/24, documented the resident had no memory difficulties. The form documented, Concerns on Feet: Yes. Description: Diabetic ulcer on the right foot second toe/right helix. Right foot. Charcot's joint of foot. The baseline care plan dated, 5/8/24 failed to document anything under, Altered Skin Integrity/Potential for. The top of the form documented, Care Plan Areas marked with an X are required to be addressed. Altered Skin Integrity/Potential for had an X marked. Nothing was checked off or written in on this section. An interview was conducted with LPN (licensed practical nurse) #6 on 5/22/24 at 10:11 a.m. When asked when the baseline care plan is developed, LPN #6 stated it is started upon admission. LPN #6 was asked if the resident's foot wounds should be addressed on the baseline care plan, LPN #6 stated, yes. LPN #6 was asked to review R235's baseline care plan. She stated, it's not there and it should be there. The Baseline Care Plan and Summary, documented in part, This document is the baseline care plan and also the summary of the same. Original to be places as part of resident's medical record, copy to resident and/or resident representative. This baseline care plnan will be effective until the development of the Comprehensive Care Plan, which will supersede the baseline care plan. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. 1.b. For Resident #235, the facility staff failed to implement the baseline care plan. The baseline care plan dated, 5/8/24, documented in part, Falls/Safety/Elopement. Under this heading, check marks are documented next to: Will remain free of injury. Will not exit facility unassisted. Will follow facility smoking policy. Observation was made of R235 on 5/20/24 at 2:20 p.m. outside on the porch, with rollator, he was overheard telling the bus driver he wanted to go to (local grocery store). He entered the bus with his rollator onto the wheelchair lift and left facility. An interview was conducted with LPN (licensed practical nurse) #6 on 5/22/24 at 10:11 a.m. When asked when the baseline care plan is developed, LPN #6 stated it is started upon admission. LPN #6 was asked if the care plan should be followed, LPN #6 stated yes. LPN #6 reviewed the baseline care plan for Falls/Safety/Elopement and stated it wasn't followed but may need to be revised. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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2. For Resident #336 (R336), the facility staff failed to follow professional standards of practice for nursing documentation when the resident left the facility against medical advice on 5/5/24. A review of R336's progress notes revealed the following: 5/5/24 at 2:13 p.m. Resident c/o (complained of) pain not relieved by medications currently ordered. Call placed to on call physician at 11:08 (a.m.). Retuned call at 11:30 (a.m.) and new order for Norco (1) obtained. 5/5/24 at 2:16 p.m. Resident left AMA (against medical advice) via stretcher by ambulance accompanied by daughter. Both of these notes were written by RN (registered nurse) #2. Further review of R336's clinical record failed to reveal any additional information regarding the circumstances surrounding R336's discharge. On 5/15/24 at 11:13 a.m., RN #2 was interviewed. When asked what documentation should occur when a resident leaves the facility, she stated the nurse should write a progress note about how they leave, any personal possessions that they take with them, any special medications that have been ordered, and any other relevant details about why the resident is being discharged . She stated without a progress note like this, the resident's clinical record is not complete. When asked to review R336's progress notes and to describe what happened that caused R336 to leave the facility AMA, she stated she could not remember. She stated that according to her note, the resident was having increased pain, and the resident received an order for a stronger pain medication (Norco). When asked if the Norco was effective in relieving the resident's pain, she said she did not remember and the note did not say. She stated she would guess the resident's pain was not relieved, but she had no memory of what happened between 11:30 a.m. when the Norco was administered and 2:15 p.m. when the resident left the faciity on a stretcher. She stated R336's daughter told her that she had called 911 from the resident's room only after the Emergency Medical Service personnel appeared in the hallway outside R336's room. She stated: I can't remember why [R336's daughter] called 911. She stated she agreed that she should have documented in more detail regarding why the resident felt the need to leave the facility AMA. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated she was working the floor on the other side of the building on the day R336 left the facility. She stated she remembered being called to R336's room to speak to the resident's daughter regarding the resident's pain management because the resident was having increased pain, but did not have an order for strong pain medication. She stated she spoke with the resident and the daughter and told them her nurse would contact the physician to get something stronger. She stated RN #2 called the physician and got an order for Norco, and the nurse was able to give the medication immediately from the facility's emergency medication supply. She stated she did not know anything else about what transpired, and did not realize the resident was leaving until she saw the Emergency Medical Services personnel taking the resident out on a stretcher. She stated RN #2 should have written a more detailed note about the circumstances around the resident's discharge, and agreed the resident's record was not complete. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to discharge. Reference (1) Hydrocodone (Norco) is used to relieve severe and persistent pain in people who are expected to need an opioid pain medication around the clock for a long time and who cannot be treated with other pain medications. Hydrocodone extended-release (long-acting) capsules or extended-release tablets should not be used to treat pain that can be controlled by medication that is taken as needed. Hydrocodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain, pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information is taken from the website https://medlineplus.gov/druginfo/meds/a614045.html. Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 43 residents in the survey sample, Residents #58, and #336. The findings include: 1. For Resident #58 (R58), the facility staff failed to clarify a physician's order for alcohol. A review of R58's clinical record revealed a physician's order dated 5/26/23 that documented, May have alcohol once a week. A nurse's note dated 9/27/23 documented, Staff went to change and assist resident to bed for the night. Patient reeked of alcohol had urinated on himself in the wheelchair, slurred speech, unable to assist staff to help him into bed. Patient stated to staff I have only been drinking mt dew. Three 24oz cans of 8% alcohol found in resident's room. Educated resident on the interactions that could occur with mixing alcohol with his medication. 2 staff assisted resident into bed changed his clothes and brief placed pillows under sheet to help assist resident from rolling out of bed, fall mat placed on the floor and bed put in low position. Administrator contacted about behavior. A nurse's note dated 5/2/24 documented, Resident checked himself out this am to go to the store he came back and appeared to be intoxicated unable to raise his head and slurred speech resident put back to bed at his requested [sic] np (nurse practitioner) ware [sic]. A nurse's note dated 5/3/24 documented, Resident left the building without signing himself out and it was reported by the activities director that when he came back into the building his breath smelled of alcohol and he appears to have slurred speech and unable to hold his head up. A nurse's note dated 5/3/24 documented, Resident noted to be in another resident's [sic] conversing with resident and leaning heavily to the left with difficulty sitting erect. There is a noted odor of alcohol when the resident converses with this nurse. This nurse also noted alcoholic beverage 'Four Loko Sour Apple' on residents' [sic] lap. Resident reports to this nurse the 'Four Loko' is his. He reports he has already consumed #2 cans. Vitals obtained: 120/78 (blood pressure), 82 (pulse), 98.8 (temperature), 97% (oxygen level) RA (room air), 16 even and unlabored (respirations). NP notified. T/O (Telephone Order) Monitor resident. ED (Executive Director) aware. DON (Director of Nursing) aware. Nursing will continue to monitor. On 5/21/24 at 3:22 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 was shown R58's physician's order for alcohol. LPN #4 stated she could not explain the meaning of the order because she had never seen an alcohol order written that way. LPN #4 stated she has only seen very specific orders such as for six ounces of beer. LPN #4 stated R58's physician's order for alcohol definitely should be clarified because the order was very gray. LPN #4 stated the order could mean that R58 may go to a restaurant and drink all night long. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. The facility policy titled, Medical Care/Standards of Practice documented, The medical record must be clean, concise, complete and current.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to ensure communication devices were in place for one of 43 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to attempt or provide alternate communication devices for a documented language barrier. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment further documented R47 having a preferred language of Korean and wanting or needing an interpreter to communicate with the doctor or health care staff. The assessment further documented R47 having adequate vision and hearing, clear speech, sometimes understood and sometimes able to understand others. On 5/15/2024 at 12:31 p.m., an observation was made of R47 in their room. R47 was observed in bed eating lunch. At that time, an interview was attempted with R47 however the resident could not be understood. On 5/16/2024 at 8:44 a.m., R47 was observed in bed asleep. On 5/20/2024 at 12:14 p.m., R47 was observed sitting in a wheelchair in the hallway near the nurse's station with an overbed table in front of them. Additional observation of R47 at 3:51 p.m. revealed the resident sitting in the hallway near the nurse's station with the overbed table in front of them. On 5/21/2024 at 8:45 a.m., R47 was observed in bed sleeping, at 1:10 p.m., R47 was observed sitting in a wheelchair in the hallway near the nurse's station with an overbed table in front of them. There were no translation sheets or communication devices observed in R47's room or available for R47 while at the hallway near the nurse's station in the wheelchair. Staff were observed speaking English to R47 when needed, R47 was not observed responding verbally to staff. The comprehensive care plan for R47 documented in part, The resident is specify: (dependent) on staff for activities, cognitive stimulation, social interaction r/t (Japanese Speaking), AEB (as evidenced by) (Translation sheets available through activity department/interpreter) . Date Initiated: 01/18/2024. Revision on: 05/02/2024. The care plan further documented, [Name of R47] has an interpretation need. She speaks English but at times will speak only in Japanese. Date Initiated: 04/25/2024 . Under Interventions it documented in part, Resident's preferred language is Japanese and Staff will contact interpreter when resident is only communicating in Japanese. The progress notes documented in part, - 3/19/2024 02:24 (2:24 a.m.) .Resident can be diff. (difficult) to work with as she does not understand English and communication can be diff . - 3/24/2024 01:10 (1:10 a.m.) .Resident has diff. communication as she does not speak English. Rejects assistance with ADLs (activities of daily living), spits at staff, hits and kicks at staff, yells at staff .Resident can be diff. to work with as she does not understand English and communication can be diff . - 4/19/2024 10:36 (10:36 a.m.) .Resident is alert with confusion. Resident does not speak English . The clinical record failed to evidence documentation of any alternate means of communication with R47 or any attempts made of communication devices used since admission to the facility. On 5/21/2024 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the staff often sat R47 in the hallway near the nurse's station with the overbed table in front of them. She stated that no one spoke R47's language and they did not have a communication board to speak with them. She stated that she had asked several times to get a communication board and was told that someone was working on one. She stated that she felt that R47 was sometimes treated like a piece of furniture placed in the hallway and everyone just walked around them. On 5/21/2024 at 3:05 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that she communicated with R47 using hand gestures. She stated that she had never used any communication devices for R47 and had always used the hand gestures and the resident could say yes and no. On 5/22/2024 at 9:06 a.m., an interview was conducted with OSM (other staff member) #13, activities director. OSM #13 stated that it was very hard to determine what R47 was interested in due to the communication barrier. She stated that she had provided the staff with Japanese translation sheets on 5/21/2024 after someone mentioned it to them. She stated that she communicated with R47 by using hand gestures but it was a little difficult. On 5/26/2024 at 9:26 a.m., an interview was conducted with OSM #14, human resource coordinator. OSM #14 stated that they were the resource at the facility for anyone who did not speak English as their primary language and was not aware of any resident who did not speak English. She stated that there were a lot of resources that they could reach out to and she was still learning but knew there were translators available. She stated that if she was aware that there was a need she was able to assist. On 5/22/2024 at 11:17 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that they had called an interpreter to come in to speak with R47 a while ago and they had told them that the resident had answered all of their questions inappropriately due to their dementia and could speak limited English. She stated that R47 was able to communicate their needs and knew multiple words when they wanted to use them. The facility policy Language Access Plan effective 5/26/2022 documented in part, .The Care Center complies and is consistent with the directives within the ADA (Americans with Disabilities) and Section 504 of the Rehabilitation Act of 1973 which requires: a. Effective communication, including through the provision of auxiliary aids and services . The Care Center disseminates a notice of consumer civil rights to each new resident telling all residents and responsible parties about their rights as well as those with limited English proficiency (LEP) about the right to receive communication assistance. Additionally, a posting designating the ADA Compliance Officer and how to reach out to them identifies another avenue that residents and their responsible parties are able to utilize to communicate the need for assistance. 4. Effective communication with LEP individuals requires the Care Center to have language assistance services in place. The Care Center offers communication in the following forms: a. Oral communication: assistance service may come in the form of in-language communication (bilingual staff member communicating directly in an LEP person ' s language), or interpreting. b. Written communication: translation is the replacement of written text from one language to another; a translator must be qualified and trained in order to be recognized as appropriate . On 5/22/2024 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care to dependent residents for two of 43 residents in the survey sample, Residents #25 and #17. The findings include: 1.a. For Resident #25 (R25), the facility staff failed to transfer him from his bed to his wheelchair on 5/13/24, 5/14/24, and 5/15/24. R25 was admitted to the facility with diagnoses including cerebral palsy and quadriplegia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/26/24, R25 was coded as being completely dependent on staff for chair/bed-to-chair transfers. On the following dates and times, R25 was observed sitting up in his bed: 5/13/24 at 3:33 p.m.; 5/14/24 at 11:51 a.m. and 3:37 p.m.; 5/15/24 at 11:40 a.m. and 2:56 p.m. A review of R25's care plan dated 5/15/24 revealed, in part: [R25] has an ADL self-care performance deficit r/t (related to) cerebral palsy, bilateral upper and lower extremity contractures .The resident is totally dependent on 2 staff for repositioning and turning in bed as necessary .The resident is totally dependent on 2 staff for transferring. On 5/15/24 at 10:29 a.m., CNA (certified nursing assistant) #6 was interviewed. She stated unless a resident's orders or care plan state otherwise, residents should be out of bed for some amount of time during the day. She stated if residents cannot get themselves out of bed, it is up to the facility staff to assist the residents. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated R25 should be out of bed every day. She stated he has a wheelchair custom-made for him, and the staff gets him out of bed every morning into that wheelchair. She stated R25 enjoys going to activities and seeing other residents and staff in other parts of the building. She stated the risks of not getting out of bed include skin breakdown and isolation. On 5/15/24 at 3:37 p.m., RN (registered nurse) #2 was interviewed. She stated R25 required a mechanical lift to be transferred from his bed to the wheelchair. She stated: He has his own chair. It is specifically designed for him and his body. She stated that the resident had not been out of bed at all that day. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Activities of Daily Living, revealed, in part: Policy: To encourage resident choice and participation in activities of daily living .and provide oversight, cuing, and assistance as necessary. No further information was provided prior to exit. 2. For Resident #17 (R17) the facility failed to get the resident dressed in street clothes on 5/13/24, 5/14/24, and 5/15/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/21/24, R17 was coded as requiring substantial/maximal assistance of staff for both upper and lower body dressing. On the following dates and times, R17 was observed dressed in a hospital gown in her room: 5/13/23 at 3:35 p.m. and 5/14/24 at 11:39 a.m. On 5/14/24 at 11:49 a.m., CNA (certified nursing assistant) #8 was observed leaving R17's room after providing care to the resident. When asked if there was reason R17 was not dressed for the day, she stated she was not sure if the resident had any clothes other than the facility hospital gown. She stated when a resident does not have clothes of their own, she goes to Lost and Found and finds clothes there for the resident. She stated: I'm not sure why she is not dressed. I will check on clothes for her. Residents should be dressed each day. On 5/15/24 at 10:29 a.m., CNA #6 was interviewed. She stated residents should be dressed every day. She stated if a resident does not have any clothes in the facility, the CNA should go and look in the clothing donation box in the laundry area and pick out some items for the resident to wear. She stated she was not sure who is responsible for doing it for other residents, but she takes care of it for residents who are assigned to her. On 5/15/24 at 2:01 p.m., OSM #11, the director of social services, was interviewed. She stated if a resident does not come in with clothes, the CNA will ordinarily go to the donation box and usually find things for the resident to wear. She stated: I recommend a resident be dressed and out of bed every day. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide individualized resident centered activities for one of 43 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to provide consistent resident centered activities to accommodate the resident's preferred primary language, documented language barrier and assessed activity preferences. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment further documented R47 having a preferred language of Korean and wanting or needing an interpreter to communicate with the doctor or health care staff. The assessment further documented R47 having adequate vision and hearing, clear speech, sometimes understood and sometimes able to understand others. Section F of the admission MDS with an ARD of 1/13/2024 documented group activities, going outside and listening to music being very important to R47. On 5/15/2024 at 12:31 p.m., an observation was made of R47 in their room. R47 was observed in bed eating lunch. At that time, an interview was attempted with R47 however the resident could not be understood. On 5/16/2024 at 8:44 a.m., R47 was observed in bed asleep. On 5/20/2024 at 12:14 p.m., R47 was observed sitting in a wheelchair in the hallway near the nurse's station with an overbed table in front of them. Additional observation of R47 at 3:51 p.m. revealed the resident sitting in the hallway near the nurse's station with the overbed table in front of them. On 5/21/2024 at 8:45 a.m., R47 was observed in bed sleeping, at 1:10 p.m., R47 was observed sitting in a wheelchair in the hallway near the nurse's station with an overbed table in front of them. There were no translation sheets or communication devices observed in R47's room or available for R47 while at the hallway near the nurse's station in the wheelchair. Staff were observed speaking English to R47 when needed, R47 was not observed responding verbally to staff. On 5/21/2024 at approximately 5:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of activities offered/participation for R47. Review of the activities documentation provided by ASM #1 from 1/1/2024 to the present documented activities on three dates in January 2024, three dates in February 2024, one day in March 2024, two dates in April 2024 and two dates in May 2024. January activities included three one to one activities, February included two one to one activities and one self-directed activity. March activities included one 1:1 activity, April included two 1:1 activities and May included three group activities. All activities documented active participation with positive facial expressions as the resident response. The comprehensive care plan for R47 documented in part, The resident is specify: (dependent) on staff for activities, cognitive stimulation, social interaction r/t (Japanese Speaking), AEB (as evidenced by) (Translation sheets available through activity department/interpreter) . Date Initiated: 01/18/2024. Revision on: 05/02/2024. Under Interventions it documented in part, 1:1 activities . Adapt activities to attention span and cognitive level . Provide a calm, non-rushed environment . The clinical record failed to evidence documentation of refusal to attend activities, communication devices used or translation sheets provided. On 5/21/2024 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the staff often sat R47 in the hallway near the nurse's station with the overbed table in front of them. She stated that no one spoke R47's language and they did not have a communication board to speak with them. She stated that she had asked several times to get a communication board and was told that someone was working on one. She stated that she felt that R47 was sometimes treated like a piece of furniture placed in the hallway and everyone just walked around them. On 5/21/2024 at 3:05 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that she communicated with R47 using hand gestures. She stated that R47 did not attend any activities except occasionally when someone came in to play music. She stated that she had never used any communication devices for R47 and had always used the hand gestures and the resident could say yes and no. On 5/22/2024 at 9:06 a.m., an interview was conducted with OSM (other staff member) #13, activities director. OSM #13 stated that it was very hard to determine what R47 was interested in due to the communication barrier. She stated that they tried to invite R47 to any music activities that they offered depending on the resident's mood. She stated that R47 had behaviors and became agitated at times so they kept them distanced. She stated that they mainly strived to offer R47 one to one activities and simple things that did not require an explanation. She stated that activities for R47 had not been as successful as they had hoped for due to the communication barrier. She stated that she had provided the staff with Japanese translation sheets on 5/21/2024 after someone mentioned it to them. She stated that she communicated with R47 by using hand gestures but it was a little difficult. She stated that the facility did not have any type of activity materials to provide to R47 in their preferred language and that they may be beneficial. The facility policy Community Life Overview effective 11/01/2021 documented in part, Community Life programming can enhance quality of life for residents by integrating meaningful and enjoyable activities into daily experiences. Center staff plans, coordinates, encourages, and supports a variety of recreational and Community Life for all residents based on individually identified needs, interests, culture, and background . Community Life programs are designed and adapted to be person-appropriate and to promote self-esteem, pleasure, comfort, education, creativity, success, and independence . The facility policy Social Activities dated 11/01/2021 documented in part, . Confused; Cognitive Impairment: Coffee Social; Sing along; Photo albums/busy boxes; Simple table games; Happy hour; Attend birthday parties; Attend themed parties; Assist in cooking activities- read recipes, mixing; Sorting; Pet Visitation. 1-2 times/week . On 5/22/2024 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was obtained prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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2. For Resident #16 (R16), the facility staff failed to administer oxygen as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/14/2024, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment indicating they were cognitively intact for making daily decisions. Section O documented R16 receiving oxygen while a resident at the facility. On 5/20/2024 at 12:10 p.m., an interview was conducted of R16 in their room. R16 was observed in bed wearing an oxygen nasal cannula with a humidifier bottle dated 5/12/2024 attached to an oxygen concentrator. The oxygen flow rate set on the concentrator was observed to be set at 1.5 lpm (liters per minute). R16 stated that they wore the oxygen all the time and the nurses took care of the machine. Additional observations of R16's oxygen were made on 5/20/2024 at 3:51 p.m. revealing the oxygen set at 1.5 lpm and 5/22/2024 at 8:46 a.m. revealing the oxygen set between the 1.5 lpm and 2 lpm lines. The physician order's for R16 documented in part, Respiratory: Oxygen 2L (liters) continuous every shift related to Chronic Respiratory Failure with Hypoxia. Order Date: 04/20/2023 . The comprehensive care plan for R16 documented in part, [Name of R16] has COPD (chronic obstructive pulmonary disease), cough, chronic respiratory failure. Takes O2 off at times. Date Initiated: 05/02/2019. Revision on: 11/21/2022 . Under Interventions it documented in part, .Oxygen 2 L nasal cannula continuous and humidified. Date Initiated: 12/08/2021. Revision on: 03/21/2022 . On 5/22/2024 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the oxygen rate should be verified every shift and was visualized at eye level to the machine. She stated that the ball on the concentrator should be centered on the line identifying the liters per minute ordered by the physician. On 5/22/2024 at 2:45 p.m., LPN #5 visualized R16's oxygen and stated that it was not set on 2 lpm as ordered and it needed to be adjusted. The facility policy Oxygen Therapy revised 8/28/2017 documented in part, .Review physician's order . Start O2 flowrate at the prescribed liter flow or appropriate flow for administration device . On 5/22/2024 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was obtained prior to exit. Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for 2 (two) of 43 residents in the survey sample, Residents #76 (R76) and R16. The findings include: 1. For R76, the facility staff failed to store a nebulizer (1) mask in a sanitary manner. R76 was admitted to the facility with diagnoses that included but were not limited to emphysema (2). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/09/2024, R76 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R76 was moderately impaired of cognition for making daily decisions. On 05/21/24 at approximately 8:25 a.m., an observation of R76's nebulizer mask revealed the mask hanging off the bedside table uncovered. On 05/21/24 at approximately 12:10 p.m., an observation of R76's nebulizer mask revealed the mask hanging off the bedside table uncovered. The physician's order for R76 dated 05/21/2024 documented in part Ipratropium-Albuterol Inhalation Solution (3) 3ML (three milliliters). 1 (one) vial inhale orally four times a day for SOB (shortness of breath). Comprehensive care plan dated 04/25/2024 documented in part, Focus. (R76) has Emphysema r/t (related to) history of smoking. Date Initiated: 04/25/2024. Under Interventions Give aerosol or bronchodialators (4) as ordered .Date Initiated: 04/25/2024. On 05/21/24 at approximately 4:01 p.m., an interview was conducted with RN (registered nurse) #4. When asked how a nebulizer mask should be stored when it was not being used, RN #4 stated in a bag to prevent contamination. The facility's policy Departmental (Respiratory Therapy) - Prevention of Infection documented in part, Infection Control Considerations Relate to Medication Nebulizers/Continuous Aerosol: 1. Obtain equipment (i.e., administration set-up, plastic bag, gauze sponges. 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. On 05/22/2024 at approximately 5:15 p.m., ASM (administrative staff member) #1, administrator, ASM #4, director of sales and marketing, ASM #5, regional director of clinical services and ASM #6, vice president of operations, and OSM (other staff member) #11, director of social services, were made aware of the above findings. No further information was provided prior to exit. References: (1) A small machine that turns liquid medicine into a mist. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm. (2) A lung condition that causes shortness of breath. This information was obtained from the website: https://www.mayoclinic.org. (3) The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease and emphysema. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601063.html. (4) Medicines that open the airways. This information was obtained from the website: https://medlineplus.gov.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for one of 43 residents in the survey sample, Resident #63. The findings include: For Resident #63 (R63), the facility staff failed to review the risks and benefits of bed rails with the resident (or resident representative) and obtain informed consent. A review of R63's clinical record revealed a physician's order dated 4/10/23 for side rails (bed rails) for bed mobility. On 5/21/24 at 8:32 a.m., R63 was observed lying in bed with bilateral one fourth bed rails in the upright position. Further review of R63's clinical record (including nurses' notes) failed to reveal the staff reviewed the risks and benefits of the bed rails with the resident (or the resident's representative) or obtained informed consent. On 5/21/24 at 4:01 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated nurses should educate residents on the risks and benefits of bed rails, obtain informed consent, and document this in a nurse's note. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. The facility policy titled, Side Rail/Bed Rail documented, 2. Review the risk and benefits with the resident and/or resident representative. 3. Obtain consent from the resident and/or resident representative.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview and facility document review, it was determined the facility failed to have sufficient staffing for the nurse to give the medications in the prescribed timeframe on one of two units. The findings include: On 5/20/24 at 10:29 a.m. observation was made of RN (registered nurse) #2 administering medications to Resident #37. The following medications were administered: Duloxetine 30 mg (milligrams) - 1 capsule (used to treat depression) Apixaban 5 mg - 1 tablet (clot prevention) Furosemide tablet 20 mg - 1/2 tablet (diuretic) Metformin 500 mg - 1 tablet - (diabetes) Omeprazole 20 mg - 1 tablet (gastroesophageal reflux disease) Oxcarbazepine 300 mg -1 tablet (bipolar disorder) Potassium Chloride 20 mEq (milliequivalent) - 1 tablet (potassium supplement) Risperdal 0.5 mg - 1 tablet (bipolar disorder) Tizanidine 2 mg - 1 tablet (muscle spasms) Vitamin D 50 mcg (micrograms) - 1 tablet - (supplement) Basaglar Kwik Pen Solution 16 units (diabetes) injected at 10:53 a.m. The Medication Administration Records were reviewed and documented the above orders. An order for Tramadol (pain) was administered after this surveyor left RN #2 but signed off for the 9:00 a.m. dose. The physician orders were reviewed. The following medications had more than once a day prescribed doses: Apixaban was scheduled every 12 hours. Metformin was scheduled twice a day. Oxcarbazepine was scheduled for twice a day. Risperdal was scheduled for every 12 hours. Tizanidine was scheduled for three times a day. Tramadol was scheduled for four times a day. An interview was conducted with RN #2 on 5/22/24 at 10:29 a.m. When asked why her 9:00 a.m. medications were not administered until 10:29 a.m., RN #2 stated, I am a very quick and thorough nurse. I do things by the book. The load on that hall, the acuity level is high, and the load is tough. It is unfortunately on that day; I could not catch up. RN #2 was asked why the insulin was so late, she stated, I just didn't get there. The resident is also a very busy lady. This writer stated that while reviewing the medication administration record, she noted the Tramadol was given after this writer left RN #2. RN #2 stated she had forgotten it and went back and gave it. A copy of the narcotic sheet was requested from RN #2. The review of the narcotic sheet documented the resident received the 9:00 a.m. dose of Tramadol at 10:57 a.m. The staffing schedule for 5/20/24 documented there were two nurses scheduled for the Rosewood unit. The census on that unit was 50 residents. An interview was conducted with OSM (other staff member) #18 on 5/23/24 at 10:58 a.m. When asked the normal staffing patterns for the three shift, OSM #18 stated the nurses work 12-hour shifts. Each shift has three nurses in the building, two on Rosewood and one on Dogwood. OSM #18 was asked if they have a callout, how do they cover, she stated she scrambles to find someone. When asked if the facility uses agency nurses, OSM #18 stated they haven't used agency nurses since February of 2023. OSM #18 was asked if she is unable to fill the position, what happens, she stated the unit managers will take the medication cart. The director of nursing would take a cart sometimes for a few hours in the evening but mostly on the weekends. OSM #18 was asked if the administrator takes a medication cart, she stated this past week, the administrator filled in on Thursday evening and Sunday from 7:00 a.m. to 7:00 p.m. ASM (administrative staff member) #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM #11, the director of social services, were made aware of the above concern on 5/23/24 at 3:15 p.m. No further information was obtained prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on staff interview and employee record review it was determined that the facility staff failed to ensure that three of five CNA (certified nursing assistant) records reviewed received annual performance reviews, CNA #3, CNA #9 and CNA #10. The findings include: The facility staff failed to ensure that three of five CNAs selected received an annual performance evaluation. CNA #3's record documented a hire date of 9/26/2022. On 5/23/2024 at 1:39 p.m., OSM (other staff member) #14, human resource coordinator, stated that they did not have a performance review to provide for CNA #3. CNA #9's record documented a hire date of 1/23/2023. On 5/23/2024 at 1:39 p.m., OSM #14, human resource coordinator, stated that they did not have a performance review to provide for CNA #9. CNA #10's record documented a hire date of 2/15/2023. On 5/23/2024 at 1:39 p.m., OSM #14, human resource coordinator, stated that they did not have a performance review to provide for CNA #10. On 5/23/2024 at 3:30 p.m., an interview was conducted with OSM #14, human resource coordinator. OSM #14 stated that they were responsible for performance reviews and set up a binder when they started at the facility to track when they were due. She stated that they did reviews 90 days after hire and then annually on their anniversary date of hire. She stated that she did not have any performance reviews for the CNA's listed above and they were overdue. The facility policy Employee [sic]Job Performance Evaluations effective 11/30/2014 documented in part, . Performance evaluations are to be conducted before the completion of the introductory period and annually thereafter. Written performance evaluations are to be prepared by the employee ' s immediate supervisor in conjunction with the department head, or in the absence of a supervisor, by the department head. All evaluations for facility employees must be reviewed and approved by the facility Executive Director prior to being reviewed with the employee . On 5/23/2024 at approximately 3:15 p.m., ASM (administrative staff member) #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was obtained prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for two of 43 residents in the survey sample, Residents #61, and #48. The findings include: 1. For Resident #61 (R61), the facility staff failed to assess the psychosocial well-being of the resident after another resident became upset, threw a vase, and the vase or a piece of the vase accidentally hit R61 in the head. A facility synopsis of events dated 4/29/24 documented that on 4/29/24, R61 reported that on 4/28/24, R58 became upset in the dining room (due to not being able to go outside to smoke), threw vases, and a vase or piece of vase hit R61 in the head. A note signed by the nurse practitioner on 4/29/24 documented, Advised by staff resident states she was struck in head while another resident was throwing vases in the dining hall. She states it struck her on the left side of her head and it is painful. Plan: Recommend routine checks by staff . The nurse practitioner's note did not document any psychosocial assessment. Further review of R61's clinical record (including nurses' notes, social services notes, psychiatry notes and physician notes) failed to reveal the facility staff assessed R61's psychosocial well-being after the incident. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated that if a resident displays behaviors that affect other residents, such as a resident throwing a vase and it hitting another resident in the head, then the social services department would refer the resident with behaviors to psychiatry services. In regard to what should be done for the other resident affected by the behaviors, OSM #11 stated staff should make sure he or she is not hurt and provide counseling services because that resident might have psychiatric issues such as post-traumatic stress disorder or anxiousness as a result of the incident. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. The facility policy titled, Assessments-Social History and Psychosocial Assessment documented, It is the policy of The Company to: Assess resident's psychosocial needs. Begin planning to meet the resident's psychosocial needs. Identify the resident's strengths. Develop a plan of care . 4. Social Services will complete the Social Services Progress Review quarterly, with significant changes and as needed. 2. For Resident #48 (R48), the facility staff failed to assess the psychosocial well-being of the resident after another resident became upset, then accidentally ran his wheelchair into R48's wheelchair and R48's leg. A facility synopsis of events dated 3/29/24 documented R58 became upset with kitchen staff then accidentally ran his wheelchair into R48's wheelchair and bumped R48's leg. Further review of R48's clinical record (including nurses' notes, social services notes, psychiatry notes and physician notes) failed to reveal the facility staff assessed R61's psychosocial well-being after the incident. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated that if a resident displays behaviors that affect other residents, such as a resident bumping his wheelchair into another resident's wheelchair and leg, then the social services department would refer the resident with behaviors to psychiatry services. In regard to what should be done for the other resident affected by the behaviors, OSM #11 stated staff should make sure he or she is not hurt and provide counseling services because that resident might have psychiatric issues such as post-traumatic stress disorder or anxiousness as a result of the incident. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to prevent residents from receiving unnecessary psychoactive medications for one of 43 residents in the survey sample, Residents #17. The findings include: For Resident #17 (R17), the facility staff administered Haldol (1) from Resident #64's supply to R17 without a physician's order. A review of R17's clinical record, including April and May 2024 physician's orders and MARs (medication administration records) revealed no evidence of an order for Haldol. A review of R17's care plan dated 4/26/24 revealed no information related to the resident's receiving Haldol. A review of a facility synopsis of events dated 5/13/24 revealed, in part: CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 stated that [R17] was the resident involved in the report, but with the investigation we have identified .[R64] .The allegation was made by a certified nursing assistant that she had knowledge that [LPN #7] was administering medications to .[R17] .to keep them calm, and she was giving them the medication without a physician's order. It was discovered during the investigation that [LPN #7] had administered a medication (Haldol) from [R64] to [R17] due to their behaviors to keep them quiet. The medication is an antipsychotic and was in liquid form. An account of the liquid revealed that 13 mls of the medication were unaccounted for .An internal investigation was started along with the assistance of APS (adult protective services). [LPN #7] (licensed practical nurse) admitted to APS that she had chemically restrained .[R64] without a physician's order. Attempts to interview LPN #7 during the survey were unsuccessful. On 5/13/24 at 10:50 a.m., OSM (other staff member) #19, an APS case worker was interviewed. He stated LPN #7 had confessed to giving another resident Haldol that belonged to R64. He stated: She said she was doing this almost every night. On 5/14/24 at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on 5/9/24 when she received an email from APS. On 5/14/24 at 1:09 p.m., ASM #2, the director of nursing (DON), was interviewed. She stated she and RN (registered nurse) #4, the former assistant DON (ADON), used R64's MAR (medication administration) to calculate how much Haldol should have been remaining in R64's supply on 5/10/24. They discovered, between two bottles of Haldol, 20 milliliters total of missing medication. On 5/15/24 at 11:35 a.m., OSM #20, a member of the local police force, was interviewed. He stated that sometime after 5/3/24, LPN #7 had confessed to him that she administered Haldol to R64 without a physician's order. On 5/21/24 at 2:54 p.m., CNA #4 was interviewed. She stated she did not recall the exact date, but she remembered standing beside the medication cart talking with LPN #7. LPN #7 was in the process of administering medications to residents on the hall. She stated R17 was yelling, Ma'am! Ma'am! LPN #7 stated something to the effect of oh, she's starting again today. CNA #4 heard LPN #7 say: I am going to take care of it. CNA stated she saw LPN #7 take out a bottle of liquid Haldol, draw some up, and squirt it into a medication cup. LPN #7 took the medication in R17's room. CNA #4 stated when LPN #7 returned to the medication cart, LPN #7 stated: You didn't see anything. On 5/21/24 at 3:55 p.m., RN #4, the ADON, was interviewed. She stated on 5/2/24, CNA #4 came in ASM #2's office to report R17's having received Haldol that was not ordered for her. She stated ASM #2 and LPN #5, the unit manager, were also present for this meeting. She stated CNA #4 reported that a week or two before, R64 was having behaviors, and LPN #7 had told her: You didn't see this. I have something for that. On 5/22/24 at 5:10 p.m., ASM #5, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. On 5/23/23 at 3:30 p.m., a policy regarding prevention of the administration of unnecessary medications to residents was requested from OSM #5. No policy was provided. No further information was provided prior to exit. References (1) Haloperidol is used to treat psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real). Haloperidol is also used to control motor tics (uncontrollable need to repeat certain body movements) and verbal tics (uncontrollable need to repeat sounds or words) in adults and children who have Tourette's disorder (condition characterized by motor or verbal tics). Haloperidol is also used to treat severe behavioral problems such as explosive, aggressive behavior or hyperactivity in children who cannot be treated with psychotherapy or with other medications. Haloperidol is in a group of medications called conventional antipsychotics. It works by decreasing abnormal excitement in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682180.html.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on staff interview, and clinical record review, and facility document review, it was determined that facility staff failed to obtain physician ordered laboratory tests for 1 (one) of 43 residents in the survey sample, Residents #65 (R65). The findings include: For R65, the facility staff failed to obtain physician ordered laboratory (lab) tests of CBC (complete blood count) (1), CMP (comprehensive metabolic panel) (2), CRP (C-Reactive protein) (3), ESR (erythrocyte sedimentation rate) (4), CPK (creatine phosphokinase) (5), on 04/04/2024, 04/25/2024 and 05/02/2024. R65 was admitted to the facility with diagnoses that included but were not limited to osteomyelitis (6) of ankle and foot. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/26/2024, R65 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R65 was cognitively intact for making daily decisions. The physician's orders for R65 documented: Lab draw weekly on Thursday through ABT labs to include CBC (complete blood count), CMP (complete metabolic panel), CRP (C-Reactive protein), ESR (erythrocyte sedimentation rate), CPK (creatine phosphokinase) one time a day every Thur (Thursday) for lab work for ABT r/t (related to) foot infection. Order Date: 03/25/2024. Start Date: 03/28/2024. DAPTOmycin (7) Intravenous Solution reconstituted 500MG (milligrams). Use 400 mg intravenously one time a day for foot infection until 04/30/2024. Order Date: 03/25/2024. DAPTOmycin Intravenous Solution reconstituted 500MG (milligrams). Use 400 mg intravenously one time a day for foot infection. Start Date: 04/26/2024. End Date: 05/14/2024. Review of the facility's EHR (electronic health record) for R65 failed to evidence the physician's ordered lab tests as stated above on 04/04/2024, 04/25/2024 and on 05/02/2024. The eMARs (electronic medication administration records) for R65 dated March 2024, April 2024 and May 2024 documented the physician's order for Daptomycin as stated above. Further review of the eMARs revealed R65 received the antibiotic daily from 03/26/2024 through 05/09/2024. On 05/22/24 at approximately 10:35 a.m., an interview was conducted with RN (registered nurse) #3. When asked to describe the procedure for obtaining physician ordered labs for a resident, RN #3 stated the nurse draws lab (blood) and sends it to the lab. When asked about the labs ordered for every Thursday for R65 RN #3 stated the labs were to continue until the antibiotic was completed. The facility's policy Laboratory, Diagnostic and X-Ray documented in part, Procedure: Results of laboratory work, diagnostic test, and x-ray to be sent to the Center or electronically uploaded to the resident EMR (electronic medical record); Document notification of the practitioner and resident/resident representative of results. On 05/22/2024 at approximately 5:15 p.m., ASM (administrative staff member) #1, administrator, ASM #4, director of sales and marketing, ASM #5, regional director of clinical services and ASM #6, vice president of operations, and OSM (other staff member) #11, director of social services, were made aware of the above findings. No further information was provided prior to exit. References: (1) A blood test. It's used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia. This information was obtained from the website: https://www.mayoclinic.org. (2) A routine blood test that measures 14 different substances in a sample of your blood. It provides important information about your metabolism (how your body uses food and energy) and the balance of certain chemicals in your body. This information was obtained from the website: https://www.medlineplus.gov. (3) Measures inflammation in the body. This information was obtained from the website: https://www.mayoclinic.org. (4) A blood test that that can show if you have inflammation in your body. This information was obtained from the website: https://www.medlineplus.gov. (5) Is an enzyme in the body. It is found mainly in the heart, brain, and skeletal muscle. the test to measures the amount of CPK in the blood. This information was obtained from the website: https://www.medlineplus.gov. (6) An infection in a bone that can be caused by bacteria, injuries, surgeries or other factors. This information was obtained from the website: https://www.mayoclinic.org. (7) Belongs to the class of medicines known as antibiotics. It works by killing bacteria or preventing their growth. This information was obtained from the website: https://www.mayoclinic.org.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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2. For Resident #47 (R47), the facility staff failed to maintain a complete and accurate medical record documenting an injury causing facial bruising first documented on 4/13/24, and again on 4/16/24 and 4/30/24. The clinical record for R47 documented in part, - 4/13/2024 12:45 Note Text: Resident rubbing at her face where bruise and abrasion are. - 4/16/2024 Progress Note (Amended) .There is bruising noted over left and midline chin. No open areas noted. See nursing assessment for full skin evaluation . - 4/30/2024 14:30 (2:30 p.m.) Weekly Skin Integrity Review . Discoloration to chin . The clinical record failed to evidence documentation of the incident causing the bruising or R47 hitting themselves in the face with anything. The record failed to evidence documentation of the initial assessment of the bruising to the face. On 5/15/2024 at 1:40 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they documented the note on 4/13/2024. She stated that she was off one day and came back and saw the bruising and abrasion on R47's face. She stated that she had asked someone about the bruising and was told that R47 had hit themselves and caused the bruising. She stated that R47 had behaviors directed towards others but had never witnessed them hitting themselves before and she was not aware of any investigation done. She stated that she did not notify the responsible party/guardian because she was told that they had already investigated and determined that R47 had hit themselves in the face. On 5/21/2024 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that R47 was sitting at the nurses station with a tube of lotion and was attempting to put it in their mouth. She stated that when they approached R47 and asked to take the lotion, R47 had jerked back with the bottle and hit themselves on the face. She stated that the bruising did not appear right away and they did not notice it until the next day. She stated that she did report the bruising to the administrator and the director of nursing and reported that the incident was witnessed. She stated that the incident should have been documented in the clinical record and the responsible party/guardian notification should have been in the record also. She stated that one of the struggles she had was not being able to properly document due to staffing concerns at the facility. On 5/22/2024 at 11:17 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that the former director of nursing had reported to them that R47 had hit themselves in the face with a bottle of lotion and a staff member had witnessed the incident. She stated that the clinical record should have documented the incident and she had just been notified that it was not in the medical record. On 5/23/2024 at approximately 3:15 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM (other staff member) #11, the director of social services were made aware of the findings. No further information was obtained prior to exit. 3. For Resident #336 (R336), the facility staff failed to maintain a complete, accurate clinical record when the resident left the faciity on 5/5/24 against medical advice. A review of R336's progress notes revealed the following: 5/5/24 at 2:13 p.m. Resident c/o (complained of) pain not relieved by medications currently ordered. Call placed to on call physician at 11:08 (a.m.). Retuned call at 11:30 (a.m.) and new order for Norco (1) obtained. 5/5/24 at 2:16 p.m. Resident left AMA (against medical advice) via stretcher by ambulance accompanied by daughter. Both of these notes were written by RN (registered nurse) #2. Further review of R336's clinical record failed to reveal any additional information regarding the circumstances surrounding R336's discharge. On 5/15/24 at 11:13 a.m., RN #2 was interviewed. When asked what documentation should occur when a resident leaves the facility, she stated the nurse should write a progress note about how they leave, any personal possessions that they take with them, any special medications that have been ordered, and any other relevant details about why the resident is being discharged . She stated without a progress note like this, the resident's clinical record is not complete. When asked to review R336's progress notes and to describe what happened that caused R336 to leave the facility AMA, she stated she could not remember. She stated that according to her note, the resident was having increased pain, and the resident received an order for a stronger pain medication (Norco). When asked if the Norco was effective in relieving the resident's pain, she said she did not remember and the note did not say. She stated she would guess the resident's pain was not relieved, but she had no memory of what happened between 11:30 a.m. when the Norco was administered and 2:15 p.m. when the resident left the faciity on a stretcher. She stated R336's daughter told her that she had called 911 from the resident's room only after the Emergency Medical Service personnel appeared in the hallway outside R336's room. She stated: I can't remember why [R336's daughter] called 911. She stated she agreed that she should have documented in more detail regarding why the resident felt the need to leave the facility AMA. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated she was working the floor on the other side of the building on the day R336 left the facility. She stated she remembered being called to R336's room to speak to the resident's daughter regarding the resident's pain management because the resident was having increased pain, but did not have an order for strong pain medication. She stated she spoke with the resident and the daughter and told them her nurse would contact the physician to get something stronger. She stated RN #2 called the physician and got an order for Norco, and the nurse was able to give the medication immediately from the facility's emergency medication supply. She stated she did not know anything else about what transpired, and did not realize the resident was leaving until she saw the Emergency Medical Services personnel taking the resident out on a stretcher. She stated RN #2 should have written a more detailed note about the circumstances around the resident's discharge, and agreed the resident's record was not complete. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to discharge. Reference (1) Hydrocodone (Norco) is used to relieve severe and persistent pain in people who are expected to need an opioid pain medication around the clock for a long time and who cannot be treated with other pain medications. Hydrocodone extended-release (long-acting) capsules or extended-release tablets should not be used to treat pain that can be controlled by medication that is taken as needed. Hydrocodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain, pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information is taken from the website https://medlineplus.gov/druginfo/meds/a614045.html. Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for three of 43 residents in the survey sample, Residents #48, #47, and #336. The findings include: 1. For Resident #48 (R48), the facility staff failed to document an incident with another resident on 3/28/24 in the clinical record. A facility synopsis of events dated 3/29/24 documented that on that date, R58 became upset with kitchen staff then accidentally ran his wheelchair into R48's wheelchair and bumped R48's leg. A review of R48's clinical record failed to reveal any documentation regarding the event. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated that if a resident is hit by another resident in a wheelchair while the other resident is having a behavior outburst, then this incident should be documented in both residents' clinical records. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. The facility policy titled, Clinical/Medical Records documented, Clinical records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control measures for three of 43 residents in the survey sample, Residents #17, #25, and #85. The findings include: 1. For Resident #17 (R17), who has a Foley catheter (1), the facility staff failed to implement enhanced barrier precautions (2). On the following dates and times, R17 was observed lying in bed, with a Foley catheter collection bag visible hanging on the bed frame: 5/13/23 at 3:36 p.m. and 5/14/24 at 11:41 a.m. At all of these observations, no sign for enhanced barrier precautions or PPE (personal protective equipment) were on or near R17's door. Staff members were observed going in and out of the room without putting on any PPE. A review of R17's physician orders and care plan revealed orders and interventions related to care of R17's Foley catheter. On 5/14/24 at 11:52 a.m., RN (registered nurse) #5, who was administering medications on the resident's hallway, stated the resident was not on any sort of isolation. On 5/15/24 at 11:13 a.m., CNA (certified nursing assistant) #6, who was working R17's hallway, was asked if any residents on the hallway were on isolation for any reason. She stated: No. When asked if residents should be on any type of isolation for feeding tubes, she stated: No. Not that I'm aware of. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated she is the infection preventionist of record at the facility. When asked if the facility had implemented any enhanced barrier precautions in the building, she stated: No. I know we should have been doing enhanced barrier precautions. She stated these precautions had not been instituted prior to her recent return to the facility as director of nursing. She stated any resident with any sort of external tube or device (indwelling medical device) is at an increased risk for infection, and should be placed on enhanced barrier precautions. She added: Gown and gloves are the protection, and should be worn. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Enhanced Barrier Precautions, revealed, in part: Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO) .to residents .EBPs are indicated .for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. No further information was provided prior to exit. References (1) Foley catheters are small flexible tubes inserted into the urethra to drain urine from the bladder. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK564404. (2) Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). This information is taken from the website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html. 2. For Resident #25 (R25), who has tube inserted directly in his stomach for all food, liquids, and medicines, the facility staff failed to implement enhanced barrier precautions. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/26/24, R25 was coded as receiving food and liquids through a feeding tube. On the following dates and times, R25 was observed lying in bed in his room: 5/13/24 at 3:33 p.m.; 5/14/24 at 11:51 a.m. and 3:37 p.m.; 5/15/24 at 11:40 a.m. and 2:56 p.m. At all of these observations, no sign for enhanced barrier precautions or PPE (personal protective equipment) were on or near R25's door. Staff members were observed going in and out of the room without putting on any PPE. A review of R25's physician orders and care plan revealed orders and interventions related to care of R25's feeding tube. On 5/14/24 at 11:52 a.m., RN (registered nurse) #5, who was administering medications on the resident's hallway stated the resident was not on any sort of isolation. On 5/15/24 at 11:13 a.m., CNA (certified nursing assistant) #6, who was working R25's hallway, was asked if any residents on the hallway were on isolation for any reason. She stated: No. When asked if residents should be on any type of isolation for feeding tubes, she stated: No. Not that I'm aware of. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated she is the infection preventionist of record at the facility. When asked if the facility had implemented any enhanced barrier precautions in the building, she stated: No. I know we should have been doing enhanced barrier precautions. She stated these precautions had not been instituted prior to her recent return to the facility as director of nursing. She stated any resident with any sort of external tube or device (indwelling medical device) is at an increased risk for infection, and should be placed on enhanced barrier precautions. She added: Gown and gloves are the protection, and should be worn. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. 3. For Resident #85 (R85), who has a Foley catheter, the facility staff failed to implement enhanced barrier precautions. On the following dates and times, R85 was observed lying in bed, with a Foley catheter collection bag visible hanging on the bed frame: 5/13/23 at 3:35 p.m. and 5/14/24 at 11:39 a.m. At all of these observations, no sign for enhanced barrier precautions or PPE (personal protective equipment) were on or near R85's door. Staff members were observed going in and out of the room without putting on any PPE. A review of R85's physician orders and care plan revealed orders and interventions related to care of R85's Foley catheter. On 5/14/24 at 11:52 a.m., RN (registered nurse) #5, who was administering medications on the resident's hallway, stated the resident was not on any sort of isolation. On 5/15/24 at 11:13 a.m., CNA (certified nursing assistant) #6, who was working R85's hallway, was asked if any residents on the hallway were on isolation for any reason. She stated: No. When asked if residents should be on any type of isolation for feeding tubes, she stated: No. Not that I'm aware of. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated she is the infection preventionist of record at the facility. When asked if the facility had implemented any enhanced barrier precautions in the building, she stated: No. I know we should have been doing enhanced barrier precautions. She stated these precautions had not been instituted prior to her recent return to the facility as director of nursing. She stated any resident with any sort of external tube or device (indwelling medical device) is at an increased risk for infection, and should be placed on enhanced barrier precautions. She added: Gown and gloves are the protection, and should be worn. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit.4. The facility staff failed to maintain infection control practices in the laundry room, a dirty fan was blowing towards the clean linens. Observation was made of the laundry room on 5/23/24 at 10:15 a.m. There were three fans in the clean side of the laundry. Two small white fans sitting on the folding table. A black fan, on a stand, was observed with dirt/lint on the front of the fan. This fan was blowing toward the clean linens on the shelves. An interview was conducted with OSM (other staff member) #15, laundry staff person, on 5/23/24 at the time of the observation. When asked how often the fans are cleaned, OSM #15 stated when they get dirty like that (pointing to the fan). OSM #15 stated she had not gotten to cleaning it this morning. An interview was conducted with OSM #16, the housekeeping account manager, on 5/23/24 at 10:18 a.m. When asked if a fans with visible dirt/lint should be on facing the clean laundry on the shelf, OSM #16 stated, no. The facility policy, Exposure Control Plan: Linen Handling documented in part, Policy: Clean and soiled linen will be kept in separate locations. Clean linen will be stored in a closed closet or a covered, wheeled linen cart. Closed doors and covered carts provide protection from airborne contamination. Soiled linen will be handled using Standard Precautions. ASM (administrative staff member) #5, regional director of clinical services, ASM #6, vice president of operations, and OSM #11, director of social services, were made aware of the above concern on 5/23/24 at 3:15 p.m. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0941 (Tag F0941)

Could have caused harm · This affected 1 resident

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Based on staff interview and facility document review, the facility staff failed to provide required training on effective communication for one of seven employee records reviewed, CNA (certified nursing assistant) #8. The findings include: For CNA #8, hired 9/17/21, the facility failed to provide the required training in effective communication. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, In-Service Training-General, revealed, in part: 1. The Executive Director and/or the Director of Nursing /designee will be responsible for assigning, coordinating, and monitoring education and in-service training. 2. Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the center Facility Assessment. Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0942 (Tag F0942)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, the facility staff failed to provide required training on resident rights and facility responsibilities for one of seven employee records reviewed, CNA (certified nursing assistant) #8, The findings include: For CNA #8, hired 9/17/21, the facility failed to provide the required training in resident rights and facility responsibilities. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social [NAME] director, were informed of these concerns. A review of the facility policy, In-Service Training-General, revealed, in part: 1. The Executive Director and/or the Director of Nursing /designee will be responsible for assigning, coordinating, and monitoring education and in-service training. 2. Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the center Facility Assessment. Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0946 (Tag F0946)

Could have caused harm · This affected 1 resident

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Based on staff interview and facility document review, the facility staff failed to provide required training compliance and ethics for two of seven employee records reviewed, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper. The findings include: For OSM#6, hired 12/4/19, the facility failed to provide the required training in compliance and ethics. For OSM #22, hired 9/6/18, the facility failed to provide the required training in compliance and ethics. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, In-Service Training-General, revealed, in part: 1. The Executive Director and/or the Director of Nursing /designee will be responsible for assigning, coordinating, and monitoring education and in-service training. 2. Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the center Facility Assessment. Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0949 (Tag F0949)

Could have caused harm · This affected 1 resident

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Based on staff interview and facility document review, the facility staff failed to provide required training on meeting behavioral needs for four of seven employee records reviewed, OSM (other staff member) #3, an occupational therapist, RN (registered nurse) #2, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper. The findings include: For OSM #3, hired 9/11/23 the facility failed to provide the required training in meeting behavioral needs. For RN #2, hired 3/19/24, the facility failed to provide the required training in meeting behavioral needs. For OSM#6, hired 12/4/19, the facility failed to provide the required training in meeting behavioral needs. For OSM #22, hired 9/6/18, the facility failed to provide the required training in meeting behavioral needs. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, In-Service Training-General, revealed, in part: 1. The Executive Director and/or the Director of Nursing /designee will be responsible for assigning, coordinating, and monitoring education and in-service training. 2. Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the center Facility Assessment. Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #47 (R47), the facility staff failed to notify the responsible party/guardian of a change in condition for A) facial bruising documented on 4/13/24, 4/16/24, and 4/30/24; B) Falls on 3/11/24 and 3/25/24 and C) timely notify the responsible party/guardian of an allegation of abuse towards R47 reported on 4/19/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment documented R47 having two falls without injury since the previous assessment. The resident demographic information documented a responsible party/guardian listed with contact information. The demographics also listed an additional responsible party and two emergency contacts with contact information listed. Guardianship documentation in the clinical record documented the guardianship effective 2/27/2024. A) facial bruising documented on 4/13/24, 4/16/24, and 4/30/24: The clinical record for R47 documented in part, - 4/13/2024 12:45 Note Text: Resident rubbing at her face where bruise and abrasion are. - 4/16/2024 Progress Note (Amended) .There is bruising noted over left and midline chin. No open areas noted. See nursing assessment for full skin evaluation . - 4/30/2024 14:30 (2:30 p.m.) Weekly Skin Integrity Review . Discoloration to chin . The clinical record failed to evidence notification of the responsible party/guardian of the bruising/abrasion observed on the face. On 5/15/2024 at 1:40 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they documented the note on 4/13/2024. She stated that she was off one day and came back and saw the bruising and abrasion on R47's face. She stated that she had asked someone about the bruising and was told that R47 had hit themselves and caused the bruising. She stated that R47 had behaviors directed towards others but had never witnessed them hitting themselves before and she was not aware of any investigation done. She stated that she did not notify the responsible party/guardian because she was told that they had already investigated and determined that R47 had hit themselves in the face. On 5/21/2024 at 11:00 a.m., an interview was conducted with ASM (administrative staff member) #3, nurse practitioner. ASM #3 stated that she did not recall getting any phone calls regarding the bruising on R47's face, she stated that the bruising was purplish colored when she assessed the resident on 4/16/2024 and she did not see any abrasions at that time. On 5/21/2024 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that R47 was sitting at the nurses station with a tube of lotion and was attempting to put it in their mouth. She stated that when they approached R47 and asked to take the lotion, R47 had jerked back with the bottle and hit themselves on the face. She stated that the bruising did not appear right away and they did not notice it until the next day. She stated that she did report the bruising to the administrator and the director of nursing and reported that the incident was witnessed. She stated that the incident should have been documented in the clinical record and the responsible party/guardian notification should have been in the record also. She stated that one of the struggles she had was not being able to properly document due to staffing concerns at the facility. On 5/21/2024 at 3:55 p.m., an interview was conducted with RN #4. RN #4 stated that they did the skin assessment on 4/30/2024 and the bruising on R47's chin was yellowing and appeared to be older at that time. She stated that she had followed up with the former director of nursing who stated that R47 had hit themselves in the face and caused the bruising. On 5/22/2024 at 11:17 a.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that the former director of nursing had reported to them that R47 had hit themselves in the face with a bottle of lotion and a staff member had witnessed the incident. She stated that the clinical record should document the incident and the guardian should have been notified of the incident. B) Falls on 3/11/24 and 3/25/24: The clinical record for R47 documented in part, - A Change in Condition dated 3/11/2024 documenting in part, .Found lying on right side of bed on the floor. No injuries. VS (vital signs) attempted several times but resident was combative, slapping and scratched this writer . Primary Care Clinician Notified: [Name of nurse practitioner] 03/11/2024 08:30 . Name of Family/Health Care Agent Notified: No family to contact . - A Change in Condition dated 3/25/2024 documenting in part, .Resident found lying on the floor to the left of her bed. No injuries noted. Resident hitting, pinching and spitting at staff while attempting to put her back to bed. Resident assisted to WC (wheelchair) . Primary Care Clinician Notified: [Name of nurse practitioner] 03/25/2024 10:00 . Name of Family/Health Care Agent Notified: No family to call . - A Change in Condition dated 3/25/2024 documenting in part, .Slid self out of WC onto floor right after being sat at nurses station post fall in resident room. No injuries noted . Primary Care Clinician Notified: [Name of nurse practitioner] 03/25/2024 10:00 . Name of Family/Health Care Agent Notified: No family to call . The clinical record failed to evidence notification of the responsible party/guardian of the falls on 3/11/2024 and 3/25/2024. The comprehensive care plan for R47 documented in part, [Name of R47] is at risk for falls r/t (related to) dementia, confusion, deconditioning, gait/balance problems, unaware of safety needs. Date Initiated: 01/08/2024. Revision on: 01/10/2024. The comprehensive care plan failed to evidence a review or revision after the falls on 3/11/2024 and 3/25/2024. On 5/21/2024 at 3:55 p.m., an interview was conducted with RN #4. RN #4 stated that when a resident had a fall the staff should review the current fall interventions in place and initiate a new intervention if deemed necessary, review the medications for possible contributing causes, provide frequent rounding and review the falls. She stated that when she started working at the facility she had implemented a fall binder to guide staff on the process for investigating and documenting a fall. She stated that the nurse was responsible for making the decision on adding any intervention and updating the care plan but they had not being doing it consistently. She stated that the care plan should at least be reviewed and a fall risk assessment completed. She stated that unless the resident was alert and oriented and their own responsible party that their representative should be made aware of the fall. On 5/22/2024 at 11:17 a.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that R47 had a guardian who was their responsible party and they should have been notified of any falls. C) notify the responsible party/guardian of an allegation of abuse towards R47 reported on 4/19/24 in a timely manner: Review of the facility synopsis of events for R47 dated 4/19/2024 documented in part, .Report Date: 04/19/2024, Incident Date: 04/19/2024 . Allegation of Abuse/mistreat . Reported that nurse smeared sputum/spit all over residents face . Employee action initiated or take: Investigation began Action documented regarding employee. If applicable, date notification provided to: Responsible party: 04/22/24 . The final report for the investigation of the allegation documented in part, .The investigation was completed on 04/20/2024 . On 5/22/2024 at 11:17 a.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that R47's guardian was notified of the abuse allegation and investigation but she preferred for them to be notified that same day and follow up the day the investigation was completed. She stated that the former director of nursing had investigated the allegation and it appeared that they had not notified the guardian until 3 days afterwards. On 5/23/2024 at approximately 3:15 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM (other staff member) #11, the director of social services were made aware of the findings. The facility policy Notification of Change in Condition revised 12/16/2020 documented in part, The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition . The facility policy Fall Management revised 7/29/2019 documented in part, .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Post Fall Strategies: .Notify the Physician and resident representative . The facility policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/2022 documented in part, .In all cases, the Executive Director or Director of Nursing will ensure notification to the resident's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment, and the resident's attending physician . No further information was obtained prior to exit. Based on family interview, staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician and/or responsible party of a change in a resident's condition for five of 43 residents in the survey sample, Residents #64, #336, #13, #47, and #13. The findings include: 1. For Resident #64, the facility staff failed to notify the physician and responsible party (RP) of an allegation of misappropriation of the resident's property. A review of R64's clinical record revealed the following order dated 4/3/24: Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter. Give 0.25 ml by mouth every 4 hours as needed for agitation. A review of R64's care plan dated 4/17/24 revealed, in part: The resident has behaviors .r/t (related to) terminal diagnosis .[R64] is on an antipsychotic medication r/t end of life care. Psychosis and terminal agitation. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date 5/13/24 .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. Further review of the facility synopses of events and of R64's clinical record failed to reveal notification to the physician or the resident's RP of the allegations of misappropriation of the resident's medication. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 stated that [R17] was the resident involved in the report, but with the investigation we have identified .[R64] .The allegation was made by a certified nursing assistant that she had knowledge that [LPN #7] was administering medications to .[R17] .to keep them calm, and she was giving them the medication without a physician's order. It was discovered during the investigation that [LPN #7] had administered a medication (Haldol) from [R64] to [R17] due to their behaviors to keep them quiet. The medication is an antipsychotic and was in liquid form. An account of the liquid revealed that 13 mls of the medication were unaccounted for .An internal investigation was started along with the assistance of APS (adult protective services). [LPN #7] (licensed practical nurse) admitted to APS that she had chemically restrained .[R64] without a physician's order . On 5/14/24 at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on 5/9/24 when she received an email from APS. On 5/14/24 at 1:09 p.m., ASM #2, the director of nursing (DON), was interviewed. She stated she and RN (registered nurse) #4, the former assistant DON (ADON), used R64's MAR (medication administration) to calculate how much Haldol should have been remaining in R64's supply on 5/10/24. They discovered, between two bottles of Haldol, 20 milliliters total of missing medication. On 5/15/24 at 9:38 a.m., OSM (other staff member) #19, an APS (adult protective services) worker, was interviewed. He stated on 5/3/24, he received an anonymous complaint regarding a possible resident-to-resident drug diversion by LPN #7. On that day, he also received a call from OSM #20, a member of the local police force, regarding the same drug diversion allegation. He stated he contacted the facility staff (ASM #2) on 5/3/24. On 5/15/24 at 2:01 p.m., OSM #11, the director of social services, was interviewed. She stated she became aware of the allegations against LPN #7 on 5/3/24 when LPN #6, the MDS nurse, called her to tell her than a staff member had just alleged a drug diversion against LPN #7. She stated she immediately called ASM #2 and ASM #6, the regional vice president of operations. She stated ASM #2 told her that it was being looked into. She stated the allegation was not reported to any of the required entities on 5/3/24, as far as she knew. She also stated an investigation was not started on 5/3/24. She stated the allegation should have been immediately reported, and that an investigation should have been immediately started. She stated it was her understanding that the investigation was currently underway, but she was not an active part of the investigation. She stated she was able to get a statement from LPN #7, who denied all allegations to her. On 5/15/24 at 3:23 p.m., ASM #2 was interviewed. She stated the allegation of the Haldol diversion came to her as a complaint regarding R17. She stated she was told CNA #4's observations had occurred at least a week before the report came to her attention. She stated she was told about this on 5/2/24. She stated she wasn't told specifically which drug was involved, but she was told which nurse and which resident were involved. She stated she asked CNA #4 why the CNA had reported the allegation sooner. She stated she did not report it to the state agency or any other required entity on 5/2/24 because she did not know what to look for or how to investigate it. She stated she did not remove LPN #7 from the schedule, and LPN #7 worked the night of 5/2/24. She stated on 5/3/24, OSM #19 came to the facility and corroborated the allegation of the drug diversion on the part of LPN #7. She stated she went ahead and removed LPN #7 from the schedule for that evening, and for subsequent evenings. She stated she called OSM #11, who was the acting administrator, to inform her. She stated OSM #11 was acting as the administrator because ASM #1, the administrator, was out of the country. She stated she and OSM #11 talked to CNAs, residents, and other nurses while ASM #1 was out of town. She stated she had the opportunity to interview LPN #7 by phone in the presence of OSM #14, the director of human resources. During that interview, she stated LPN #7 denied the allegations. ASM #2 stated at no time did she report the allegation or initiate an official investigation. On 5/21/24 at 2:54 p.m., CNA #4 was interviewed. She stated she did not recall the exact date, but she remembered standing beside the medication cart talking with LPN #7. LPN #7 was in the process of administering medications to residents on the hall. She stated R17 was yelling, Ma'am! Ma'am! LPN #7 stated something to the effect of oh, she's starting again today. CNA #4 heard LPN #7 say: I am going to take care of it. CNA stated she saw LPN #7 take out a bottle of liquid Haldol, draw some up, and squirt it into a medication cup. LPN #7 took the medication in R17's room. CNA #4 stated when LPN #7 returned to the medication cart, LPN #7 stated: You didn't see anything. CNA #4 stated it took a while to work up the courage to report LPN #7's actions. She stated: I was scared to tell anybody. We had new management. They had not been the friendliest, and I did not feel comfortable. She stated she went to RN #4, the former ADON, and ASM #2, the DON. She stated ASM #2 told her: It's your word against hers. It won't go anywhere. But we will talk to [LPN #7]. She stated this was 5/3/24, the same day OSM #19 came to the facility. She added: I took it to mean [ASM #2] was not going to investigate it. She stated ASM #2 said to her: It's hearsay. It's your word against hers. When asked if she had ever received training about reporting allegations of abuse, mistreatment, or misappropriation of resident property, she stated she had. She stated she had been told to report any concerns immediately to a supervisor, and if this is not effective, to go higher up the chain of command with the reports. She stated ultimately this is what she did, as she reported these allegations to both APS and to the local police department. On 5/21/24 at 3:32 p.m., LPN #6, the MDS nurse, was interviewed. She stated she received a report from CNA #4 regarding LPN #7 giving medications to R64 without an order on 5/3/24. She stated she called OSM #11, who was the acting administrator, and told her what she had been told. She stated OSM #11 told her that OSM #11 was going to call ASM #2 and ASM #6. She stated she did not know when or if an investigation was started. She stated CNA #4 told her that ASM #2 told CNA #4 that there would never be a way to prove that LPN #7 had done anything wrong, and that is was strictly a he-said/she-said situation. She added: That's why I called OSM #11. On 5/21/24 at 3:55 p.m., RN #4, the former ADON, was interviewed. She stated CNA #4 went to ASM #2 and her the day before OSM #19 came into the facility. She stated: This would have been May 2 when she initially came in to talk to us. She stated the report was that there was a diversion of a medication, but she was not aware on 5/2/24 that the medication was Haldol. She stated CNA #4 came into ASM #2's office, and that LPN #5, the unit manager, was also present. CNA #4 told them she did not know to whom she should be talking, but that about a week before, R17 was having increased behaviors, and LPN #7 told her (CNA #4), You didn't see this. I have something for this. She stated ASM #2 told CNA #4 that this is a he said/she said situation, but that she would look into it. She stated she was aware that this allegation was not reported to facility management in a timely manner. On 5/23/24 at 2:30 p.m., OSM #11 was interviewed. When asked if R64's physician or RP had been notified of the allegation regarding misappropriation of R64's property, she stated: We did not notify the physician or RP. Both of them should have been notified. [R64] was a victim, as well. On 5/23/24 at 3:15 p.m., ASM #5, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. 2. For Resident #336 (R336), the facility staff failed to notify the physician when R336 did not receive treatments as ordered. R336 was admitted to the facility on [DATE] with a past medical history of a recurrent perirectal (area around the rectum) abscess. A review of R336's admission Nursing assessment dated [DATE] revealed, in part: Skin .Perirectal drain with brown drainage in brief. A review of R336's admitting history and physical dated 5/1/24 revealed, in part: History of present illness .There is a Penrose drain (1) sutured in place .Resident is doing well since admission to skilled facility. She states she still has some discomfort at the abscess site, but otherwise has no complaints .She feels she is developing a yeast rash .around her wound .Plan .I and D (incision and drainage) is open .Continue to monitor closely for signs and symptoms of infection. A review of R336's progress notes revealed a note dated 5/1/24. The note reported R336 saw the surgeon, who removed the Penrose drain, and gave orders for a Sitz bath (2) three times a day, and at least one shower per day. A review of R336's May 2024 MAR (medication administration record) revealed the following. On 5/1/24, the resident refused at 9:00 a.m. and 1:00 p.m., and the 5:00 p.m. Sitz bath was not given. On 5/2/24, the resident refused the Sitz bath at 9:00 a.m. On 5/3/23, the resident did not receive the Sitz bath at 5:00 p.m. On 5/5/23, the resident was discharged . Further review of R336's progress notes revealed the following: 5/1/24 at 3:11 p.m. Sitz bath unavailable. Will contact MD. 5/1/24 at 3:12 p.m. Sitz bath unavailable. Will speak with MD. Resident did have a shower with a sprayer and was able to irrigate area well.: 5/2/24 at 10:22 a.m. Sitz bath not available in facility. RN (registered nurse) will assist resident to clean well in peri-rectal area. This review revealed no evidence of the physician's response to the notifications. On 5/14/24 at 8:52 a.m., RN (registered nurse) #1, who cared for R336 during her stay at the facility, was interviewed. She stated R336 was pretty much self-care, and that the resident was very independent, not needing very much help. She stated the facility did not have the right equipment to provide a Sitz bath for R336. Instead, the resident stood in the shower and used a handheld sprayer. RN #1 stated the resident did this herself, and could not say for certain if the resident was getting completely clean. When asked what the physician said when she notified him about not having the Sitz bath equipment, she stated: I don't recall. I'm sure I told him, and he didn't give us any new orders. On 5/15/24 at 1:39 p.m., ASM (administrative staff member) #8, the attending physician, was interviewed. When asked how he responded to the facility nurses when they notified him that R336 was not receiving Sitz baths, he stated: They did not contact me. I would have given a different order. He stated a Sitz bath is different in substance from a shower. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. Reference (1)A sitz bath is a warm water bath used for healing or cleansing purposes. You sit in the bath. The water covers only your hips and buttocks. The water may contain medicine. Sitz baths are often used to relieve pain, itching, or muscle spasms. This information is taken from the website https://medlineplus.gov/ency/article/002299.htm#:~:text=A%20sitz%20bath%20is%20a,%2C%20itching%2C%20or%20muscle%20spasms. 5. For R65, the facility staff failed to notify the physician and responsible party of the laboratory (lab) tests CBC (complete blood count) (1), CMP (comprehensive metabolic panel) (2), CRP (C-Reactive protein) (3), ESR (erythrocyte sedimentation rate) (4), CPK (creatine phosphokinase) (5), were not obtained on 04/04/2024, 04/25/2024 and 05/02/2024. R65 was admitted to the facility with diagnoses that included but were not limited to osteomyelitis (6) of ankle and foot. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/26/2024, R65 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R65 was cognitively intact for making daily decisions. The physician's orders for R65 documented: Lab (laboratory) draw weekly on Thursday through ABT (antibiotic) labs to include CBC (complete blood count), CMP (comprehensive metabolic panel), CRP (C-Reactive protein), ESR (erythrocyte sedimentation rate), CPK (creatine phosphokinase) one time a day every Thur (Thursday) for lab work for ABT r/t (related to) foot infection. Order Date: 03/25/2024. Start Date: 03/28/2024. DAPTOmycin (7) Intravenous Solution reconstituted 500MG (milligrams). Use 400 mg intravenously one time a day for foot infection until 04/30/2024. Order Date: 03/25/2024. DAPTOmycin Intravenous Solution reconstituted 500MG (milligrams). Use 400 mg intravenously one time a day for foot infection. Start Date: 04/26/2024. End Date: 05/14/2024. Review of the facility's EHR (electronic health record) for R65 failed to evidence the physician's ordered lab tests as stated above were obtained on 04/04/2024, 04/25/2024 and on 05/02/2024. Review of the facility's progress notes for R65 dated 04/01/2024 through 05/09/2024 failed to evidence documentation of the physician and responsible party being notified that the labs were not obtained on 04/04/2024, 04/25/2024 and on 05/02/2024. The eMARs (electronic medication administration records) for R65 dated March 2024, April 2024 and May 2024 documented the physician's order for Daptomycin as stated above. Further review of the eMARs revealed R65 received the antibiotic daily from 03/26/2024 through 05/09/2024. On 05/22/24 at approximately 10:35 a.m., an interview was conducted with RN (registered nurse) #3. When asked to describe the procedure for obtaining physician ordered labs for a resident, RN #3 stated the nurse draws lab (blood) and sends it to the lab. When asked about the labs ordered for every Thursday for R65 RN #3 stated the labs were to continue until the antibiotic was completed. When asked to describe the procedure when physician ordered labs were obtained RN #3 stated the nurse should notify the physician and the responsible party and document the notification in the nurse's notes. The facility's policy Laboratory, Diagnostic and X-Ray documented in part, Procedure: Document notification of the practitioner and resident/resident representative of results. On 05/22/2024 at approximately 5:15 p.m., ASM (administrative staff member) #1, administrator, ASM #4, director of sales and marketing, ASM #5, regional director of clinical services and ASM #6, vice president of operations, and OSM (other staff member) #11, director of social services, were made aware of the above findings. No further information was provided prior to exit. References: (1) A blood test. It's used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia. This information was obtained from the website: https://www.mayoclinic.org. (2) A routine blood test that measures 14 different substances in a sample of your blood. It provides important information about your metabolism (how your body uses food and energy) and the balance of certain chemicals in your body. This information was obtained from the website: https://www.medlineplus.gov. (3) Measures inflammation in the body. This information was obtained from the website: https://www.mayoclinic.org. (4) A blood test that that can show if you have inflammation in your body. This information was obtained from the website: https://www.medlineplus.gov. (5) Is an enzyme in the body. It is found mainly in the heart, brain, and skeletal muscle. the test to measures the amount of CPK in the blood. This information was obtained from the website: https://www.medlineplus.gov. (6) An infection in a bone that can be caused by bacteria, injuries, surgeries or other factors. This information was obtained from the website: https://www.mayoclinic.org. (7) Belongs to the class of medicines known as antibiotics. It works by killing bacteria or preventing their growth. This information was obtained from the website: https://www.mayoclinic.org. 3. For Resident #13 (R13), the facility staff failed to notify the physician/nurse practitioner and responsible party of holding the insulin related to the blood sugar readings. An interview was conducted on 5/21/24 1:25 p.m. with R13's responsible party (RP). The RP stated that she does not get notified by the nurses for changes in R13's condition such as low blood sugars and not eating. The physician order dated, 2/15/24, documented, Humalog Kwik Pen Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Lispro) Inject as per sliding scale. If (blood sugar) 80-150 = 5 units; 151-200 = 8 units; 210-250 = 10 units; 251-300 = 12 units; 301-350=13 units; 351-400 = 15 units subcutaneously before meals for DM (diabetes mellitus). Call hospice MD/NP (medical doctor/nurse practitioner) for BS (blood sugar) less than 60 or greater than 400. The April 2024 MAR (medication administration record) documented the above order. On the following dates at 6:30 a.m. the blood sugar was documented as: 4/8/24 - 99 4/11/24 - 125 4/12/24 - 80 4/20/24 - 82 4/21/24 - 127 A 12 was documented under each blood sugar. The chart code for a 12 indicated, Insulin not required. Review of the nurse's notes failed to evidence documentation as to why the insulin was not given or notification of the physician/nurse practitioner or responsible party. The May 2024 MAR documented the above order. On the following dates at 6:30 a.m. the blood sugar was documented as: 5/1/24 - 83 5/14/24 - 138 5/20/24 - 124 A 9 was documented under each blood sugar. The chart code for a 9 indicated, Other/See nurse notes. The nurse's notes dated, 5/1/24 at 6:19 a.m. documented, Not given as FBS (fasting blood sugar) was 83. The nurse's note dated, 5/14/24 at 5:30 a.m. documented, Held BS 138. The nurse's note dated, 5/20/24 at 5:33 a.m. documented, FBS 124 did not give d/t (due to) breakfast is a couple of hours from now and did not want resident to bottom out. There was no evidence of notification to the physician/nurse practitioner or the RP. The comprehensive care plan dated, 2/14/22, documented, Focus: (R13) has Diabetes Mellitus. The Interventions documented in part, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #5, the unit manager, on 5/22/24 at 2:33 p.m. LPN #5 was asked to review the above MARs for R13. LPN #5 stated, Wow, that's a problem. The nurse chose no insulin coverage when the order says to give coverage. When asked if that is following the physician orders, LPN #5 stated, no. LPN #5 was asked if the medication was held, should you tell anyone, she stated that the provider and the RP should be notified. When asked where that is documented, LPN #5 stated, in a chart note or change of condition note. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to post notice of employee rights regarding abuse reporting in a conspicuous location in the facility for staff. On [DATE] at 9:25 a.m., an observation was made of the facility employee break room, no abuse reporting employee rights posting was observed. On [DATE] at 9:27 a.m., a request was made to OSM (other staff member) #11, the director of social services for the location of the posting, OSM #11 stated that she thought there was a poster in the employee break room and proceeded to check the bulletin boards located in the room. On [DATE] at 9:29 a.m., ASM (administrative staff member) #1, the administrator, stated that there was a posting hanging on the bulletin board in the employee break room at the facility. ASM #1 observed the bulletin boards in the break room and stated that it was not there and may have been taken down by mistake. An observation was made of each nurses station bulletin board with ASM #1 also, and no posting was seen, ASM #1 stated that the notice was not posted and she would get one put up as soon as possible. On [DATE] at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. On [DATE] at 7:47 p.m., OSM #11 stated via email that the facility did not have a policy regarding mandated reporter postings. No further information was provided prior to exit. Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement policies for abuse prevention, reporting, and investigation for five of 43 residents in the survey sample, Residents #17, #59, #64, #136, and #38; and on one of one facility bulletin board. The findings include: 1. For Resident #17 (R17), the facility staff failed to implement their policy for reporting and investigating an allegation of misappropriation of R17's property in a timely manner. A review of R64's clinical record revealed the following order dated [DATE]: Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter. Give 0.25 ml by mouth every 4 hours as needed for agitation. A review of R64's care plan dated [DATE] revealed, in part: The resident has behaviors .r/t (related to) terminal diagnosis .[R64] is on an antipsychotic medication r/t end of life care. Psychosis and terminal agitation. A review of a facility synopsis of events dated [DATE] revealed, in part: Incident Date [DATE] .Report Date [DATE] .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated [DATE] revealed, in part: The initial report that was filed on [DATE] stated that [R17] was the resident involved in the report, but with the investigation we have identified .[R64] .The allegation was made by a certified nursing assistant that she had knowledge that [LPN #7] was administering medications to .[R17] .to keep them calm, and she was giving them the medication without a physician's order. It was discovered during the investigation that [LPN #7] had administered a medication (Haldol) from [R64] to [R17] due to their behaviors to keep them quiet. The medication is an antipsychotic and was in liquid form. An account of the liquid revealed that 13 mls of the medication were unaccounted for .An internal investigation was started along with the assistance of APS (adult protective services). [LPN #7] (licensed practical nurse) admitted to APS that she had chemically restrained .[R64] without a physician's order .The [name of local police] is involved as well, and criminal charges pending currently .[LPN #7] will be termed from our employment. On [DATE] at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on [DATE] when she received an email from APS. On [DATE] at 1:09 p.m., ASM #2, the director of nursing (DON), was interviewed. She stated she and RN (registered nurse) #4, the former assistant DON (ADON), used R64's MAR (medication administration) to calculate how much Haldol should have been remaining in R64's supply on [DATE]. They discovered, between two bottles of Haldol, 20 milliliters total of missing medication. On [DATE] at 9:38 a.m., OSM (other staff member) #19, an APS (adult protective services) worker, was interviewed. He stated on [DATE], he received an anonymous complaint from a facility staff member regarding a possible resident-to-resident drug diversion by LPN #7.He stated he contacted the facility staff (ASM #2) on [DATE]. On [DATE] at 2:01 p.m., OSM #11, the director of social services, was interviewed. She stated she became aware of the allegations against LPN #7 on [DATE] when LPN #6, the MDS nurse, called her to tell her than a staff member had just alleged a drug diversion against LPN #7. She stated she immediately called ASM #2 and ASM #6, the regional vice president of operations. She stated ASM #2 told her that it was being looked into. She stated the allegation was not reported to any of the required entities on [DATE], as far as she knew. She also stated an investigation was not started on [DATE]. She stated the allegation should have been immediately reported, and that an investigation should have been immediately started. She stated it was her understanding that the investigation was currently underway, but she was not an active part of the investigation. She stated she was able to get a statement from LPN #7, who denied all allegations to her. On [DATE] at 3:23 p.m., ASM #2 was interviewed. She stated the allegation of the Haldol diversion came to her as a complaint regarding R17. She stated she was told CNA #4's observations had occurred at least a week before the report came to her attention. She stated she was told about this on [DATE]. She stated she wasn't told specifically which drug was involved, but she was told which nurse and which resident were involved. She stated she asked CNA #4 why the CNA had reported the allegation sooner. She stated she did not report it to the state agency or any other required entity on [DATE] because she did not know what to look for or how to investigate it. She stated she did not remove LPN #7 from the schedule, and LPN #7 worked the night of [DATE]. She stated on [DATE], OSM #19 came to the facility and corroborated the allegation of the drug diversion on the part of LPN #7. She stated she went ahead and removed LPN #7 from the schedule for that evening, and for subsequent evenings. She stated she called OSM #11, who was the acting administrator, to inform her. She stated OSM #11 was acting as the administrator because ASM #1, the administrator, was out of the country. She stated she and OSM #11 talked to CNAs, residents, and other nurses while ASM #1 was out of town. She stated she had the opportunity to interview LPN #7 by phone in the presence of OSM #14, the director of human resources. During that interview, she stated LPN #7 denied the allegations. ASM #2 stated at no time did she report the allegation or initiate an official investigation. On [DATE] at 2:54 p.m., CNA #4 was interviewed. She stated she did not recall the exact date, but she remembered standing beside the medication cart talking with LPN #7. LPN #7 was in the process of administering medications to residents on the hall. She stated R17 was yelling, Ma'am! Ma'am! LPN #7 stated something to the effect of oh, she's starting again today. CNA #4 heard LPN #7 say: I am going to take care of it. CNA stated she saw LPN #7 take out a bottle of liquid Haldol, draw some up, and squirt it into a medication cup. LPN #7 took the medication in R17's room. CNA #4 stated when LPN #7 returned to the medication cart, LPN #7 stated: You didn't see anything. CNA #4 stated it took a while to work up the courage to report LPN #7's actions. She stated: I was scared to tell anybody. We had new management. They had not been the friendliest, and I did not feel comfortable. She stated she went to RN #4, the ADON, and ASM #2, the DON. She stated ASM #2 told her: It's your word against hers. It won't go anywhere. But we will talk to [LPN #7]. She stated this was [DATE], the same day OSM #19 came to the facility. She added: I took it to mean [ASM #2] was not going to investigate it. She stated ASM #2 said to her: It's hearsay. It's your word against hers. When asked if she had ever received training about reporting allegations of abuse, mistreatment, or misappropriation of resident property, she stated she had. She stated she had been told to report any concerns immediately to a supervisor, and if this is not effective, to go higher up the chain of command with the reports. She stated ultimately this is what she did, as she reported these allegations to both APS and to the local police department. On [DATE] at 3:32 p.m., LPN #6, the MDS nurse, was interviewed. She stated she received a report from CNA #4 regarding LPN #7 giving medications to R64 without an order on [DATE]. She stated she called OSM #11, who was the acting administrator, and told her what she had been told. She stated OSM #11 told her that OSM #11 was going to call ASM #2 and ASM #6. She stated she did not know when or if an investigation was started. She stated CNA #4 told her that ASM #2 told CNA #4 that there would never be a way to prove that LPN #7 had done anything wrong, and that is was strictly a he-said/she-said situation. She added: That's why I called OSM #11. On [DATE] at 3:55 p.m., RN #4, the ADON, was interviewed. She stated CNA #4 went to ASM #2 and her the day before OSM #19 came into the facility. She stated: This would have been [DATE] when she initially came in to talk to us. She stated the report was that there was a diversion of a medication, but she was not aware on [DATE] that the medication was Haldol. She stated CNA #4 came into ASM #2's office, and that LPN #5, the unit manager, was also present. CNA #4 told them she did not know to whom she should be talking, but that about a week before, R17 was having increased behaviors, and LPN #7 told her (CNA #4), You didn't see this. I have something for this. She stated ASM #2 told CNA #4 that this is a he said/she said situation, but that she would look into it. She stated she was aware that this allegation was not reported to facility management in a timely manner. On [DATE] at 5:10 p.m., ASM #1, ASM #5, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation, revealed, in part: Identification: All reported events .will be investigated by the Director of Nursing/designee. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted. In the absence of the Executive Director, the Director of Nursing will serve as Abuse Coordinator .Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation, and exploitation. A Social Service representative may be offered int he role of resident advocate during any questioning or interviewing of residents .Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation, and notify the attending physician .Upon the completion of the investigation, a detailed report shall be prepared .Any suspect(s) who is an employee or contract service provider, once he/she has been identified, will be suspended pending the investigation .Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive director and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting as may be required by law. In all cases, the Executive Director or Director of Nursing will ensure notification to the resident's legal guardian, family member, responsible party, or significant other of the alleged, suspected, or observed abuse, neglect, or mistreatment, and the resident's attending physician. No further information was provided prior to exit. References (1) Haloperidol is used to treat psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real). Haloperidol is also used to control motor tics (uncontrollable need to repeat certain body movements) and verbal tics (uncontrollable need to repeat sounds or words) in adults and children who have Tourette's disorder (condition characterized by motor or verbal tics). Haloperidol is also used to treat severe behavioral problems such as explosive, aggressive behavior or hyperactivity in children who cannot be treated with psychotherapy or with other medications. Haloperidol is in a group of medications called conventional antipsychotics. It works by decreasing abnormal excitement in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682180.html. 2. For Resident #59 (R59), the facility staff failed to implement their policy for reporting and investigating an allegation of abuse and misappropriation of property in a timely manner. A review of R59's clinical record revealed the following orders: [DATE] Admit to [name of local hospice provider]. [DATE] Morphine Sulphate (1) Concentrate Oral Solution 20 mg/ml (milligrams per milliliter) Give 0.25 mls by mouth every 4 hours as needed for pain. [DATE] [DATE] Morphine Sulphate Concentrate Oral Solution 20 mg/ml (milligrams per milliliter) Give 0.5 ml by mouth every 8 hours for pain. On [DATE] at 1:47 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated that on the night shift during the previous week (she could not remember the exact date), she became suspicious of LPN (licensed practical nurse) #9, who was taking care of R59. LPN #5 stated she was administering medications on the night shift on one unit, and LPN #9 was administering medications on the other unit. At the end of LPN #9's shift, she did not do a narcotic reconciliation with the oncoming nurse, LPN #8. Later that morning, LPN #8 commented to her that he wasn't going to give R59 any of the Morphine in the medication cart because it looked watered down. She stated she asked LPN #8 to show her the Morphine bottle in question. She stated the Morphine bottle contained more liquid (4 mls) than was recorded on the narcotic reconciliation sheet (2.5 mls) most recently updated by LPN #9 after administering medications to R59 during the night. LPN #5 further stated that LPN #9 had been asleep at the nurses' station during the night shift that night. LPN #5 stated nursing management was made aware of the discrepancy, but could not recall exactly whom she notified. LPN #5 stated LPN #9 was back in the building the following evening shift, but walked out of the facility without finishing her shift, and without relief. She stated that, as far as she knew, no investigation had been initiated. On [DATE] at 3:32 p.m., LPN #6, the MDS (minimum data set) Coordinator, was interviewed. She stated that the previous week, LPN #9 had left the facility without having a nurse to relieve her, essentially abandoning her residents. She stated when LPN #9 left without relief, she and LPN #5 counted the narcotics in the medication cart. She stated that a bottle of R59's Morphine was 4 mls short, according to the narcotic sheet. She stated she took the bottle of Morphine immediately to ASM (administrative staff member) #5, regional director of clinical services, and told her that some medication was missing. On [DATE] at 3:55 p.m., RN (registered nurse) #4, the former assistant director of nursing (ADON), was interviewed. She stated the management staff have discovered discrepancies in the color of Morphine in R59's bottles. She stated: The color is not consistently deep blue. It's a shame. [R59] died so we can't talk to him about it. On [DATE] at 10:32 a.m., ASM #5 was interviewed. She stated: Yesterday morning, they were telling me something about the Morphine. I didn't know anything about the Morphine until yesterday morning ([DATE]). [LPN #5] was the one who shared it with me. She stated she attempted to reach out to LPN #9 on [DATE], but was unsuccessful. When asked if LPN #6 had brought a bottle of Morphine to her on [DATE] after LPN #9 walked out of the facility, she stated: Oh yeah. [LPN #6] brought a bottle in her, and said there were 2.5 mls in it when there should have been 4 or 5. When asked to clarify that she actually was informed of the Morphine concern as early as [DATE], rather than [DATE], she stated: Yes, that's right. When asked if she reported this to the state agency on [DATE] and removed LPN #9 from the facility schedule, she stated she did not. When asked why she did not file a report, remove the nurse from the schedule, or initiate an investigate immediately on [DATE], she did not give a response. She stated: Usually I try to get it within 24 hours, and I didn't. She stated on [DATE], she put the Morphine bottle in a locked drawer in ASM #1's, the administrator's, office. She stated ASM #1 was in the facility working the floor as a nurse on [DATE]. She stated she did not remember whether or not she informed ASM #1 of the problem with the Morphine on that day. On [DATE] at 11:17 p.m., ASM #5 returned to the survey team. She stated: When [LPN #6] brought [the bottle of Morphine] to me, it was actually on the 18th ([DATE]). She stated on [DATE], LPN #6 was attempting to explain to her why there was a problem with the Morphine bottle, and that her understanding was that this particular Morphine bottle was short two or three mls. She stated she started an investigation that day. She stated on [DATE], OSM (other staff member) #11, the director of social services/acting administrator, began to help her. She stated ASM #1 told her that she did not hear her inform her of any problems on the day she locked the Morphine in ASM #1's office. When asked what should have happened on [DATE] or [DATE] - whichever date she became aware of the potential drug diversion - she stated: I did the cart audits. I notified [ASM #1]. I didn't get to pull everything together. When you are here on the weekend, it is hard. I didn't have the HR (human resources) piece to it. She stated on [DATE] she was running around doing education on a previous delayed investigation. She then stated: I let [ASM #1] know on Sunday ([DATE]) when she was here working the floor. She added: [ASM #1] says she has not reported anything yet. On [DATE] at 5:44 p.m., OSM #11 and ASM #1 were interviewed. She stated the allegations against LPN #9 were reported to facility management staff on Friday, [DATE]. OSM #11 stated LPN #5 reported to ASM #1 that R59's Morphine count was off on [DATE]. ASM #1 stated: I don't remember being told about the Morphine. On [DATE] at 5:10 p.m., ASM #1, ASM #5, ASM #6, the regional vice president of operations, and OSM #11, the social services director, were informed of these concerns. No further information was provided prior to exit. References (1) Morphine is used to relieve moderate to severe pain. Morphine extended-release tablets and capsules are only used to relieve severe (around-the-clock) pain that cannot be controlled by the use of other pain medications. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682133.html. 3. For Resident #64 (R64), the facility staff failed to implement their policy for reporting and investigating an of misappropriation of property in a timely manner. A facility nurse allegedly took R64's Haldol (1) and administered it to Resident #17 (R17) without an order. A review of R64's clinical record revealed the following order dated [DATE]: Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter. Give 0.25 ml by mouth every 4 hours as needed for agitation. A review of R64's care plan dated [DATE] revealed, in part: The resident has behaviors .r/t (related to) terminal diagnosis .[R64] is on an antipsychotic medication r/t end of life care. Psychosis and terminal agitation. A review of a facility synopsis of events dated [DATE] revealed, in part: Incident Date [DATE] .Report Date [DATE] .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated [DATE] revealed, in part: The initial report that was filed on [DATE] stated that [R17] was the resident involved in the report, but with the investigation we have identified .[R64] .The allegation was made by a certified nursing assistant that she had knowledge that [LPN #7] was administering medications to .[R17] .to keep them calm, and she was giving them the medication without a physician's order. It was discovered during the investigation that [LPN #7] had administered a medication (Haldol) from [R64] to [R17] due to their behaviors to keep them quiet. The medication is an antipsychotic and was in liquid form. An account of the liquid revealed that 13 mls of the medication were unaccounted for .An internal investigation was started along with the assistance of APS (adult protective services). [LPN #7] (licensed practical nurse) admitted to APS that she had chemically restrained .[R64] without a physician's order . On [DATE] at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on [DATE] when she received an email from APS. On [DATE] at 1:09 p.m., ASM #2, the director of nursing (DON), was interviewed. She stated she and RN (registered nurse) #4, the former assistant DON (ADON), used R64's MAR (medication administration) to calculate how much Haldol should have been remaining in R64's supply on [DATE]. They discovered, between two bottles of Haldol, 20 milliliters total of missing medication. On [DATE] at 9:38 a.m., OSM (other staff member) #19, an APS (adult protective services) worker, was interviewed. He stated on [DATE], he received an anonymous complaint from a facility staff member regarding a possible resident-to-resident drug diversion by LPN #7. On that day, he also received a call from OSM #20, a member of the local police force, regarding the same drug diversion allegation. He stated he contacted the facility staff (ASM #2) on [DATE]. On [DATE] at 2:01 p.m., OSM #11, the director of social services, was interviewed. She stated she became aware of the allegations against LPN #7 on [DATE] when LPN #6, the MDS nurse, called her to tell her than a staff member had just alleged a drug diversion against LPN #7. She stated she immediately called ASM #2 and ASM #6, the regional vice president of operations. She stated ASM #2 told her that it was being looked into. She stated the allegation was not reported to any of the required entities on [DATE], as far as she knew. She also stated an investigation was not started on [DATE]. She stated the allegation should have been immediately reported, and that an investigation should have been immediately started. She stated it was her understanding that the investigation was currently underway, but she was not an active part of the investigation. She stated she was able to get a statement from LPN #7, who denied all allegations to her. On [DATE] at 3:23 p.m., ASM #2 was interviewed. She stated the allegation of the Haldol diversion came to her as a complaint regarding R17. She stated she was told CNA #4's observations had occurred at least a week before the report came to her attention. She stated she was told about this on [DATE]. She stated she wasn't told specifically which drug was involved, but she was told which nurse and which resident were involved. She stated she asked CNA #4 why the CNA had reported the allegation sooner. She stated she did not report it to the state agency or any other required entity on [DATE] because she did not know what to look for or how to investigate it. She stated she did not remove LPN #7 from the schedule, and LPN #7 worked the night of [DATE]. She stated on [DATE], OSM #19 came to the facility and corroborated the allegation of the drug diversion on the part of LPN #7. She stated she went ahead and removed LPN #7 from the schedule for that evening, and for subsequent evenings. She stated she called OSM #11, who was the acting administrator, to inform her. She stated OSM #11 was acting as the administrator because ASM #1, the administrator, was out of the country. She stated she and OSM #11 talked to CNAs, residents, and other nurses while ASM #1 was out of town. She stated she had the opportunity to interview LPN #7 by phone in the presence of OSM #14, the director of human resources. During that interview, she stated LPN #7 denied the allegations. ASM #2 stated at no time did she report the allegation or initiate an official investigation. On [DATE] at 2:54 p.m., CNA #4 was interviewed. She stated she did not recall the exact date, but she remembered standing beside the medication cart talking with LPN #7. LPN #7 was in the process of administering medications to residents on the hall. She stated R17 was yelling, Ma'am! Ma'am! LPN #7 stated something to the effect of oh, she's starting again today. CNA #4 heard LPN #7 say: I am going to take care of it. CNA stated she saw LPN #7 take out a bottle of liquid Haldol, draw some up, and squirt it into a medication cup. LPN #7 took the medication in R17's room. CNA #4 stated when LPN #7 returned to the medication cart, LPN #7 stated: You didn't see anything. CNA #4 stated it took a while to work up the courage to report LPN #7's actions. She stated: I was scared to tell anybody. We had new management. They had not been the friendliest, and I did not feel comfortable. She stated she went to RN #4, the ADON, and ASM #2, the DON. She stated ASM #2 told her: It's your word against hers. It won't go anywhere. But we will talk to [LPN #7]. She stated this was [DATE], the same day OSM #19 came to the facility. She added: I took it to mean [ASM #2] was not going to investigate it. She stated ASM #2 said to her: It's hearsay. It's your word against hers. When asked if she had ever received training about reporting allegations of abuse, mistreatment, or misappropriation of resident property, she stated she had. She stated she had been told to report any concerns immediately to a supervisor, and if this is not effective, to go higher up the chain of command with the reports. She stated ultimately this is what she did, as she reported these allegations to both APS and to the local police department. On [DATE] at 3:32 p.m., LPN #6, the MDS nurse, was interviewed. She stated she received a report from CNA #4 regarding LPN #7 giving medications to R64 without an order on [DATE]. She stated she called OSM #11, who was the acting administrator, and told her what she had been told. She stated OSM #11 told her that OSM #11 was going to call ASM #2 and ASM #6. She stated she did not know when or if an investigation was started. She stated CNA #4 told her that ASM #2 told CNA #4 that there would never be a way to prove that LPN #7 had done anything wrong, and that is was strictly a he-said/she-said situation. She added: That's why I called OSM #11. On [DATE] at 3:55 p.m., RN #4, the ADON, was interviewed. She stated CNA #4 went to ASM #2 and her the day before OSM #19 came into the facility. She stated: This would have been [DATE] when she initially came in to talk to us. She stated the report was that there was a diversion of a medication, but she was not aware on [DATE] that the medication was Haldol. She stated CNA #4 came into ASM #2's office, and that LPN #5, the unit manager, was also present. CNA #4 told them she did not know to whom she should be talking, but that about a week before, R17 was having increased behaviors, and LPN #7 told her (CNA #4), You didn't see this. I have something for this. She stated ASM #2 told CNA #4 that this is a he said/she said situation, but that she would look into it. She stated she was aware that this allegation was not reported to facility management in a timely manner. On [DATE] at 5:10 p.m., ASM #1, ASM #5, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. References (1)Haloperidol is used to treat psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real). Haloperidol is also used to control motor tics (uncontrollable need to repeat certain body movements) and verbal tics (uncontrollable need to repeat sounds or words) in adults and children who have Tourette's disorder (condition characterized by motor or verbal tics). Haloperidol is also used to treat severe behavioral problems such as explosive, aggressive behavior or hyperactivity in children who cannot be treated with psychotherapy or with other medications. Haloperidol is in a group of medications called conventional antipsychotics. It works by decreasing abnormal excitement in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682180.html. 4. For Resident #136, the facility staff failed to implement th[TRUNCATED]

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on staff interview, facility document review, and clinical record review, the facility staff failed to report allegations of abuse in a timely manner for five of 43 residents in the survey sample, Residents #17, #59, #64, #136, and #38. The findings include: 1. For Resident #17 (R17), the facility staff failed to report an allegation of misappropriation of R17's property in a timely manner. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date 5/13/24 .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. Please see F605 and F607 for additional details regarding R17. 2. For Resident #59 (R59), the facility staff failed to report an allegation of abuse and misappropriation of property in a timely manner. On 5/22/24 at 10:32 a.m., ASM #5 was interviewed. She stated: Yesterday morning, they were telling me something about the Morphine. I didn't know anything about the Morphine until yesterday morning (5/21/24). [LPN #5] was the one who shared it with me. She stated she attempted to reach out to LPN #9 on 5/21/24, but was unsuccessful. When asked if LPN #6 had brought a bottle of Morphine to her on 5/16/24 after LPN #9 walked out of the facility, she stated: Oh yeah. [LPN #6] brought a bottle in her, and said there were 2.5 mls in it when there should have been 4 or 5. When asked to clarify that she actually was informed of the Morphine concern as early as 5/16/24, rather than 5/21/24, she stated: Yes, that's right. When asked if she reported this to the state agency on 5/16/24 and removed LPN #9 from the facility schedule, she stated she did not. When asked why she did not file a report, remove the nurse from the schedule, or initiate an investigate immediately on 5/16/24, she did not give a response. She stated: Usually I try to get it within 24 hours, and I didn't. She stated on 5/16/24, she put the Morphine bottle in a locked drawer in ASM #1's, the administrator's, office. She stated ASM #1 was in the facility working the floor as a nurse on 5/16/24. She stated she did not remember whether or not she informed ASM #1 of the problem with the Morphine on that day. Please refer to F605 and F607 for additional details related to R59. 3. For Resident #64 (R64), the facility staff failed to report an allegation of misappropriation of property in a timely manner. A facility nurse allegedly took R64's Haldol (1) and administered it to Resident #17 (R17) without an order, and the facility failed to report it immediately. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 On 5/14/24 at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on 5/9/24 when she received an email from APS. On 5/15/24 at 2:01 p.m., OSM #11, the director of social services, was interviewed. She stated she became aware of the allegations against LPN #7 on 5/3/24 when LPN #6, the MDS nurse, called her to tell her than a staff member had just alleged a drug diversion against LPN #7. She stated she immediately called ASM #2 and ASM #6, the regional vice president of operations. She stated ASM #2 told her that it was being looked into. She stated the allegation was not reported to any of the required entities on 5/3/24, as far as she knew. She also stated an investigation was not started on 5/3/24. She stated the allegation should have been immediately reported, and that an investigation should have been immediately started. She stated it was her understanding that the investigation was currently underway, but she was not an active part of the investigation. She stated she was able to get a statement from LPN #7, who denied all allegations to her. Please see F605 and F607 for additional details regarding R64.4. For Resident #136 and Resident #38, the facility staff failed to report an allegation of verbal abuse to the State Agency. A review of facility synopses of events submitted to the State Agency between 4/20/23 through 5/22/24, revealed no information related to Residents #136 and #38 altercation. The altercation occured on 4/15/24. Please refer to F605 and F607 for more details regarding R#136 and R#38.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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Based on staff interview, facility documentation, clinical record review the facility staff failed to report allegations of abuse in a atimely manner for 5 of 43 residents in the survey sample (Residents #17, #59, #64, #136, and #38) 1. For Resident #17 (R17), the facility staff failed to report an allegation of misappropriation of R17's property in a timely manner. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date 5/13/24 .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. Please see F605 and F607 for additional details regarding R17. 2. For Resident #59 (R59), the facility staff failed to report an allegation of abuse and misappropriation of property in a timely manner. On 5/22/24 at 10:32 a.m., ASM #5 was interviewed. She stated: Yesterday morning, they were telling me something about the Morphine. I didn't know anything about the Morphine until yesterday morning (5/21/24). [LPN #5] was the one who shared it with me. She stated she attempted to reach out to LPN #9 on 5/21/24, but was unsuccessful. When asked if LPN #6 had brought a bottle of Morphine to her on 5/16/24 after LPN #9 walked out of the facility, she stated: Oh yeah. [LPN #6] brought a bottle in her, and said there were 2.5 mls in it when there should have been 4 or 5. When asked to clarify that she actually was informed of the Morphine concern as early as 5/16/24, rather than 5/21/24, she stated: Yes, that's right. When asked if she reported this to the state agency on 5/16/24 and removed LPN #9 from the facility schedule, she stated she did not. When asked why she did not file a report, remove the nurse from the schedule, or initiate an investigate immediately on 5/16/24, she did not give a response. She stated: Usually I try to get it within 24 hours, and I didn't. She stated on 5/16/24, she put the Morphine bottle in a locked drawer in ASM #1's, the administrator's, office. She stated ASM #1 was in the facility working the floor as a nurse on 5/16/24. She stated she did not remember whether or not she informed ASM #1 of the problem with the Morphine on that day. Please refer to F605 and F607 for additional details related to R59. 3. For Resident #64 (R64), the facility staff failed to report an allegation of misappropriation of property in a timely manner. A facility nurse allegedly took R64's Haldol (1) and administered it to Resident #17 (R17) without an order, and the facility failed to report it immediately. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 On 5/14/24 at 11:46 a.m., ASM (administrative staff member) #5, the regional director of clinical services, was interviewed. She stated prior to the events related to R64 and R17, the facility was not maintaining a record of the remaining liquid Haldol amounts after each administration. she stated: Once I found out, I asked them to start counting the liquid and pill forms of Haldol. She added the nursing management staff told her there were 13 mls of Haldol missing form R64's supply. She stated she became aware of the missing medication on 5/9/24 when she received an email from APS. On 5/15/24 at 2:01 p.m., OSM #11, the director of social services, was interviewed. She stated she became aware of the allegations against LPN #7 on 5/3/24 when LPN #6, the MDS nurse, called her to tell her than a staff member had just alleged a drug diversion against LPN #7. She stated she immediately called ASM #2 and ASM #6, the regional vice president of operations. She stated ASM #2 told her that it was being looked into. She stated the allegation was not reported to any of the required entities on 5/3/24, as far as she knew. She also stated an investigation was not started on 5/3/24. She stated the allegation should have been immediately reported, and that an investigation should have been immediately started. She stated it was her understanding that the investigation was currently underway, but she was not an active part of the investigation. She stated she was able to get a statement from LPN #7, who denied all allegations to her. Please see F605 and F607 for more details on R36). 4. For Resident #136 and Resident #38, the facility staff failed to report an allegation of verbal abuse to the State Agency. A review of facility synopses of events submitted to the State Agency between 4/20/23 through 5/22/24, revealed no information related to Residents #136 and #38 altercation. The altercation occured on 4/15/24. Please refer to F605 and F607 for more details regarding R#136 and R#38. A review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation, revealed, in part: Identification: All reported events .will be investigated by the Director of Nursing/designee. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted. In the absence of the Executive Director, the Director of Nursing will serve as Abuse Coordinator .Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation, and exploitation. A Social Service representative may be offered int he role of resident advocate during any questioning or interviewing of residents .Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation, and notify the attending physician .Upon the completion of the investigation, a detailed report shall be prepared .Any suspect(s) who is an employee or contract service provider, once he/she has been identified, will be suspended pending the investigation .Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive director and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting as may be required by law. In all cases, the Executive Director or Director of Nursing will ensure notification to the resident's legal guardian, family member, responsible party, or significant other of the alleged, suspected, or observed abuse, neglect, or mistreatment, and the resident's attending physician.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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3. For Resident #16 (R16), the facility staff failed to implement the comprehensive care plan to administer oxygen as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/14/2024, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment indicating they were cognitively intact for making daily decisions. Section O documented R16 receiving oxygen while a resident at the facility. On 5/20/2024 at 12:10 p.m., an interview was conducted of R16 in their room. R16 was observed in bed wearing an oxygen nasal cannula with a humidifier bottle dated 5/12/2024 attached to an oxygen concentrator. The oxygen flow rate set on the concentrator was observed to be set at 1.5 lpm (liters per minute). R16 stated that they wore the oxygen all the time and the nurses took care of the machine. Additional observations of R16's oxygen were made on 5/20/2024 at 3:51 p.m. revealing the oxygen set at 1.5 lpm and 5/22/2024 at 8:46 a.m. revealing the oxygen set between the 1.5 lpm and 2 lpm lines. The comprehensive care plan for R16 documented in part, [Name of R16] has COPD (chronic obstructive pulmonary disease), cough, chronic respiratory failure. Takes O2 off at times. Date Initiated: 05/02/2019. Revision on: 11/21/2022 . Under Interventions it documented in part, .Oxygen 2 L nasal cannula continuous and humidified. Date Initiated: 12/08/2021. Revision on: 03/21/2022 . The physician order's for R16 documented in part, Respiratory: Oxygen 2L (liters) continuous every shift related to Chronic Respiratory Failure with Hypoxia. Order Date: 04/20/2023 . On 5/21/2024 at 3:55 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the purpose of the care plan was to drive the care of the resident for staff and it should be implemented. On 5/22/2024 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the oxygen rate should be verified every shift and was visualized at eye level to the machine. She stated that the ball on the concentrator should be centered on the line identifying the liters per minute ordered by the physician. On 5/22/2024 at 2:45 p.m., LPN #5 visualized R16's oxygen and stated that it was not set on 2 lpm as ordered and it needed to be adjusted. On 5/22/2024 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was obtained prior to exit. 4. For Resident #47 (R47), the facility staff failed to implement the comprehensive care plan to provide resident centered activities accommodating the resident's language barrier. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment further documented R47 having a preferred language of Korean and wanting or needing an interpreter to communicate with the doctor or health care staff. The assessment further documented R47 having adequate vision and hearing, clear speech, sometimes understood and sometimes able to understand others. Section F of the admission MDS with an ARD of 1/13/2024 documented group activities, going outside and listening to music being very important to R47. The comprehensive care plan for R47 documented in part, The resident is specify: (dependent) on staff for activities, cognitive stimulation, social interaction r/t (Japanese Speaking), AEB (as evidenced by) (Translation sheets available through activity department/interpreter) . Date Initiated: 01/18/2024. Revision on: 05/02/2024. Under Interventions it documented in part, 1:1 activities . Adapt activities to attention span and cognitive level . Provide a calm, non-rushed environment . On 5/15/2024 at 12:31 p.m., an observation was made of R47 in their room. R47 was observed in bed eating lunch. At that time, an interview was attempted with R47 however the resident could not be understood. On 5/16/2024 at 8:44 a.m., R47 was observed in bed asleep. On 5/20/2024 at 12:14 p.m., R47 was observed sitting in a wheelchair in the hallway near the nurse's station with an overbed table in front of them. Additional observation of R47 at 3:51 p.m. revealed the resident sitting in the hallway near the nurse's station with the overbed table in front of them. On 5/21/2024 at 8:45 a.m., R47 was observed in bed sleeping, at 1:10 p.m., R47 was observed sitting in a wheelchair in the hallway near the nurse's station with an overbed table in front of them. There were no translation sheets or communication devices observed in R47's room or available for R47 while at the hallway near the nurse's station in the wheelchair. Staff were observed speaking English to R47 when needed, R47 was not observed responding verbally to staff. On 5/21/2024 at approximately 5:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of activities offered/participation for R47. Review of the activities documentation provided by ASM #1 from 1/1/2024 to the present documented activities on three dates in January 2024, three dates in February 2024, one day in March 2024, two dates in April 2024 and two dates in May 2024. The only group activity participation documented was in May 2024. The clinical record failed to evidence documentation of refusal to attend activities. On 5/21/2024 at 11:43 a.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the staff often sat R47 in the hallway near the nurse's station with the overbed table in front of them. She stated that no one spoke R47's language and they did not have a communication board to speak with them. She stated that she had asked several times to get a communication board and was told that someone was working on one. She stated that she felt that R47 was sometimes treated like a piece of furniture placed in the hallway and everyone just walked around them. On 5/21/2024 at 3:05 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that R47 did not attend any activities except occasionally when someone came in to play music. She stated that she had never used any communication devices or translation sheets for R47 and had always used the hand gestures and the resident could say yes and no. On 5/21/2024 at 3:55 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the purpose of the care plan was to drive the care of the resident for staff and it should be implemented. On 5/22/2024 at 9:06 a.m., an interview was conducted with OSM (other staff member) #13, activities director. OSM #13 stated that it was very hard to determine what R47 was interested in due to the communication barrier. She stated that they tried to invite R47 to any music activities that they offered depending on the resident's mood. She stated that R47 had behaviors and became agitated at times so they kept them distanced. She stated that they mainly strived to offer R47 one to one activities and simple things that did not require an explanation. She stated that activities for R47 had not been as successful as they had hoped for due to the communication barrier. She stated that she had provided the staff with Japanese translation sheets on 5/21/2024 after someone mentioned it to them. She stated that she communicated with R47 by using hand gestures but it was a little difficult. She stated that the facility did not have any type of activity materials to provide to R47 in their preferred language and that they may be beneficial. On 5/22/2024 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was provided prior to exit.5. For Resident #25 (R25), the facility staff failed to implement his care plan to transfer him from his bed to his wheelchair on 5/13/24, 5/14/24, and 5/15/24. R25 was admitted to the facility with diagnoses including cerebral palsy and quadriplegia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/26/24, R25 was coded as being completely dependent on staff for chair/bed-to-chair transfers. On the following dates and times, R25 was observed sitting up in his bed: 5/13/24 at 3:33 p.m.; 5/14/24 at 11:51 a.m. and 3:37 p.m.; 5/15/24 at 11:40 a.m. and 2:56 p.m. A review of R25's care plan dated 5/15/24 revealed, in part: [R25] has an ADL self-care performance deficit r/t (related to) cerebral palsy, bilateral upper and lower extremity contractures .The resident is totally dependent on 2 staff for repositioning and turning in bed as necessary .The resident is totally dependent on 2 staff for transferring. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated R25 should be out of bed every day. She stated he has a wheelchair custom-made for him, and the staff gets him out of bed every morning into that wheelchair. She stated R25 enjoys going to activities and seeing other residents and staff in other parts of the building. She stated the risks of not getting out of bed include skin breakdown and isolation. On 5/21/24 at 3:55 p.m., RN (registered nurse) #4 was interviewed. She stated that the care plan drives all the care for each resident. She stated it is up to the whole team to implement the care plan. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Activities of Daily Living, revealed, in part: Policy: To encourage resident choice and participation in activities of daily living .and provide oversight, cuing, and assistance as necessary. No further information was provided prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for five of 43 residents in the survey sample, Residents #45, #13, #16, #47, and #25. The findings include: 1. For Resident #45, the facility staff failed to implement the comprehensive care plan for the bilateral leg wound treatments as ordered. The comprehensive care plan dated, last revised on 8/25/23, documented in part, Focus: (R45) has potential for impairment to skin r/t (related to) PVD (peripheral vascular disease), Venous insufficiency, left lower extremity wound. The Interventions documented in part, Treatments as ordered. The care plan also documented in part on 9/7/23, Focus: (R45) has a venous/stasis ulcer of the left lower extremity r/t PVD. The Interventions documented in part, Treatments per MD (medical doctor) orders. The physician order dated, 3/27/24 documented, Cleanse Left shin and left calf with wound cleanser. Pat dry with 4x4 (gauze pad). Apply moist 4x4's with 1/4 strength Dakins solution. Cover with gauze, wrap with ace wrap two times a day. The physician order dated, 3/27/24, documented, Cleanse right shin and right calf with wound cleanser. Pat dry with 4x4 (gauze pad). Apply moist 4x4's with 1/4 strength Dakins solution. Cover with gauze, wrap with ace wrap two times a day. The April TAR (treatment administration record) documented the above orders. On 4/5/24, there were blanks for both dressings for both scheduled times of 9:00 a.m. and 9:00 p.m. 5/7/24, there was a blank for both dressings for the 9:00 a.m. treatment. on 5/11/24, there was a blank for the 9:00 p.m. dressing. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. The resident was transferred to the hospital on 4/17/24 and returned on 5/1/24. The physician orders dated 5/11/24, documented, Cleanse area to LLE (left lower extremity -leg) with 1/4 strength Dakins solution. Pat dry. Apply 1/4 strength Dakins moistened gauze to wound bed, cover with ABD (abdominal) pad and wrap with kerlix. Apply Tubi Grip double layered in AM (morning) with compression of 20 - 30 mmg (sic)(mmHg) (millimeters of mercury) one time a day for wound care. The physician order dated 5/11/24, documented, Cleanse area to RLE (right lower extremity -leg) with 1/4 strength Dakins solution. Pat dry. Apply 1/4 strength Dakins moistened gauze to wound bed, cover with ABD pad and wrap with kerlix. Apply Tubi Grip double layered in AM with compression of 20 - 30 mmg (sic) one time a day for wound care. The physician order dated, 5/2/24 documented, Right heel wound: Cleanse area with DWC (wound cleanser), pat dry and apply Xeroform dressing and wrap. Daily TX (treatment) One time a day for Wound Care. The May TAR documented the above orders. On 5/3/24, there was a blank on the TAR for the right heel wound dressing. On 5/13/24 there were blanks on the TAR for all three dressings. On 5/17/24, there were blanks on the TAR for the right heel wound dressing and the RLE dressing. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. When asked the purpose of the care plan, RN #4 stated the care plan drives the care for the resident. An interview was conducted with LPN (licensed practical nurse) #6, the MDS (minimum data set) coordinator, on 5/22/24 at 10:11 a.m. When asked should the care plan be followed, LPN #6 stated, yes, the plan of care should be followed. The facility policy, Plans of Care documented in part, Develop and implement an individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. 2. For Resident #13, the facility staff failed to implement the comprehensive care plan for administering insulin per the physician orders. The comprehensive care plan dated, 2/14/22, documented, Focus: (R13) has Diabetes Mellitus. The Interventions documented in part, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The physician order dated, 2/15/24, documented, Humalog Kwik Pen Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Lispro) Inject as per sliding scale. If (blood sugar) 80-150 = 5 units; 151-200 = 8 units; 210-250 = 10 units; 251-300 = 12 units; 301-350=13 units; 351-400 = 15 units subcutaneously before meals for DM (diabetes mellitus). Call hospice MD/NP (medical doctor/nurse practitioner) for BS (blood sugar) less than 60 or greater than 400. The April 2024 MAR (medication administration record) documented the above order. On the following dates at 6:30 a.m. the blood sugar was documented as: 4/8/24 - 99 4/11/24 - 125 4/12/24 - 80 4/20/24 - 82 4/21/24 - 127 A 12 was documented under each blood sugar. The chart code for a 12 indicated, Insulin not required. Review of the nurse's notes failed to evidence documentation as to why the insulin was not given. The May 2024 MAR documented the above order. On the following dates at 6:30 a.m. the blood sugar was documented as: 5/1/24 - 83 5/14/24 - 138 5/20/24 - 124 A 9 was documented under each blood sugar. The chart code for a 9 indicated, Other/See nurse notes. The nurse's notes dated, 5/1/24 at 6:19 a.m. documented, Not given as FBS (fasting blood sugar) was 83. The nurse's note dated, 5/14/24 at 5:30 a.m. documented, Held BS 138. The nurse's note dated, 5/20/24 at 5:33 a.m. documented, FBS 124 did not give d/t (due to) breakfast is a couple of hours from now and did not want resident to bottom out. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. When asked the purpose of the care plan, RN #4 stated the care plan drives the care for the resident. An interview was conducted with LPN (licensed practical nurse) #6, the MDS (minimum data set) coordinator, on 5/22/24 at 10:11 a.m. When asked should the care plan be followed, LPN #6 stated, yes, the plan of care should be followed. The facility policy, Administering Medications, documented in part, Medications are administered in accordance with prescriber's orders, including any required timeframe. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for six of 43 residents in the survey sample, Residents #42, #61, #48, #58, #45, and #73. The findings include: 1. For Resident #42 (R42), the facility staff failed to review and revise the resident's comprehensive care plan after the resident fell on 1/5/24. A change in condition note dated 1/5/24 documented, a CNA (certified nursing assistant) reported R42 rolled out of bed during peri-care. A review of R42's comprehensive care plan (initiated on 6/25/21) failed to reveal the care plan was reviewed and revised after the resident's 1/5/24 fall. Further review of R42's clinical record revealed the resident fell again on 4/30/24. On 5/21/24 at 4:01 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated the care plan drives all of the care that staff provides residents. RN #4 stated residents' care plans should be reviewed and revised after each fall and staff should look at the care plan and make sure the appropriate interventions are on it. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. The facility policy titled, Plans of Care documented, Review, update and/or revise the comprehensive plan of care based on changing goals, preferences, and needs of the resident and in response to current interventions after the completion of each OBRA (Omnibus Budget Reconciliation Act) MDS (Minimum Data Set) assessment and as needed. 2. For Resident #61 (R61), the facility staff failed to review and revise the resident's comprehensive care plan after another resident became upset, threw a vase, and the vase or a piece of the vase accidentally hit R61 in the head. A facility synopsis of events dated 4/29/24 documented that on 4/29/24, R61 reported that on 4/28/24, R58 became upset in the dining room (due to not being able to go outside to smoke), threw vases, and a vase or piece of vase hit R61 in the head. A note signed by the nurse practitioner on 4/29/24 documented, Advised by staff resident states she was struck in head while another resident was throwing vases in the dining hall. She states it struck her on the left side of her head and it is painful. Plan: Recommend routine checks by staff . A review of R61's comprehensive care plan (initiated on 6/16/22) failed to reveal the care plan was reviewed or revised after the 4/28/24 incident. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated the care plan should probably be reviewed and revised after a resident is hit by another resident displaying behaviors and throwing objects due to the fact that the resident who was hit might have some psychological issues such as post-traumatic stress disorder, or anxiety when around that resident or other residents with similar behaviors. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. 3. For Resident #48 (R48), the facility staff failed to review and revise the resident's comprehensive care plan after another resident became upset then accidentally ran his wheelchair into R48's wheelchair and leg. A facility synopsis of events dated 3/29/24 documented R58 became upset with kitchen staff then accidentally ran his wheelchair into R48's wheelchair and bumped R48's leg. A review of R48's comprehensive care plan (initiated on 1/30/20) failed to reveal the care plan was reviewed or revised after the incident. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated the care plan should probably be reviewed and revised after a resident is hit by another resident displaying behaviors due to the fact that the resident who was hit might have some psychological issues such as post-traumatic stress disorder, or anxiety when around that resident or other residents with similar behaviors. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. 4. For Resident #58 (R58), the facility staff failed to review and revise the resident's comprehensive care plan for behavioral outbursts that affected other residents. A review of R58's clinical record revealed a nurse's note dated 3/28/24 that documented, The resident wheeled himself into the clean utility room attempting to take the cigarettes stating, 'I can go smoke off property.' Since the cigarettes are [sic] out of his reach, he demanded the staff get them for him but they were busy with another resident and passing dinner trays so he began yelling and screaming aggressively to the staff in the hall and called the police, police arrived and talked to him outside. Afterward he parked himself in the middle of the hallway obstructing the food carts from passing through. A south hall rosewood resident reported he bumped his wheelchair into her 3 times, but she was not hurt. A facility synopsis of events dated 3/29/24 documented R58 became upset with kitchen staff then accidentally ran his wheelchair into R48's wheelchair and bumped R48's leg. Further review of R58's clinical record revealed a nurse's note dated 4/28/24 that documented, Resident got angry because he was refused a smoke this AM. Cursed nurse shouting pushed his w/c (wheelchair) into med cart when I was giving meds. Cna (Certified nursing assistant) stated he was transferring himself from bed to chair and almost slipped to floor before she got their [sic]. Resident went into dinning [sic] room and turned over chairs, broke flower vases. A facility synopsis of events dated 4/29/24 documented that on 4/29/24, R61 reported that on 4/28/24, R58 became upset in the dining room (due to not being able to go outside to smoke), threw vases, and a vase or piece of vase hit R61 in the head. R58's comprehensive care plan (initiated on 8/21/23) failed to reveal the care plan was reviewed and revised after both of R58's behavioral outbursts that affected other residents. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated R58's care plan should have been reviewed and revised after both incidents; therefore, if an incident were to occur again, staff would know what interventions were in place and staff could try to figure out a solution. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. 6. For R73, the facility staff failed to review or revise comprehensive care plan following a fall on 03/23/2024. (R73) was admitted to the facility with diagnosis that included but was not limited to a history of falls. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/20/2024, R73 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating R73 was severely impaired of cognition for making daily decisions. The facility's progress note for R73 dated 03/23/2024 at 6:09 p.m., documented, 24 Resident observed sliding from bed onto floor mat next to bed. No apparent injury, MD (medical doctor) and RP (responsible party) notified. The facility's Change in Condition form for R73 dated 03/23/2024 documented in part, A. SITUATION: witnessed fall, no injury, did not hit head, Review of R73's comprehensive care plan with a revision date of 05/08/2024 failed to evidence documentation of R73's fall on 03/23/2024. On 05/22/24 at approximately 9:14 a.m., an interview was conducted with LPN (licensed practical nurse) #6, MDS coordinator. When asked who was responsible for updating a resident's care plan LPN #6 stated it was the responsibility of the nurses and they should put in a new intervention on the care plan. She further stated the care plan should be updated following a resident's fall. When asked about R73's comprehensive care plan being updated following the fall on 03/23/2024, LPN #6 stated she would review the care plan. On 05/22/24 at approximately 10:10 a.m., LPN #6 stated that R73's comprehensive care plan was not updated to reflect the fall on 03/23/2024. On 05/22/2024 at approximately 5:15 p.m., ASM (administrative staff member) #1, administrator, ASM #4, director of sales and marketing, ASM #5, regional director of clinical services and ASM #6, vice president of operations, and OSM (other staff member) #11, director of social services, were made aware of the above findings. No further information was provided prior to exit. 5. For Resident #45, the facility staff failed to review and revise the comprehensive care plan for newly acquired pressure injuries (1). The comprehensive care plan dated, last revised on 8/25/23, documented in part, Focus: (R45) has potential for impairment to skin r/t (related to) PVD (peripheral vascular disease), Venous insufficiency, left lower extremity wound. The Interventions documented in part, Treatments as ordered. The care plan also documented in part on 9/7/23, Focus: (R45) has a venous/stasis ulcer of the left lower extremity r/t PVD. The Interventions documented in part, Treatments per MD (medical doctor) orders. Further review of the comprehensive care plan failed to evidence the presence or interventions for the treatment of two newly acquired pressure injuries. The Weekly Skin Integrity Review dated, 5/14/24, documented in part, Left thigh (rear) lateral abrasion 4x3x0 (centimeters). Site: right upper back, stage 3 (2) PI (pressure injury) 5x10x0. 2 Notes: Wound care currently seeing weekly. Device associated PI. The wound care specialist notes dated 5/15/24, documented in part, Staff noticed 2 open areas, one on pt's (patient's) left lateral thigh they think from transfer with a Hoyer due to pad rubbing and a wound at pt's right upper back they think is from the back of his wheelchair PLAN: Left lateral thigh (+) partial thickness ulceration that measures 4.0 x 3.0 x 0.2 cm. Wound base 100% pale pink moist tissue with bioform before debridement, 100% pink/red moist tissue after. Edges adherent to wound base, scant non-odorous serous drainage, peri wound without erythema, no induration or cellulitis. Patient does demonstrate evidence of pain when area is palpated, subsides with care .Wound to left lateral thigh as follows: Cleanse with wound cleanser or NS (normal saline), pat dry. Apply xeroform to wound bed. (TX (treatment) for moist wound healing and/or autolytic debridement). Cover with dry dressing. Change dressing QD (every day) and as needed for saturation or soilage. Right upper back (+) full thickness ulceration that measures 5.0 x 10.0 x 0.2 cm. Wound base 20% intact, 40% granular, 40% thin slough before debridement, 20% intact, 60% granular, 20% thin adherent slough after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration or cellulitis. Patient does demonstrate evidence of pain when area is palpated, subsides with care Wound care to right upper back as follows: Cleanse with normal saline or wound cleanser, pat dry. Apply alginate to wound bed. cover with foam dressing. (tx for moist wound healing and/or autolytic debridement). Change dressing every day and as needed for saturation or soilage. Review of the physician orders and the TAR (treatment administration record) failed to evidence the above treatment orders for the left lateral thigh had been implemented. The physician orders dated 5/19/24, four days after the wound specialist treated the resident, documented, Cleanse area to right upper back with normal saline or wound cleanser, pat dry. Apply calcium alginate to wound bed, cover with foam dressing (tx for moist wound healing and/or autolytic debridement). change dressing every day and as needed for saturation or soilage one time a day for wound care. Observation was made of R45 with the wound care specialist, administrative staff member (ASM) #7 on 5/22/24 at 8:43 a.m. ASM #7 stated there was no dressing in place on the left lateral thigh and the wound was weeping onto the wheelchair. The wound measured 5.0 x 6.0 x 0.2 cm. When asked if the wound got worse since the previously week because there was no treatment order in place for this wound, ASM #7 stated, absolutely. The right upper back wound measured 2 cm. x 10 cm. x 0.2 cm. ASM #7 stated that the wound did improve as demonstrated by a decrease in area. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. When asked the purpose of the care plan, RN #4 stated the care plan drives the care for the resident. An interview was conducted with LPN (licensed practical nurse) #6, the MDS (minimum data set) coordinator, on 5/22/24 at 10:11 a.m. When asked who updates the care plans, LPN #4 stated everyone, with a fall the nurse should put in a new intervention. But the team reviews in morning meeting and will update care plans as needed right there. When asked if pressure injuries should be addressed on the care plan, LPN #6 stated, yes. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. References: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.a. For Resident #336 (R336), the facility staff failed to assess a surgical drain and the surrounding skin. R336 was admitted to the facility on [DATE] with a past medical history of heart failure, chronic obstructive pulmonary disease, and a recurrent perirectal (area around the rectum) abscess. A review of R336's admission Nursing assessment dated [DATE] revealed, in part: Skin .Perirectal drain with brown drainage in brief. A review of R336's admitting history and physical dated 5/1/24 revealed, in part: History of present illness .There is a Penrose drain (1) sutured in place .Resident is doing well since admission to skilled facility. She states she still has some discomfort at the abscess site, but otherwise has no complaints .She feels she is developing a yeast rash .around her wound .Plan .I and D (incision and drainage) is open .Continue to monitor closely for signs and symptoms of infection. Further review of R336's clinical record, including physician orders, April and May 2024 MARs (medication administration records) or TARs (treatment administration records), or progress notes failed to reveal evidence of consistent nurse assessment of R336's perirectal wound or Penrose drain status during her stay at the facility. On 5/14/24 at 8:52 a.m., RN (registered nurse) #1, who cared for R336 during her stay at the facility, was interviewed. She stated R336 had a Penrose drain that produced brown discharge. She stated R336 was pretty much self-care, and could not remember any formal assessments of the gauze surrounding the drain, or the condition of the skin surrounding the wound. She stated the resident was very independent, and didn't need very much help. On 5/15/24 at 1:39 p.m., ASM (administrative staff member) #8, the attending physician, was interviewed. When asked about what routine care should have been provided for R336's Penrose drain, he stated the nurses should be observing for drainage, and assessing the would regularly to see if there were any signs of infection. He stated he looked at the drain and wound one time, and saw no signs of infection at that point. He stated the skin surrounding the wound was fragile and should have been monitored for irritation or breakdown. On 5/21/24 at 11:00 a.m., ASM #3, the nurse practitioner, was interviewed. She stated she saw R336 before ASM #8. She stated the Penrose drain should have been assessed by the nurses each day and as needed for drainage, and the wound should have been assessed for signs and symptoms of infection. When asked why there were no orders for wound or drain assessment, she stated: That is the responsibility of whoever put the orders in from the hospital. She stated that is the facility nursing staff's responsibility, not hers. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Non Pressure Skin Condition Record, revealed, in part: Policy: To document the presence of skin impairment/new skin impairment not related to pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc .Enter the date, size, drainage information, description of the wound edges, and peri-wound area .Each week the non-pressure skin condition is to be evaluated and the information recorded until resolved. No further information was provided prior to exit. Reference (1) Wound drains designed to remove fluid from wounds by means of tubing that is open to the atmosphere at its distal end. These open wound drainage systems (also known as Penrose drains) typically are composed of short stretches of flexible tube and may be used in combination with an exudate-absorbing wound dressing. Open wound drain systems draw fluid out of the wound through a combination of gravity and capillary action. b. For R336, the facility staff failed to implement a fluid restriction as recommended by the discharging hospital physician. A review of R336's hospital Discharge summary dated [DATE] revealed, in part: Discharge Diagnoses: Acute hypoxic respiratory failure, Acute diastolic heart failure, Pulmonary edema, Pulmonary hypertension .Patient has history of 40 pack per year smoking .She will be discharged home on .fluid restriction, recommendation for daily weight monitoring. A review of R336's clinical record, including physician orders, April and May 2024 MARs (medication administration records) and TARs (treatment administration records), and progress notes, failed to reveal evidence that R336 was placed on a fluid restriction or daily weights at any time during her stay at the facility. A review of R336's baseline care plan dated 4/26/24 revealed, in part: Dietary Orders/Instructions .1500 (milliliter) fluid restrictions. On 5/15/24 at 3:01 p.m., ASM (administrative staff member) #8 was interviewed. When asked if R336 had orders for a fluid restriction while she was at the facility, he stated he could not find any. When asked the process for implementing orders from the discharging facility for residents admitted to the facility, he stated: Usually, nursing puts the orders in [the computer]. The NP (nurse practitioner) gets to them way before I do. I'm not sure why [R336] did not have a fluid restriction here. It looks like she should have. On 5/15/24 at 3:23 p.m., ASM #2, the director of nursing, was interviewed. She stated residents most often arrive at the facility with a discharge summary from the hospital. Facility nurses are responsible for entering the orders into the facility's electronic medical record, and sending the orders to the pharmacy for review. She stated the nurse practitioner and/or attending physician are responsible for signing the orders as accurate and providing the residents with the care they require. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, Fluid Restrictions, revealed, in part: Policy: Residents receive adequate fluid intake within the limitations determined by the attending physician .A written order will be obtained from the attending physician .Caregivers will be notified on limitations .Resident education will be provided on established limits and importance of adhering to restrictions. No further information was provided prior to exit. c. For R336, the facility staff failed to provide Sitz baths and showers to treat a resident's post-surgical site. R336 was admitted to the facility on [DATE] with a past medical history of a recurrent perirectal (area around the rectum) abscess. A review of R336's admission Nursing assessment dated [DATE] revealed, in part: Skin .Perirectal drain with brown drainage in brief. A review of R336's admitting history and physical dated 5/1/24 revealed, in part: History of present illness .There is a Penrose drain (1) sutured in place .Resident is doing well since admission to skilled facility. She states she still has some discomfort at the abscess site, but otherwise has no complaints .She feels she is developing a yeast rash .around her wound .Plan .I and D (incision and drainage) is open .Continue to monitor closely for signs and symptoms of infection. A review of R336's progress notes revealed a note dated 5/1/24. The note reported R336 saw the surgeon, who removed the Penrose drain, and gave orders for a Sitz bath (2) three times a day, and at least one shower per day. A review of R336's May 2024 MAR (medication administration record revealed the following. On 5/1/24, the resident refused at 9:00 a.m. and 1:00 p.m., and the 5:00 p.m. Sitz bath was not given. On 5/2/24, the resident refused the Sitz bath at 9:00 a.m. On 5/3/23, the resident did not receive the Sitz bath at 5:00 p.m. On 5/5/23, the resident was discharged . Further review of R336's progress notes revealed the following: 5/1/24 at 3:11 p.m. Sitz bath unavailable. Will contact MD. 5/1/24 at 3:12 p.m. Sitz bath unavailable. Will speak with MD. Resident did have a shower with a sprayer and was able to irrigate area well.: 5/2/24 at 10:22 a.m. Sitz bath not available in facility. RN (registered nurse) will assist resident to clean well in peri-rectal area. On 5/14/24 at 8:52 a.m., RN (registered nurse) #1, who cared for R336 during her stay at the facility, was interviewed. She stated R336 was pretty much self-care, and that the resident was very independent, not needing very much help. She stated the facility did not have the right equipment to provide a Sitz bath for R336. Instead, the resident stood in the shower and used a handheld sprayer. RN #1 stated the resident did this herself, and could not say for certain if the resident was getting completely clean. When asked what the physician said when she notified him about not having the Sitz bath equipment, she stated: I don't recall. I'm sure I told him, and he didn't give us any new orders. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility's instructions for implementation of a Sitz bath revealed, in part: Fill Sitz bath basin with warm water and place on toilet bowl. Fill bag with warm water .and attach tubing to basin .Warm water is soothing and results in vasodilation to enhance healing .Flow of water in the basin continually replenishes warm water and enhances cleansing and circulation of the perineum .Allow patient to sit for 20 minutes. No further information was provided prior to exit. Reference (2)A sitz bath is a warm water bath used for healing or cleansing purposes. You sit in the bath. The water covers only your hips and buttocks. The water may contain medicine. Sitz baths are often used to relieve pain, itching, or muscle spasms. This information is taken from the website https://medlineplus.gov/ency/article/002299.htm#:~:text=A%20sitz%20bath%20is%20a,%2C%20itching%2C%20or%20muscle%20spasms. Based on staff interview, resident interview, and clinical record review, it was determined the facility staff failed to provide care and services to promote the highest level of well-being for four of 43 residents in the survey sample, Residents #45, #235, #13 and #336. The findings include: 1. For Resident #45, the facility staff failed to administer the treatments per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/4/24, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 3/27/24 documented, Cleanse Left shin and left calf with wound cleanser. Pat dry with 4x4 (gauze pad). Apply moist 4x4's with 1/4 strength Dakins solution. Cover with gauze, wrap with ace wrap two times a day. The physician order dated, 3/27/24, documented, Cleanse right shin and right calf with wound cleanser. Pat dry with 4x4 (gauze pad). Apply moist 4x4's with 1/4 strength Dakins solution. Cover with gauze, wrap with ace wrap two times a day. The April TAR (treatment administration record) documented the above orders. On 4/5/24, there were blanks for both dressings for both scheduled times of 9:00 a.m. and 9:00 p.m. 5/7/24, there was a blank for both dressings for the 9:00 a.m. treatment. on 5/11/24, there was a blank for the 9:00 p.m. dressing. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. The resident was transferred to the hospital on 4/17/24 and returned on 5/1/24. The physician orders dated 5/11/24, documented, Cleanse area to LLE (left lower extremity -leg) with 1/4 strength Dakins solution. Pat dry. Apply 1/4 strength Dakins moistened gauze to wound bed, cover with ABD (abdominal) pad and wrap with kerlix. Apply Tubi Grip double layered in AM (morning) with compression of 20 - 30 mmg (sic)(mmHg) (millimeters of mercury) one time a day for wound care. The physician order dated 5/11/24, documented, Cleanse area to RLE (right lower extremity -leg) with 1/4 strength Dakins solution. Pat dry. Apply 1/4 strength Dakins moistened gauze to wound bed, cover with ABD pad and wrap with kerlix. Apply Tubi Grip double layered in AM with compression of 20 - 30 mmg (sic) one time a day for wound care. The physician order dated, 5/2/24 documented, Right heel wound: Cleanse area with DWC (wound cleanser), pat dry and apply Xeroform dressing and wrap. Daily TX (treatment) One time a day for Wound Care. The May TAR documented the above orders. On 5/3/24, there was a blank on the TAR for the right heel wound dressing. On 5/13/24 there were blanks on the TAR for all three dressings. On 5/17/24, there were blanks on the TAR for the right heel wound dressing and the RLE dressing. The comprehensive care plan dated, last revised on 8/25/23, documented in part, Focus: (R45) has potential for impairment to skin r/t (related to) PVD (peripheral vascular disease), Venous insufficiency, left lower extremity wound. The Interventions documented in part, Treatments as ordered. The care plan also documented in part on 9/7/23, Focus: (R45) has a venous/stasis ulcer of the left lower extremity r/t PVD. The Interventions documented in part, Treatments per MD (medical doctor) orders. An interview was conducted with 05/21/24 3:55 p.m. with RN (registered nurse) #4. When asked how do nurses evidence they did a treatment, RN #4 stated by marking a yes on the TAR. She stated if it's not signed off on the TAR then it's not completed. ASM (administrative staff member) #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information or policy was provided prior to exit. 2. For Resident # 235 (R235), the facility staff failed to administer treatments to the resident's right foot per the physician orders. The admission assessment completed on 5/8/24, documented the resident had no memory difficulties. The physician order dated 5/10/24, documented, Cleanse right foot wound with wound cleanser. Pat dry. Apply Iodosorb to wound, apply alginate, telfa and CCD (clean dry dressing) Q (every) Monday, Wednesday and Friday and PRN (as needed), The TAR (treatment administration record) documented the above order. Nothing was documented on 5/17/24 and 5/20/24. The Baseline Care Plan dated 5/8/24 failed to evidence documentation of the resident's wound. Review of the nurse's notes failed to evidence documentation as to why the dressings were not done. An interview was conducted with R235 on 5/21/2024 at 4:15 p.m. He stated his dressing has not been changed since last Tuesday (5/14/24) when he was seen at the doctor's office. He stated he asked the nurses on Friday, Saturday, Sunday, and Monday to have it done. The resident stated he has all of the supplies except the Iodosorb sitting on the windowsill covered in a washcloth for him to do the dressing himself. An interview was conducted with 05/21/24 3:55 p.m. with RN (registered nurse) #4. When asked how do nurses evidence they did a treatment, RN #4 stated by marking a yes on the TAR. She stated if it's not signed off on the TAR then it's not completed. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. 3. For Resident #13 (R13), the facility did not follow the physician orders for administering rapid acting insulin. The physician order dated, 2/15/24, documented, Humalog Kwik Pen Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Lispro) Inject as per sliding scale. If (blood sugar) 80-150 = 5 units; 151-200 = 8 units; 210-250 = 10 units; 251-300 = 12 units; 301-350=13 units; 351-400 = 15 units subcutaneously before meals for DM (diabetes mellitus). Call hospice MD/NP (medical doctor/nurse practitioner) for BS (blood sugar) less than 60 or greater than 400. The April 2024 MAR (medication administration record) documented the above order. On the following dates at 6:30 a.m. the blood sugar was documented as: 4/8/24 - 99 4/11/24 - 125 4/12/24 - 80 4/20/24 - 82 4/21/24 - 127 A 12 was documented under each blood sugar. The chart code for a 12 indicated, Insulin not required. Review of the nurse's notes failed to evidence documentation as to why the insulin was not given. The May 2024 MAR documented the above order. On the following dates at 6:30 a.m. the blood sugar was documented as: 5/1/24 - 83 5/14/24 - 138 5/20/24 - 124 A 9 was documented under each blood sugar. The chart code for a 9 indicated, Other/See nurse notes. The nurse's notes dated, 5/1/24 at 6:19 a.m. documented, Not given as FBS (fasting blood sugar) was 83. The nurse's note dated, 5/14/24 at 5:30 a.m. documented, Held BS 138. The nurse's note dated, 5/20/24 at 5:33 a.m. documented, FBS 124 did not give d/t (due to) breakfast is a couple of hours from now and did not want resident to bottom out. The comprehensive care plan dated, 2/14/22, documented, Focus: (R13) has Diabetes Mellitus. The Interventions documented in part, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #5, the unit manager, on 5/22/24 at 2:33 p.m. LPN #5 was asked to review the above MARs for R13. LPN #5 stated, Wow, that's a problem. The nurse chose no insulin coverage when the order says to give coverage. When asked if that is following the physician orders, LPN #5 stated, no. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined that the facility staff failed to staff accordingly to ensure the director of nursing did not serve as a floor nurse for five of 30 days reviewed for nurse staffing. The findings include: The facility staff failed to staff the facility to ensure the director of nursing did not serve as a floor nurse when the facility had a census greater than 60 residents on 4/21/2024, 4/26/2024, 5/4/2024, 5/5/2024 and 5/18/2024. Review of the PBJ Staffing Data Report for 10/1/2023-12/31/2023 revealed concerns related to one star staffing. On 5/20/2024 at approximately 10:03 a.m., during entrance conference, ASM (administrative staff member) #1, the administrator stated that the facility did not have any staffing waivers in place in the facility. Review of the as worked nursing schedules from 4/20/2024 to the present documented the director of nursing working on the floor on 4/21/2024 6:45 a.m. to 7:15 p.m. with a facility census of 76, on 4/26/2024 from 3:00 p.m. to 7:00 p.m. with a facility census of 79, on 5/4/2024 from 7:00 a.m. to 7:00 p.m. with a facility census of 80, on 5/5/2024 from 7:00 a.m. to 7:00 p.m. with a facility census of 80 and on 5/18/2024 from 6:45 p.m. to 7:15 a.m. with a facility census of 81. On 5/21/2024 at 11:43 a.m. an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that it was hard to get all of the work done and that the former director of nursing was frequently working on the floor passing medications. On 5/23/2024 at 11:03 a.m., an interview was conducted with OSM (other staff member) #18, staffing coordinator. OSM #18 stated that normally she staffed the facility with three floor nurses for the facility on the 7:00 a.m. to 7:00 p.m. shift and three floor nurses for the facility on the 7:00 p.m. to 7:00 a.m. shift. She stated that sometimes they had four nurses but not often. She stated that if there was a call out she scrambled trying to find coverage. She stated that they had not used any agency staff since February of 2023 and she had a couple of nurses who worked set days part time. She stated that she tried the nurses who were scheduled off first and tried her best to piece it together. She stated that if she was unable to find coverage they had the unit manager to take the cart when they had one, or the assistant director of nursing and director of nursing. She stated that the director of nursing was working the floor mostly until someone got there to take over and worked on the weekends. She stated that she always tried to cover the floor with the nurses before the director of nursing or administrator had to work the units. The director of nursing no longer worked at the facility and could not be interviewed. The facility assessment dated [DATE] and reviewed 3/18/2024 documented in part, .Staff: Licensed Nurses (LN): RN (registered nurse), LPN, LVN (licensed vocational nurse) providing direct care. Plan: DON (director of nursing): 1 DON RN full-time (Monday-Friday), ADON (assistant director of nursing), RN Full-time Days (Monday-Friday), Unit Manager LPN Full-time (Monday-Friday), They rotate on call for Saturday and Sunday. RN or LPN Charge Nurse: 3 for 7-3, 3p-11p, 2 for 11p-7a . On 5/23/2024 at approximately 3:15 p.m., ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications at a error rate of less than 5%. There were eight errors out of 28 opportunities, with a medication error rate of 28.57%. The findings include: On 5/20/24 at 10:29 a.m. observation was made of RN (registered nurse) #2 administering medications to Resident #37. The following medications were administered: Duloxetine 30 mg (milligrams) - 1 capsule (used to treat depression) Apixaban 5 mg - 1 tablet (clot prevention) Furosemide tablet 20 mg - 1/2 tablet (diuretic) Metformin 500 mg - 1 tablet - (diabetes) Omeprazole 20 mg - 1 tablet (gastroesophageal reflux disease) Oxcarbazepine 300 mg -1 tablet (bipolar disorder) Potassium Chloride 20 mEq (milliequivalent) - 1 tablet (potassium supplement) Risperdal 0.5 mg - 1 tablet (bipolar disorder) Tizanidine 2 mg - 1 tablet (muscle spasms) Vitamin D 50 mcg (micrograms) - 1 tablet - (supplement) Basaglar Kwik Pen Solution 16 units (diabetes) injected at 10:53 a.m. The Medication Administration Records were reviewed and documented the above orders. An order for Tramadol (pain) was administered after this surveyor left RN #2 but signed off for the 9:00 a.m. dose. The physician orders were reviewed. The following medications had more than once a day prescribed doses: Apixaban was scheduled every 12 hours. Metformin was scheduled twice a day. Oxcarbazepine was scheduled for twice a day. Risperdal was scheduled for every 12 hours. Tizanidine was scheduled for three times a day. Tramadol was scheduled for four times a day. An interview was conducted with RN #2 on 5/22/24 at 10:29 a.m. When asked why her 9:00 a.m. medications were not administered until 10:29 a.m., RN #2 stated, I am a very quick and thorough nurse. I do things by the book. The load on that hall, the acuity level is high, and the load is tough. It is unfortunately on that day I could not catch up. RN #2 was asked why the insulin was so late, she stated, I just didn't get there. The resident is also a very busy lady. This writer stated that while reviewing the medication administration record, she noted the Tramadol was given after this writer left RN #2. RN #2 stated she had forgotten it and went back and gave it. A copy of the narcotic sheet was requested from RN #2. The review of the narcotic sheet documented the resident received the 9:00 a.m. dose of Tramadol at 10:57 a.m. The facility policy, Administering Medications, documented in part, 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). ASM (administrative staff member) #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and facility document review it was determined facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 05/20/2024 at approximately 9:55 a.m., an observation of the facility's kitchen revealed the following: 1. Observation of a ladder rack set between the steamer cabinet and the convection oven in the facility's kitchen revealed three sheet pans of frozen chicken breast thawing directly above two sheet pans of uncooked diced potatoes. 2. Observation of the facility dry storage room revealed three 50 pound bags, one each of flour, with approximately 25 pounds remaining, sugar, with approximately 25 pounds and corn meal, with approximately 5 pounds remaining, sitting on a bottom shelf and open to the environment, a 25-pound box of powder thickener sitting on the bottom another shelf, with approximately 20 pounds remaining, open to the environment and two loaves of bread with approximately one-third remaining, open to the environment. 3. Observation of the walk-in freezer revealed a 20-pound box of frozen okra sitting on a middle shelf open to the environment. 4. At approximately 10:10 a.m., OSM #6, cook, was observed placing pans of cooked food for the resident's lunch, onto the kitchen's steam table. Observation of the steam table revealed old food debris. Further observation of the steam table revealed two of the pans with cooked food for the resident's lunch were covered with metal lids. Observation of the lids revealed food debris on them. 5. At approximately 11:20 a.m., OSM #7, maintenance worker, was observed to walk into the facility's kitchen to OSM #5, kitchen account manager, who was plating desserts for the resident's lunch. Observation of OSM #7 revealed he was not wearing a hair net. 6. At approximately 11:23 a.m., an observation of OSM #6, cook, revealed he was taking temperatures of the prepared food for the resident's lunch. Observations revealed OSM #6 wiping the thermometer probe with a cloth from a sanitizer bucket after obtaining the temperature each food item on the steam table. Observation of the sanitizer bucket revealed the bucket to be empty. 7. On 05/20/2024 at approximately 10:25 a.m., an observation of the facility's two nourishment rooms was conducted. Observation of the inside of the refrigerator in the nourishment room located on the Rosewood unit revealed a 12-ounce can of sparkling water, a 4.5-ounce container of yogurt, 11.5-ounce bottle of mayonnaise, 1.5-ounce package of cheese and crackers, a container of four chicken tenders and a pint of chicken salad. Further observation of the above food items failed to evidence a resident's name and/or a room number; Observation of the inside of the freezer in the nourishment room located on the Dogwood unit revealed an 11-ounce frozen meal and 2-four-ounce cups of a chocolate parfait. Observation of the inside of the refrigerator revealed a lunch bag without a name or room number, further observation of the contents of the bag revealed an 11-ounce carton of flavored water, small bag of chips, and an 8-ounce container of sour cream. Further observation of the inside of the refrigerator revealed a tray of 13-bite size chocolate desserts, a liter bottle of tea, a quart of chocolate milk and 3-eight-ounce bottles of soda. Further observation of the above food items failed to evidence a resident's name and/or a room number. On 05/21/2024 at approximately 11:34 p.m. an interview was conducted with OSM #6. When informed of the observation described above, numbers 4, regarding the steam table and lids for pans OSM #6 stated that the steam table should have been cleaned between meals, the lids should not have been used and sent to the dishwasher. When informed of the observation listed above, number 6, regarding sanitizing the food thermometer, he stated that the pail should have had sanitizing solution in it. On 05/20/2024 at approximately 12:59 p.m., an interview was conducted with OSM #7. When informed of the observation described above, number 5, OSM #7 stated he recalled the incident and that he should have had a hair net on, On 05/21/2024 at approximately 1:20 p.m. an interview was conducted with OSM #5, kitchen account manager and OSM #8, regional dietary manager. When informed of the observation described above in number 1, OSM #5 was asked to describe the procedure for thawing meat and poultry OSM #5 stated that the meat or, poultry should be placed on a sheet pan, covered with another sheet pan and placed on the bottom of a rack. He further stated that the thawing meat and poultry should never be placed above other food. When informed of the observation described above in number 1, OSM #5 stated that the chicken was not being thawed correctly. When asked about the procedure for the storage of food items that have been opened as described above in numbers 2 and 3, OSM #5 stated the packaging should have been closed to prevent contamination. When informed of the observation described above in number 5, OSM #5 stated that all staff were to wear a hair net when in the kitchen. When asked to describe the procedure for food brought in from outside of the facility OSM #5 stated that nursing should label the food item with the resident's name and the date it was brought in. When asked who was responsible for checking the refrigerators and freezers in the nourishment rooms OSM #5 stated that the dietary aides should be checking the freezer and refrigerators in the nourishment rooms. He further stated that the nourishment rooms are checked three times a day. When informed of the observation described above in number 7, OSM #7, regional dietary manager, stated the nourishment room refrigerators and freezers were checked this morning and unlabeled food items were discarded. The facility policy's Food: Preparation documented in part, 5. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevent cross-contamination; Thawing the item in a microwave oven, then transferring immediately to conventional cooking equipment; Completely submerging the item under cold water (at a temperature of 70 degrees F (Fahrenheit) or below) that is running fast enough to agitate and float off loose ice particles; Cooking directly from the frozen state, when directed. The facility's policy Food Storage: Dry Goods documented in part, 5. All packaged and canned food items will be kept clean, dry, and properly sealed. The facility's policy Food Storage: Cold Foods documented in part, 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranges in a manner to prevent cross contamination. The facility's policy Equipment documented in part, Policy Statement: All food service equipment will be clean, sanitary, and in proper working order. Procedures. 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials; 3. All food contact equipment will be clean and sanitized after every use. The facility policy Staff Attire documented in part, 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The facility's policy Food: Safe Handling for Food from Visitors documented in part, 4. When food items are intended for later consumption, the responsible facility staff member will .Label foods with the resident's name and the current date. On 05/22/2024 at approximately 5:15 p.m., ASM (administrative staff member) #1, administrator, ASM #4, director of sales and marketing, ASM #5, regional director of clinical services and ASM #6, vice president of operations, and OSM (other staff member) #11, director of social services, were made aware of the above findings. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

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Based on staff interview and facility document review, the facility staff failed to maintain an effective training program for six of ten employee record reviews and failed to develop and implement a training program based on the facility assessment. The findings include: The facility staff failed to implement training for multiple training topics, including communication, resident rights, abuse/neglect/exploitation, QAPI, compliance/ethics, and behavioral health, was completed by all required staff. Refer to F941, F952, F943, F944, 945, F946, F947, and F949 for specific staff and topics that were not in compliance. A review of the facility assessment was conducted during the survey. This review revealed, in part: Facility Assessment Tool dated 3/15/24: Are there training, education and/or competency needs based on resident and/or staff data or trends identified in the Facility Assessment .Areas Facility Assessment Informed/Action to Be Taken/Already Taken This Year .Infection Prevention/Control .Training Continuously .Training Competencies Yearly Relias Training. On 5/23/24 at 2:30 p.m., OSM (other staff member) #11, the social services director and acting administrator, was interviewed. She stated she could not provide evidence that the facility's training program was based on the facility assessment. She stated: I am not as familiar with it as I should be. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, were informed of these concerns. A review of the facility policy, In-Service Training - General, revealed, in part: Employees will be provided training on required topics on an annual basis. Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0944 (Tag F0944)

Could have caused harm · This affected multiple residents

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Based on staff interview and facility document review, the facility staff failed to provide required training on QAPI for five of seven employee records reviewed, CNA (certified nursing assistant) #8, CNA #5, RN (registered nurse) #2, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper. The findings include: For CNA #8, hired 9/17/21, the facility failed to provide the required training in QAPI (quality assurance and performance improvement). For CNA #5, hired 6/19/21, the facility failed to provide the required training in QAPI. For RN #2, hired 3/19/24, the facility failed to provide the required training in QAPI. For OSM#6, hired 12/4/19, the facility failed to provide the required training in QAPI. For OSM #22, hired 9/6/18, the facility failed to provide the required training in QAPI. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, In-Service Training-General, revealed, in part: 1. The Executive Director and/or the Director of Nursing /designee will be responsible for assigning, coordinating, and monitoring education and in-service training. 2. Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the center Facility Assessment. Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

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Based on staff interview and employee record review it was determined that the facility staff failed to ensure that four of five CNA (certified nursing assistant) records reviewed received the required 12 hours of annual training, and/or received annual dementia training, CNA #8, CNA #3, CNA #9 and CNA #10. The findings include: The facility staff failed to ensure that four of five CNAs selected met the required 12-hours of annual training and one of five did not complete annual dementia training. Review of CNA #8's record documented a hire date of 9/17/2021. Further review of the education transcripts documented a total amount of training hours of 9.25 hours in the past year. Review of CNA #3's record documented a hire date of 9/26/2022. Further review of the education transcripts documented a total amount of training hours of 3 hours in the past year and no dementia training. Review of CNA #9's record documented a hire date of 1/23/2023. Further review of the education transcripts documented a total amount of training hours of 2 hours in the past year. Review of CNA #10's record documented a hire date of 2/15/2023. Further review of the education transcripts documented a total amount of training hours of 2 hours in the past year. On 5/23/2024 at 3:30 p.m., an interview was conducted with OSM (other staff member) #14, human resource coordinator. OSM #14 stated that they oversee about 50% of employee education including abuse, dementia, and compliance. She stated that she was new to the facility and was actively working on increasing compliance with staff education. She stated that she ran reports to track staff that were out of compliance with education and had started tracking education since she started working at the facility in April and had started increasing education completion since then. The facility policy In-Service Training-General revised 10/24/2022 documented in part, Employees will be provided training on required topics on an annual basis . On 5/23/2024 at approximately 3:15 p.m., ASM (administrative staff member) #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM #11, the director of social services were made aware of the findings. No further information was provided prior to exit.

Dec 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the care plan for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to implement the comprehensive care plan for pressure injury and catheter care. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), renal disease, UTI (urinary tract infection) and chronic cystitis. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/14/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as being dependent for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A review of Section M- skin conditions coded the resident as a having pressure injury (1) Stage 2 (2)=1, Unstageable (3)=1 present on admission. A review of the comprehensive care plan dated 11/8/23 revealed, FOCUS: Resident has pressure injuries related to immobility: Left buttock stage 3 (4), right buttock stage 3, sacral stage 3 and left gluteal fold skin tear. Resident has an indwelling catheter due to atonal bladder and status post CVA (cerebrovascular accident). INTERVENTIONS: Administer treatments as ordered and monitor for effectiveness. Catheter care every shift and as needed. Monitor and document intake and output as per facility protocol. Monitor/record/report to physician signs and symptoms (s/s) related to UTI. A review of the physician orders dated 11/7/23 revealed, Cleanse wound to right buttock with NS (normal saline), apply silver alginate and apply foam patch daily. Cleanse wound to left buttock with NS (normal saline), apply silver alginate and apply foam patch daily. Cleanse wound to sacrum with wound cleanser, pat dry, skin prep to perineum, apply calcium alginate to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged. Catheter care every shift and as needed. Monitor catheter for patency and drainage every shift. Monitor urine for s/s infection every shift. If present document and notify physician. A review of physician orders dated 11/17/23 revealed, Cleanse wound to left buttocks with wound cleanser, pat dry, skin prep to perineum, apply Medi-honey to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged. Cleanse wound to right buttocks with wound cleanser, pat dry, skin prep to perineum, apply Medi-honey to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged. A review of the TAR (treatment administration record) for November 2023 revealed no evidence of completion of the treatments for the following: -Cleanse wound to right buttock with NS (normal saline), apply silver alginate and apply foam patch daily, documentation was missing for four out of 22 (12 hour) day shifts: 11/13, 11/18, 11/21 and 11/28. Cleanse wound to left buttock with NS (normal saline), apply silver alginate and apply foam patch daily missing four out of 22 (12-hour) day shifts: 11/13, 11/18, 11/21 and 11/29. Cleanse wound to sacrum with wound cleanser, pat dry, skin prep to perineum, apply calcium alginate to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged missing one out of ten (12-hour) day shifts: 11/13. -Catheter care every shift and as needed documentation was missing four out of 22 (12-hour) night shifts: 11/13, 11/18, 11/21 and 11/22. Monitor catheter for patency and drainage every shift was missing four out of 22 (12-hour) day shifts: 11/18, 11/21, 11/25 and 11/28; missing six out of 22 (12-hour) night shifts: 11/13, 11/18, 11/19, 11/21, 11/22 and 11/27. Monitor urine for s/s infection every shift. If present document and notify physician: missing four out of 22 (12-hour) night shifts: 11/13, 11/18, 11/21 and 11/22. An interview was conducted on 12/19/23 at 8:30 AM with LPN (licensed practical nurse) #2, when asked if the care plan was being followed when there is no evidence of treatments, LPN #2 stated, no, the care plan is not being followed. An interview was conducted on 12/19/23 at 1:40 PM with LPN #3, and when asked if there are blanks on the TAR documentation for treatment ordered is the care plan being followed, LPN #3 stated, no, it is not. On 12/19/23 at 2:15 PM, ASM (administrative staff member) #1, the executive director and ASM #5, the market leader was made aware of the findings. No further information was provided prior to exit. References: The following definitions were obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (2) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. (3) Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. (4) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide the care and services to treat a pressure injury for one of seven residents in the survey sample, Resident #1. The findings include: The facility failed to ensure pressure injury care was provided to Resident #1 per physician orders. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/14/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as being dependent for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A review of Section M- skin conditions coded the resident as having one Stage 2 pressure injury (1,2), and one Unstageable pressure injury (3) which were present on admission. A review of the comprehensive care plan dated 11/8/23 revealed, FOCUS: Resident has pressure injuries related to immobility: Left buttock stage 3 (4), right buttock stage 3, sacral stage 3 and left gluteal fold skin team. INTERVENTIONS: Administer treatments as ordered and monitor for effectiveness. A review of the physician orders dated 11/7/23 revealed, Cleanse wound to right buttock with NS (normal saline), apply silver alginate and apply foam patch daily. Cleanse wound to left buttock with NS (normal saline), apply silver alginate and apply foam patch daily. Cleanse wound to sacrum with wound cleanser, pat dry, skin prep to perineum, apply calcium alginate to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged. A review of physician orders dated 11/17/23 revealed, Cleanse wound to left buttocks with wound cleanser, pat dry, skin prep to perineum, apply Medi-honey to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged. Cleanse wound to right buttocks with wound cleanser, pat dry, skin prep to perineum, apply Medi-honey to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged. A review of the TAR (treatment administration record) for November 2023 revealed the following missing documentation of pressure injury care: Cleanse wound to right buttock with NS (normal saline), apply silver alginate and apply foam patch daily: missing four out of 22 (12-hour) day shifts: 11/13, 11/18, 11/21 and 11/28. Cleanse wound to left buttock with NS (normal saline), apply silver alginate and apply foam patch daily missing four out of 22 (12-hour) day shifts: 11/13, 11/18, 11/21 and 11/29. Cleanse wound to sacrum with wound cleanser, pat dry, skin prep to perineum, apply calcium alginate to area, cover with silicone super absorbent foam bordered dressing once daily and as needed if soiled or dislodged missing one out of ten (12-hour) day shifts: 11/13. An interview was conducted on 12/19/23 at 10:30 AM with ASM (administrative staff member) #3, the assistant director of nursing. When asked how they would evidence treatments when there are blanks in the documentation, ASM #3 stated, if there are holes in the documentation, it means it was not done. An interview was conducted on 12/19/23 at 1:22 PM with RN (registered nurse) #2, the wound/ostomy nurse. When asked if there are blanks in the pressure injury treatment documentation, was the treatment being provided, RN #2 stated, no, it is not. An interview was conducted on 12/19/23 at 1:40 PM with LPN #3, when asked if there are blanks on the TAR documentation for treatments ordered is the care plan being followed, LPN #3 stated, no, it is not. On 12/19/23 at 2:15 PM, ASM (administrative staff member) #1, the executive director and ASM #5, the market leader was made aware of the findings. No further information was provided prior to exit. References: The following definitions were obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (2) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. (3) Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. (4) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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Apr 2023 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review an advanced directive periodically for one of 37 residents in the survey sample, Resident #51. The findings include: For Resident #51, a DDNR (durable do not resuscitate) form dated 4/25/2021 was in the clinical record. An Advance Directives Discussion Document was dated 4/25/2021. Further review of the clinical record failed to evidence any documentation related to reviewing the advance directive with the resident. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date 2/7/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. The comprehensive care plan dated 7/11/2021, documented in part, Focus: Resident has advanced directives r/t (related to) DNR AEB (as evidenced by) DNR (do not resuscitate). The Interventions documented, Discuss advanced directives with resident and or residents representative. Physician order for DNR. An interview was conducted with OSM (other staff member) #5, the director of social services, on 4/19/2023 at 1:22 p.m. When asked how often she reviews the advance directives with the resident and or resident representative, OSM #5 stated she does them upon admission with every resident. Then upon readmission verbally review with them. She further stated if there is a change in condition, then she verbally talks to them and update the chart. OSM #5 stated she does not document unless there is a change. The facility policy was reviewed with OSM #5. OSM #5 stated she was not aware of the policy. The facility policy, Advanced Directives documented in part, 5. Advanced Directives will be reviewed: Quarterly. Hospice Admission. Additional times as need or requested by the resident/resident representative. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/19/2023 at 4:41 p.m. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to notify the physician of the inability to administer newly ordered medications for one of 37 residents in the survey sample, Resident #276. The findings include: The facility failed to notify the physician of failure to obtain and administer admission medications for Resident #276. Resident #276 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. The most recent MDS (minimum data set) assessment, a five-day Medicare assessment, with an ARD (assessment reference date) of 6/29/22, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 7/7/22, revealed, FOCUS: The resident has pain related to fracture of right femur. INTERVENTIONS: Administer medications per physician orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A review of the physician orders dated 6/24/22, revealed, Levothyroxine 125 mcg (microgram), give 1 tablet by mouth in the morning every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Methocarbamol 500 mg (milligram), give 1 tablet by mouth four times a day for pain for 7 days. Oxycodone 10 mg, give 1 tablet by mouth every 6 hours for pain for 7 days. Resident was admitted to the facility on [DATE], a Friday evening after 5 PM. A review of Resident #276's June 2022 MAR (medication administration record) revealed, Levothyroxine 125 mcg was not administered 6/25/22 at 6:00 AM, Methocarbamol 500 mg was not administered on 6/25/22 at 6 AM, and Oxycodone 10 mg tablet not administered on 6/25/22 at 12 AM and 6 AM. There was no documentation of physician notification, regarding inability to administer medication. A review of the nursing notes dated 6/24/22 at 11:04 PM and 6/25/22 at 5:55 AM, revealed, Medication not in from pharmacy. A review of the physician orders dated 7/2/22, revealed, Oxycodone 10 mg, give 1 tablet by mouth every 6 hours for pain for 8 days. A review of Resident #276's July 2022 MAR, revealed, Oxycodone 10 mg was not administered 7/2/22 at 12 AM, 6 AM, 12 PM and 6 PM. No nursing progress note was written. An interview was conducted on 4/19/23 at 10:20 AM with LPN (licensed practical nurse) #1. When asked the process for obtaining medications for new admissions, LPN #1 stated, the narcotics and other medications are in Omnicell (automated medication dispensing cabinet) and typically, the hospital faxes a script from the hospital to (Name of Pharmacy), our pharmacy. They would use our on-call book to notify the physician or nurse practitioner if we do not have the medication on site. LPN #1 stated, We do not get orders filled from (Name of Pharmacy) 'until the next afternoon if a resident is admitted on a Friday evening. The staff should have used the on-call book to call the NP (nurse practitioner) or physician to get the order for oxycodone/acetaminophen 5mg /325 mg x 2 tablets which we do have in stock. If they had notified the NP or physician that would have been documented in the progress notes. On 4/20/23 at 9:30 AM, OSM #1, the executive director, OSM #2, the director of clinical services, OSM #3, the administrative market leader and OSM #4, the regional nurse consultant was informed of the concerns. A review of the facilities' Notification of Change in Condition policy dated 12/2020, revealed the following: The nurse is to notify the attending physician when there is a need to alter the treatment and document in the medical record. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of the required documents sent to the receiving facility upon transfer, for two of 37 residents in the survey sample, Residents #30 and #48. The findings include: 1. For Resident #30, the facility staff failed to evidence what required documents were sent with the resident upon transfer to the hospital on 2/6/2023. The nurse's note dated, 2/6/2023 at 9:23 p.m. documented, Pt (patient) c/o (complain of) acid reflux but cannot describe the chest pressure. Pt is also c/o on shortness of breath on exertion. RLE (right lower extremity) is red, warm to touch. Pt is requesting to be sent to ED (emergency department) for further evaluation. Paperwork sent with pt. VS (vital signs) = 116/68, HR (heart rate) 89, RESP (respiration) 18, TEMP (temperature) 97.8, and 97% on room air. The Change in Condition form dated, 2/6/2023, failed to evidence documentation of documents sent to the ED with the resident. The Hospital Transfer Form dated 2/6/2023, failed to evidence documentation of documents sent to the ED with the resident. An interview was conducted with LPN (licensed practical nurse) #1, on 4/19/2023 at 2:14 p.m. When asked the process for sending a resident to the hospital and what documents they send with them, LPN #1 stated, the nurse should assess the resident, get a set of vital signs, call the doctor or nurse practitioner and get an order to send the resident to the ED. The nurse then completes the SBAR (change in condition form), notify the DON (director of nursing), RP (responsible party). Then they need to print out the physician order summary, face sheet, copy of the DNR, if applicable, any recent labs (laboratory test results), the care plan and any notes related to why they are being sent out. LPN #1 stated once they gather all these documents, they go in an envelope that has a check off list. A copy of the list is kept for the clinical record. The nurse's note above was reviewed with LPN #1. LPN #1 stated, the nurse didn't document what was sent with the resident. The facility policy, Transfer/Discharge Notification & Right to Appeal documented in part, Documentation in the medical record to include: Information provided to the receiving provider must include but is not limited to: Contact information of the practitioner responsible for the care of the resident. Resident representative information including contact information. Advance Directives. Special care instructions or precautions for ongoing care as indicated. Comprehensive care plan goals. All other necessary information, including copies of the resident's discharge summary and other documentation, as applicable to ensure safe and effective transition of care. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/19/2023 at 4:41 p.m. No further information was provided prior to exit. 2. For Resident #48, the facility staff failed to evidence what required documents were sent with the resident upon transfer to the hospital on [DATE]. Review of the nurse's notes failed to evidence documentation of the transfer to the hospital on [DATE]. A request was made on 4/19/2023 at 2:15 p.m. for documentation related to the transfer to the hospital on [DATE]. 04/19/2023 at 3:16 p.m., ASM (administrative staff member) #1, the executive director, stated they had no documentation related to the resident's transfer to the hospital on [DATE]. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/19/2023 at 4:41 p.m. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to develop and implement a baseline care plan for one of 37 residents in the survey sample, Resident #276. The findings include: The facility failed to develop and implement a baseline care plan regarding pain medication and an indwelling urinary catheter (Foley catheter) that was present upon admission for Resident #276. Resident #276 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. A review of the baseline care plan dated 6/24/22 revealed, FOCUS: Fracture: Hip. INTERVENTIONS: Weight bearing as tolerated. Monitor pain and treat as ordered. Assist with repositioning. Rehab orders/recommendations. A review of the physician orders dated 6/24/22 revealed, Lidocaine patch 5% apply to right hip topically one time a day for pain and remove per schedule-apply 9 AM, remove 9PM. Methocarbamol 500 mg (milligram), give 1 tablet by mouth four times a day for pain for 7 days. Oxycodone 10 mg, give 1 tablet by mouth every 6 hours for pain for 7 days. Pregabalin capsule 100 mg, give 1 capsule by mouth two times a day for pain. A review of Resident #276's June 2022 MAR (medication administration record) revealed, Lidocaine 5% patch was not administered on 6/25/22 at 9 AM, Methocarbamol 500 mg was not administered on 6/25/22 at 6 AM and 12 PM, Oxycodone 10 mg tablet not administered on 6/25/22 at 12 AM, 6 AM and 12 PM, and Pregabalin 100 mg was not administered on 6/25/22 at 9 AM. A review of the physician orders dated 7/2/22, revealed, Oxycodone 10 mg, give 1 tablet by mouth every 6 hours for pain for 8 days. A review of Resident #276's July 2022 MAR revealed, Oxycodone 10 mg was not administered 7/2/22 12 AM, 6 AM, 12 PM and 6 PM. Review of physician orders did not include an order for an indwelling catheter or catheter care until 7/2/22. Physician orders dated 7/2/22 revealed, Foley catheter 16 French 10 cc (cubic centimeter) balloon, measure urinary output every shift and as needed. Change catheter as needed. Change catheter bag as needed. Catheter care every shift and as needed. A review of the June 2022 TAR (treatment administration record) and the July 2022 TAR, revealed, catheter care documented as beginning 7/2/22 at 12 AM. A review of the nursing progress notes did not include any references to pain medication not being given or Foley care not provided. An interview was conducted on 4/20/23 at 9:00 AM with LPN (licensed practical nurse) #2. When asked the purpose of the baseline care plan, LPN #2 stated, the purpose of the care plan is to provide individual care for the resident and not to assume anything, and they are all responsible for making sure we abide by it. When asked if not providing pain medication per physician orders was following the care plan, LPN #2 stated, No, we were not following orders. When asked if a resident is admitted with a Foley catheter, should be included on the baseline care plan, LPN #2 stated, Yes, the Foley definitely should be included, otherwise it is not complete. On 4/20/23 at 9:30 AM, OSM #1, the executive director, OSM #2, the director of clinical services, OSM #3, the administrative market leader and OSM #4, the regional nurse consultant was informed of the concerns. A review of the facilities' Plan of Care policy dated 9/2017, revealed the following: Develop and implement and individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, ASA (preadmission screening and resident review) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 37 residents in the survey sample, Residents #51 and #66. The findings include: 1. For Resident #51, the facility staff failed to implement the comprehensive care plan for reviewing advance directives. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date 2/7/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. The comprehensive care plan dated 7/11/2021, documented in part, Focus: Resident has advanced directives r/t (related to) DNR AEB (as evidenced by) DNR (do not resuscitate). The Interventions documented, Discuss advanced directives with resident and or resident's representative. Physician order for DNR. A DDNR (durable do not resuscitate) form dated 4/25/2021 was in the clinical record. An Advance Directives Discussion Document was dated 4/25/2021. Further review of the clinical record failed to evidence any documentation related to reviewing the advance directive with the resident. On 4/19/2023 at 1:22 p.m., an interview was conducted with OSM (other staff member) #5, the director of social services. When asked how often she reviews the advance directives with the resident and or resident representative, OSM #5 stated she does them upon admission with every resident. Then upon readmission verbally review with them. She further stated if there is a change in condition, then she verbally talks to them and update the chart. OSM #5 stated she does not document unless there is a change. The facility policy was reviewed with OSM #5. OSM #5 stated she was not aware of the policy. An interview was conducted with LPN (licensed practical nurse) #1 on 4/19/2023 at 3:34 p.m. When asked what the purpose of the care plan was, LPN #1 stated it's pretty much their plan of care. It has goals that they [the resident] want to lead to. If a resident has a specific condition, then there are things we must initiate as well, and the care plan should be followed. The facility policy, Plans of Care documented in part, Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team. On 4/19/2023 at 4:41 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern. No further information was provided prior to exit. 2. For Resident #66, the facility staff failed to implement the care plan for the administration of oxygen. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/24/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The comprehensive care plan, dated, 1/2/2023, documented in part, Focus: (R66) has altered respiratory status/difficulty berating r/t (related to) likely restrictive lung disease. The Interventions documented in part, O2 (oxygen) per order. R66 was observed on 4/18/2023 at 8:45 a.m. in bed asleep with oxygen via nasal cannula in place. The setting on the oxygen concentrator was between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. A second observation was made on 4/19/2023 at 8:22 a.m. R66 was again in bed with the oxygen on. The setting on the oxygen concentrator was between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. The physician order dated, 4/10/2023, documented, Respiratory: Oxygen 2L (liters) continuous NC (nasal cannula) every shift for oxygen. The nurses note dated, 4/18/2023 at 3:05 p.m., documented in part, Oxygen is used via nasal cannula. The nurses' note dated, 4/18/2023 at 5:17 p.m. documented in part, Oxygen is used via nasal cannula 2 liters. On 4/19/2023 at 2:14 p.m. R66 was observed with LPN (licensed practical nurse) #1. The oxygen concentrator was set between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. When asked if the oxygen concentrator was set correctly for the prescribed rate, LPN #1 stated the resident should be on 2 liters. When asked if it was set correctly, LPN #1 stated, no, it was not set correctly. An interview was conducted with LPN #1 on 4/19/2023 at 3:34 p.m. When asked what the purpose of the care plan was, LPN #1 stated it's pretty much their plan of care. It has goals that they [the resident] want to lead to. If a resident has a specific condition, then there are things we have to initiate as well, and the care plan should be followed. On 4/19/2023 at 4:41 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern. No further information was provided prior to exit.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the medication administration for two of 37 residents in the survey sample, Resident #13 and Resident #48. The findings include: For Resident #13, the nurse documented a narcotic medication as administered although it was not administered to the resident. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/13/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The facility synopsis of the event for 1/4/2023, documented in part, The DCS (director of clinical services) and the executive director on the afternoon of January 4, 2023, were in the process of completing a reconciliation of narcotic medications to ensure accuracy of the narcotics .While completing the reconciliation it was noted that a hydrocodone (used to treat severe pain) (1) a narcotic, had been administered to a resident (R13) by a nurse (RN [registered nurse]) #4 who had not gotten this pain medication for several days. The resident was interviewed regarding her pain and they stated that they had not taken any pain medications for several days. When asked about taking the pain meds (medications) this morning, (R13) stated no they did not ask for any and they did not take any. Resident #13 was no longer a resident at the facility and could not be interviewed. RN #4 was no longer employed at the facility and was not available for interview. An interview was conducted with ASM (administrative staff member) #1, the executive director, on 4/10/2023 at 7:51 a.m. She reiterated the above information written in the facility synopsis of the event. An interview was conducted with LPN (licensed practical nurse) #1, on 4/19/2023 at 2:14 p.m. When asked to describe the process for giving a pain medication/narcotic, LPN #1 stated the nurse should assess the resident's pain level on a scale of one to ten, ten being the worse pain ever had. Then check the physician orders and give medication according to the physician's orders. LPN #1 stated after the administration of the medication you need to go back and see if the medication was effective. When asked where this is documented, LPN #1 stated you have to sing off the medication on the narcotic sheet and then document it on the MAR (medication administration record). The facility policy, Providing Pharmacy Services and Products provided to the survey team failed to evidence documentation of the process for address the documentation of the administration of medications. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/20/2023 at 10:30 a.m. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a614045.html. No further information was provided prior to exit. 2. For Resident # 48, the facility staff failed to administer medications per the physician orders for one of 37 residents in the survey sample, Resident #48. The physician order dated, 7/5/2022, documented, Sertraline Tablet (used to treat depression) (1) 50 MG (milligram); Give 1 tablet by mouth at bedtime for Depression. The March 2023 MAR (medication administration record) documented the above order. On 3/25/2023 and 3/27/2023 for the evening dose documented a 9. A 9 indicates, Other/See Nurse Notes. The nurse's note dated, 3/25/2023 at 8:32 p.m. documented, Pending delivery. The nurse's note dated, 3/27/2023 at 9:39 p.m. documented, Medication is on order with pharmacy and the nurse does not have (name of back up medication system) access. An interview was conducted with LPN (licensed practical nurse) #1, on 4/19/2023 at 2:14 p.m. When asked the process to follow when a medication is not in the medication cart to administer, LPN #1 stated, the nurse should first call the pharmacy to see when it is going to be delivered. Then check the (name of back up medication system) and pull it out from there. She stated if it is not in the (name of back up medication system), you have to call the doctor or nurse practitioner to make them aware and to get further orders or instructions. When asked if all nurses have access to the (name of back up medication system), LPN #1 stated, yes. She further stated in March there was a problem with the (name of back up medication system). The caplock key was stuck and she stated she had gotten locked out of the system. The review of the list of medications available in the (name of back up medication system) was conducted. Sertraline 25 mg tablets and 100 mg tablets were available in the system. The facility policy, Providing Pharmacy Products and Services failed to document the process a nurse should take when a medication is not available for administration. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/19/2023 at 4:41 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to administer oxygen per the physician's order for one of 37 residents in the survey sample, Resident #66. The findings include: For Resident #66 (R66), the facility staff failed to administer the oxygen at the prescribed rate of 2 LPM (liters per minute). R66 was observed on 4/18/2023 at 8:45 a.m. in bed asleep with oxygen via nasal cannula in place. The setting on the oxygen concentrator was between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. A second observation was made on 4/19/2023 at 8:22 a.m., again R66 was in bed with the oxygen on with the setting on the oxygen concentrator between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. The physician order dated, 4/10/2023, documented, Respiratory: Oxygen 2L (liters) continuous NC (nasal cannula) every shift for oxygen. The nurses note dated, 4/18/2023 at 3:05 p.m., documented in part, Oxygen is used via nasal cannula. The nurses' note dated, 4/18/2023 at 5:17 p.m. documented in part, Oxygen is used via nasal cannula 2 liters. The comprehensive care plan, dated, 1/2/2023, documented in part, Focus: (R66) has altered respiratory status/difficulty berating r/t (related to) likely restrictive lung disease. The Interventions documented in part, O2 (oxygen) per order. On 4/19/2023 at 2:14 p.m. R66 was observed with LPN (licensed practical nurse) #1. The oxygen concentrator setting was between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. When asked if the oxygen concentrator was set correctly for the prescribed rate, LPN #1 stated the resident should be on 2 liters. When asked if it was set correctly, LPN #1 stated it was not set correctly. The facility policy, Oxygen Administration documented in part, Start O2 (oxygen) at the prescribed liter flow or appropriate flow for administration device. The manufacturer's instruction manual for the oxygen concentrator, documented in part, To set the flow rate to the prescribed oxygen level, adjust the flow meter knob until the ball floats at the appropriate flow line on the flow meter. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/19/2023 at 4:41 p.m. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to serve food in a sanitary manner during meal tray delivery on the Rosewood unit. On 4/18/2023 at approximately 8:22 a.m., an observation was conducted of meal tray delivery to the rooms on the Rosewood unit. Six staff members were observed delivering trays to residents in rooms, all six staff members were observed wearing gloves and going room to room delivering trays to residents with the same gloves on. CNA (certified nursing assistant) #3 was observed wearing gloves pushing the meal cart containing resident trays into the middle of the lower hallway. CNA #3 was observed preparing a cup of coffee, gathering condiments and placing them onto a tray and entering room [ROOM NUMBER]. CNA #3 was observed to exit the room with the same gloves on and prepare a drink and condiments for another tray which they carried into room [ROOM NUMBER]. CNA #3 was observed preparing the tray and cutting up the food on the tray for the resident in room [ROOM NUMBER]. CNA #3 was observed exiting room [ROOM NUMBER] with the same gloves on and returning to the meal cart preparing the next tray and entering room [ROOM NUMBER]. CNA #3 was observed to exit the room with the same gloves on and prepare coffee and return to room [ROOM NUMBER] knocking on the door. CNA #3 was observed returning to the meal cart with the same gloves on and obtained a meal tray taking it into room [ROOM NUMBER] to the resident. CNA #3 then returned to the meal cart with the same gloves on and pushed the meal cart down the hallway further and entered room [ROOM NUMBER]. CNA #3 failed to change gloves or wash their hands between residents. None of the residents were on contact precautions. On 4/18/2023 at 9:11 a.m., an interview was conducted with CNA #3. CNA #3 stated that they were told to wear gloves while passing trays sometime last year. CNA #3 stated that they did not remember who told them and thought it was around the time of the last survey. CNA #3 stated that they did not feel that they should be wearing the gloves from room to room. CNA #3 stated, Its kind of like cross contamination going in and out of rooms. CNA #3 stated that their normal practice was to start at the top of the hallway and work their way to the bottom and not wear gloves, sanitizing their hands between every room. CNA #3 stated that almost every resident required some set up of their tray so they assisted them and then sanitized their hands afterwards to keep their hands clean. CNA #3 stated that when the second cart came from the kitchen they had removed the gloves and returned to their normal practice. The facility policy, Meal Distribution revised 9/2017 documented in part, .Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining . On 4/19/2023 at approximately 4:37 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the administrative market leader and ASM #4, the regional nurse consultant were notified of the findings. No further information was provided prior to exit. Based on observation, staff interview and facility document review, the facility staff failed to store food in a safe manner in one of two unit nourishment rooms, the dogwood nourishment room, and failed to serve food in a sanitary manner on one of two units, the rosewood unit. The findings include: 1. The facility staff failed to label food stored in the dogwood nourishment room refrigerator. On 4/18/23 at 2:42 p.m., an observation of the dogwood nourishment room refrigerator was conducted with CNA (certified nursing assistant) #1. The refrigerator contained an opened container of pre-cooked macaroni and cheese, an opened container of pre-cooked mashed potatoes, and an opened container of pre-cooked barbeque. All containers were covered with aluminum foil and were not labeled with the resident's name or date. At this time, an interview was conducted with CNA #1. CNA #1 stated staff is supposed to label food with the resident's name and date. On 4/18/23 at 4:10 p.m., ASM (administrative staff member) #1, the executive director, was made aware of the above concern. The facility policy titled, Food: Safe Handling for Foods from Visitors documented, 4. When food items are intended for later consumption, the responsible facility staff member will: Label foods with the resident name and the current date .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected 1 resident

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Based on staff interview and facility document review, the facility staff failed to implement their policy for ensuring that all staff were fully vaccinated for COVID-19, or who have been granted exemptions for three of 79 employee records reviewed. The findings include: The facility COVID-19 records documented that 3 staff were partially vaccinated, however there was no follow up information documented. An interview was conducted on 4/17/23 with ASM #2, the director of clinical services, who was filling in for the Infection Preventionist who had been out of the building for approximately one month. ASM #2 stated, My start date was in February, so I am learning a lot, and I am trying to keep up with the documentation but not everything is in the form. On 4/18/23, the facility provided the F888, staff vaccination matrix, which listed three employees as partially vaccinated, LPN (licensed practical nurse) #3, CNA (certified nursing assistant) #8 and OSM (other staff member) #6. On 4/19/23, a request was made for the hire dates for the three employees with partial vaccinations. At approximately 2:00 PM information was provided LPN #3 was hired 2/21/23, CNA #8 was hired 9/17/21 and OSM #6 was hired 7/21/22. Information provided included LPN #3 worked nights and was sleeping, that were currently unable to reach her regarding her vaccination status, CNA #8 had taken initial vaccination in 2021, requested and been granted a religious exemption on 4/1/2023 and OSM #6 received her first vaccine 8/3/22 and second vaccine on 8/25/22. On 4/19/23 at approximately 3:30 PM ASM (administrative staff member) #2, the director of clinical services was informed that there was an issue with the facility not knowing these three staff accurate vaccination status. ASM #2 stated that she was filling in for the Infection Preventionist who was out on sick leave for approximately the last month but was unsure of exact date. ASM #2 was informed that OSM #6 had received her second dose 8/2022 and CNA #8 had gap between first vaccine and request for and granting of religious exemption. The facility's vaccine exemption form for CNA #11, temporary nursing aide, documented the form was signed by CNA #11 on 04/21/2022. Review of CNA #11's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/24/2022. Further review failed to evidence an approved or unapproved exemption. In addition, they did not know the status of LPN #3. ASM #2 stated, they were continuing to contact LPN #3 to obtain the documentation. On 4/20/23 at 7:45 AM, the vaccination record for LPN #3 was provided, with the initial vaccine on 6/24/22 and the second vaccine on 8/3/22. On 4/20/23 at 9:30 AM, OSM #1, the executive director, OSM #2, the director of clinical services, OSM #3, the administrative market leader and OSM #4, the regional nurse consultant was informed of the concerns. OSM #3 stated, we tried to pull these from the VIS (Vaccine Information Statement) site but it only had them listed as 1 vaccine. The records were incomplete. The facility's policy COVID-19 Vaccination of Staff policy with a date of 10/22, revealed, All staff are required to be fully vaccinated for COVID-19 in accordance with 483.80(i), unless exempted by law, as specified below. Prior to providing care, treatment or other services for the facility or its residents. Staff who received the initial dose of a primary vaccination series prior to providing care, treatment or other services for the facility or its residents will have completed the series within 30 days or must: have been granted a qualifying exemption; or have been identified as having a temporary delay as recommended by the CDC. The infection preventionist maintains a tracking worksheet of staff members and their vaccination status. The tracking worksheet provides the most current vaccination status of all staff who provide any care, treatment or other services for the facility and/or its residents. The worksheet includes staff name, initial start date of employment, termination of employment, job title, assigned work area, vaccination status including date of next scheduled dose (for multi-dose vaccine), exemption status and delays (reason for delay and date when vaccination can be safely administered). No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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Based on staff interview, facility document review, and clinical record review, it was determined the facility staff to prevent the misappropriation of resident property, specifically narcotic medications, for five of 37 residents in the survey sample, Resident #128, #52, #22, #129, and #27. This is cited as past non-compliance. The findings include: Facility staff found narcotic medication cards tampered with as follows: 1. For Resident #128 (R128), the facility staff failed to prevent the misappropriation of Oxycodone - Acetaminophen (Percocet) used to treat moderate to severe pain. (1). The physician order dated, 12/4/2021, documented, Oxycodone-Acetaminophen Tablet 5-325 MG (milligrams); give 2 tablets by mouth every 4 hours as needed for severe pain 8/10 - 10/10. (pain rating of 8 to 10 and 10 being the worse pain on a pain scale of 1-10). The Narcotic Card contained spaces for 30 tablets. There were 25 tablets in the card at the time of discovery. All the 25 tablets had been tampered with. According to the clinical record, this resident had been discharged prior to the misappropriation. 2. For Resident #52 (R52), the facility staff failed to prevent the misappropriation of Oxycodone Immediate Release (used to treat moderate to severe pain.) (1) tablets. The physician order dated, 4/27/2022, documented, Oxycodone HCL (hydrochloride) Tablet 5 MG; Give 5 mg by mouth every 8 hours for pain. The Narcotic Card #1 contained spaces for 30 tablets. There were 30 tablets in the card at the time of discovery. Thirteen tablets had been tampered with. The Narcotic Card #2 contained spaces for 30 tablets. There were 18 tablets in the card at the time of discovery. Four tablets had been tampered with. Review of the clinical record failed to evidence any increase in the resident's pain. 3. For Resident #22 (R22), the facility staff failed to prevent the misappropriation of Oxycodone Immediate Release tablets. The physician order dated, 12/15/2022, documented, Oxycodone HCL (hydrochloride) Tablet 5 MG; Give 5 mg by mouth every 6 hours for pain. The Narcotic Card contained spaces for 30 tablets. There were 17 tablets in the card at the time of discovery. Six tablets had been tampered with. Review of the clinical record failed to evidence any increase in the resident's pain. 4. For Resident #129 (R129), the facility staff failed to prevent the misappropriation of Oxycodone Immediate Release tablets. The physician order dated 12/22/2022, documented, Oxycodone HCL Oral Tablet 5 MG; give 1 tablet by mouth at bedtime for pain. A second order dated 12/22/2022, documented, Oxycodone HCL Oral Tablet 5 MG; give 1 tablet by mouth every 8 hours as needed for pain. The resident had two narcotic cards, one for each of the orders above. The Narcotic Card #1 contained spaces for 14 tablets. There were 11 tablets in the card at the time of discovery. One tablet had been tampered with. The Narcotic Card #2 contained spaces for 15 tablets. There were 6 tablets in the card at the time of discovery. One tablet had been tampered with. Review of the clinical record failed to evidence any increase in the resident's pain. The resident had been discharged after the discovery. 5. For Resident 27 (R27), the facility staff failed to prevent the misappropriation of Oxycodone - Acetaminophen (Percocet). The facility synopsis of the event, dated 1/4/2023, documented in part, A narcotic count reconciliation was being conducted by DON (director of nursing) (ASM #2) and ED (executive director) (ASM #1). It was discovered that R27 count was off by 1 Hydrocodone-acetaminophen 5/325 mg. Nurse (RN- registered nurse #4) working medication cart could not account to where the medication was. An interview was conducted with LPN (licensed practical nurse) #8 on 4/20/2023 at 7:31 a.m. When asked to explain what happened when she found the narcotic medication cards that appeared to have been tampered with, LPN #8 stated, she noticed on Saturday, following (RN#4) I noticed fingernail areas on a few of the narcotics. The next day I noticed other different peoples cards were punched with fingernail marks. LPN #8 stated she said to RN #4, What was with all these punches. LPN #8 stated that RN #4 stated, Yeah. LPN #8 stated she didn't say anything to anyone at this time. Then, that same evening, she got a nurse from the other side to look at them. They used the light on their phone and started looking at the numbers on the pills. LPN #8 stated she and the other nurse started looking up the numbers on the pills and the numbers did not match what was supposed to be in the card. LPN #8 stated she called (ASM - administrative staff member #1) the executive director and told her what was happening. When asked what the drugs were that had been replaced, LPN #8 stated, some were loratadine (used to treat allergies) (2), and some were tizanidine (used to treat muscle spasms) (3). LPN #8 stated all the pills that were replaced were for oxycodone. LPN #8 stated the never had that problem before on her cart and they haven't had the problem since (RN#4) left. An interview was conducted with ASM #1, the executive director, on 4/20/2023 at 7:51 a.m. ASM#1 stated she had received a call from LPN (licensed practical nurse) #8 and was informed the narcotic cards had been tampered with. ASM #1 stated she pulled all the card, that had been tampered with, from the narcotic drawers. She stated she did a complete audit of all the narcotic cards in the building. For R128, the resident had been discharged . When she turned over the card of pills, all of them had been tampered with. ASM #1 stated she called the pharmacy to get replacements. For R128, the pills were replaced with docusate sodium (used as a stool softener) (4). ASM #1 stated she then notified the police. When asked which pills were found for which resident, ASM #1 stated, R52, they were replaced with tizanidine. For R129, they were replaced with Loratadine. For R22, they were replaced with Loratadine. For R128, they were replaced with docusate sodium. The facility policy, Abuse, Neglect, Exploitation & Misappropriation, documented in part, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. Employee Misappropriating includes but is not limited to: Diversion of resident's medication(s), including but not limited to, controlled substances for staff use or personal gain. The facility Performance Improvement Plan dated, 12/28/2022, documented in part, Plan is specific for Controlled Substances. Identified Area for Assessed Improvement: Controlled Substances. Residents receiving controlled substances medications will be reviewed to ensure suitable documentation is in place to support the administration of the medication. Suitable documentation includes the Medication Administration Record, Controlled Substance Count Sheet, and Applicable ancillary documentation such as a Pain Flow Sheet, or a Behavior Monitoring Sheet. Action/Steps to Implement Plan: Education to licensed nurses on facility practices as it related to acceptance of, documentation and reconciliation of controlled substances. Audits to be completed 100% audit weekly x 2 months and the re-evaluate for compliance. The date of compliance is 1/27/2023. The audits completed by the director of clinical services and the executive director were reviewed. There were no further discrepancies or evidence of tampering. Two of the four medication carts were observed. There were no discrepancies and no evidence of tampering. Interviews were completed with staff nurses on the process for counting and administration of medications. This will be cited as past non-compliance. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html (2) This information was obtained form the following website: https://medlineplus.gov/druginfo/meds/a697038.html (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601121.html (4) This information was obtined from the following website: https://medlineplus.gov/druginfo/meds/a601113.html

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) care for one of 37 residents, Resident #276. The findings include: The facility staff failed to provide evidence of transfer (in and out of bed) and bed mobility for Resident #276. Resident #276 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. The most recent MDS (minimum data set) assessment, a five-day Medicare assessment, with an ARD (assessment reference date) of 6/29/22, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, locomotion, dressing, bathing and hygiene. A review of the baseline care plan dated 6/24/22, which revealed, FOCUS: Fracture: Hip. INTERVENTIONS: Weight bearing as tolerated. Monitor pain and treat as ordered. Assist with repositioning. Rehab orders/recommendations. A review of the hospital Discharge summary dated [DATE], revealed Right Hip Fracture: Posterior precautions, help with assist 1 to 2 [staff], weight bearing as tolerated. A review of the physician orders dated 6/24/22, revealed, Physical Therapy evaluate and treat as indicated. Occupational Therapy evaluate and treat as indicated. A review of the June 2022 ADL (activities of daily living) document for bed mobility included missing documentation on the day/evening shift for 6/25, 6/26, 6/27, 6/28 and 6/29; and the evening/night shift for 6/25, 6/26, 6/27, 6/28 and 6/29. Transferring included missing documentation on the day/evening shift for 6/25, 6/26, 6/27, 6/28 and 6/29; and the evening/night shift for 6/25, 6/26, 6/27, 6/28 and 6/29. An interview was conducted on 4/19/23 at 3:15 PM with OSM (other staff member) #2, the occupational therapist. When asked the process for mobility and transfers for a resident with a hip replacement, OSM #2 stated, the staff are able to get the resident out of bed and to a chair, keeping the knees lower than the hip. The staff are encouraged to get the residents out of bed to reduce any potential complications. An interview was conducted on 4/20/23 at 8:45 AM with CNA (certified nursing assistant) #2. When asked if residents with a hip replacement are gotten out of bed, CNA #2 stated, yes, they are gotten up. When asked where this would be documented, CNA #2 stated, it would be documented on the ADL form either under bed mobility or transfers. When shown Resident #276's ADL form for June 2022 with the missing documentation, CNA #2 was asked what the missing documentation indicated. CNA #2 stated, if it is not documented we can not say it was done. On 4/20/23 at 9:30 AM, OSM #1, the executive director, OSM #2, the director of clinical services, OSM #3, the administrative market leader and OSM #4, the regional nurse consultant was informed of the concerns. A review of the facilities' Lifting and Moving Residents policy dated 12/2014, revealed the following: All residents will be assessed before attempting a transfer or move. Document assistance necessary and resident's tolerance. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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Based on clinical record review, staff interview, and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for one of 37 residents in the survey sample, Resident #262. The findings include: For Resident #262 (R262), the facility staff failed to provide incontinence care. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/22/2022, the resident was assessed as requiring extensive assistance from one staff member for toileting and being always incontinent of bladder and bowel. The comprehensive care plan for R262 documented in part, (Name of R262) has bladder incontinence r/t (related to) impaired mobility. Date Initiated: 12/01/2022 .(Name of R262) has bowel incontinence r/t immobility. Date Initiated: 12/01/2022 . The care plan further documented, (Name of R262) has an ADL self-care performance deficit r/t fracture of right patella, muscle weakness, difficulty walking. Date Initiated: 11/30/2022 . The ADL documentation summary for R262 dated 11/1/2022-11/30/2022 failed to evidence incontinence care provided on the day shift (7:00 a.m. to 3:00 p.m.) on 11/18/2022 through 11/21/2022 and 11/23/2022 through 11/29/2022; on evening shift (3:00 p.m. to 11:00 p.m.) on 11/17/2022 to 11/18/2022 and 11/20/2022 through 11/30/2022; and on night shift (11:00 p.m. to 7:00 a.m.) on 11/17/2022 through 11/30/2022. The progress notes documented incontinence care provided on night shift 11/26/2022 and 11/27/2022 however failed to evidence incontinence care provided on the other dates listed above. On 4/19/2023 at 11:04 a.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that incontinence care was provided every two hours and documented it in the computer under the ADL's. CNA #4 stated that they documented incontinence care provided every shift which was every eight hours. CNA #4 stated that they documented how many times the resident went to the bathroom and what assistance was provided and whether they were continent of not. CNA #4 stated that they remembered R262 being continent the first couple of days after admission and then becoming totally incontinent requiring them to change them every two hours. On 4/19/2023 at 3:48 p.m., an interview was conducted with CNA #9. CNA #9 stated that incontinence care was provided every two hours and as needed. CNA #9 stated that they documented incontinence care in the computer. CNA #9 stated they they documented every two hours as the care was provided under the bowel and bladder section of the ADL's. CNA #9 reviewed the ADL documentation for R262 and stated that if there was nothing documented they could not say that anything was done or that the care was provided. The facility provided ADL policy Activities of Daily Living dated 02/01/2022 documented in part, .ADLs includes bathing, dressing, grooming, hygiene, toileting and eating .CNA will document care provided in the medical record. On 4/19/2023 at 4:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the administrative market leader and ASM #4, the regional nurse consultant were made aware of the findings. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide care and services for indwelling urinary catheter care for one of 37 residents, Resident #276. The findings include: Resident #276 was admitted to the facility with a urinary catheter on 6/24/22 however there was no documentation of catheter care until 7/2/22. Resident #276 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur with hip replacement. Review of physician orders did not include the use of a catheter or care until 7/2/22. Physician orders dated 7/2/22, read, Foley catheter 16 French 10 cc (cubic centimeter) balloon, measure urinary output every shift and as needed. Change catheter as needed. Change catheter bag as needed. Catheter care every shift and as needed. A review of the June 2022 TAR (treatment administration record) and the July 2022 TAR, revealed catheter care was not documented from admission on [DATE] to 7/2/22 12 AM. An interview was conducted on 4/19/23 at 10:20 AM with LPN (licensed practical nurse) #1. When asked the process for providing catheter care for a new admission, LPN #1 stated, We can initiate standing batch orders, catheter care, type of catheter and balloon size, and as needed order to change bag and Foley. Normally we change the catheter every 30 days. Catheter care is performed every shift. When asked what it indicates if there is no documentation for catheter care, LPN #1 stated, nothing was done if it was not documented. On 4/20/23 at 9:30 AM, OSM #1, the executive director, OSM #2, the director of clinical services, OSM #3, the administrative market leader and OSM #4, the regional nurse consultant was informed of the concerns. A review of the facility Catheter Care, Urinary policy dated 9/2017, revealed the following: Procedure: Identify Resident, Provide privacy and explain procedure, Assemble the following (towel/washcloth, basin with warm water, soap and disposable gloves), perform hand hygiene, put on gloves, wash perineal area with soap and water from front to back, rinse well and dry, clean catheter tubing with soap and water starting close to urinary meatus-about 4 inches-moving away from the body-rinse in the same direction, may use incontinent wipes instead of soap and water and perform hand hygiene. No further information was provided prior to exit.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure medications were available for administration for two of 37 residents, Resident #276 and Resident #48. The findings include: 1. For Resident #276, the facility staff failed to ensure Levothyroxine 125 mcg (microgram), Lidocaine patch 5%, Methocarbamol 500 mg (milligram), Oxycodone 10 mg and Pregabalin capsule 100 mg were available for administration. Resident #276 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. A review of the comprehensive care plan dated 7/7/22, which revealed, FOCUS: The resident has pain related to fracture of right femur. INTERVENTIONS: Administer medications per physician orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A review of the physician orders dated 6/24/22, revealed, Levothyroxine 125 mcg (microgram), give 1 tablet by mouth in the morning every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Lidocaine patch 5% apply to right hip topically one time a day for pain and remove per schedule-apply 9 AM, remove 9PM. Methocarbamol 500 mg (milligram), give 1 tablet by mouth four times a day for pain for 7 days. Oxycodone 10 mg, give 1 tablet by mouth every 6 hours for pain for 7 days. Pregabalin capsule 100 mg, give 1 capsule by mouth two times a day for pain. A review of Resident #276's June 2022 MAR (medication administration record) revealed, Levothyroxine 125 mcg not administered 6/25/22 at 6:00 AM, Lidocaine 5% patch not administered on 6/25/22 at 9 AM, Methocarbamol 500 mg not administered on 6/25/22 at 6 AM and 12 PM, Oxycodone 10 mg tablet not administered on 6/25/22 at 12 AM, 6 AM and 12 PM and Pregabalin 100 mg not administered 6/25/22 at 9 AM. A review of the (Name of automated medication dispensing system) drug list did not include Levothyroxine 125 mcg (microgram), Lidocaine patch 5%, Methocarbamol 500 mg (milligram), Oxycodone 10 mg and Pregabalin capsule 100 mg. A review of the nursing note dated 6/24/23 at 11:04 PM and 6/25/22 at 5:55 AM, revealed, Medication not in from pharmacy. A review of the nursing note dated 6/25/22 at 10:16 AM and 1:02 PM, revealed, Awaiting pharmacy delivery. Resident and NP (nurse practitioner) aware. A review of the physician orders dated 7/2/22, revealed, Oxycodone 10 mg, give 1 tablet by mouth every 6 hours for pain for 8 days. A review of Resident #276's July 2022 MAR revealed, Oxycodone 10 mg not administered 7/2/22 12 a.m., 6 AM, 12 p.m. and 6 PM. No nursing progress notes regarding the Oxycodone were written. An interview was conducted on 4/19/23 at 10:20 AM with LPN (licensed practical nurse) #1. When asked the process for obtaining medications for new admissions, LPN #1 stated, the narcotics and other medications are in Omnicell. Typically, the hospital faxes a script from the hospital to (Name of pharmacy), our pharmacy. We would use our on-call book to notify the physician or nurse practitioner if we do not have the medication on site. We do not get orders filled from (Name of pharmacy) until the next afternoon if a resident is admitted on a Friday evening. The staff should have used the on-call book to call the NP (nurse practitioner) or physician to get the order for Oxycodone/acetaminophen 5mg /325 mg x 2 tablets which we do have in stock. If they had notified the NP or physician that would have been documented in the progress notes. On 4/20/23 at 9:30 AM, OSM #1, the executive director, OSM #2, the director of clinical services, OSM #3, the administrative market leader and OSM #4, the regional nurse consultant was informed of the concerns. A review of the facilities' Providing Pharmacy Products and Services policy dated 1/2022, revealed the following: If orders for medications are received from Physician/Prescriber when Pharmacy is closed, Facility staff should take the following steps: 1. Remind the Physician/Prescriber that Pharmacy is closed and that a delay in medication therapy can be prevented by using a medication that is included in Facility's Emergency Medication Supply. 2. If a medication cannot be substituted, ask Physician/Prescriber if the medication therapy can be initiated the next morning. If it is possible to initiate the medication therapy the next morning. Facility staff should document the conversation with the prescriber and include the start time in the order. 3. If a medication is considered essential and cannot be substituted or delayed, contact the emergency number provided by Pharmacy. The emergency number should either page the on-call pharmacist or contact an answering service. Orders should be received directly from a Facility nurse or licensed Physician/Prescriber, and cannot be faxed, e-mailed or provided to answering service personnel. No further information was provided prior to exit. 2. For Resident #48, the facility staff failed to ensure the antidepressant medication, Sertraline, were available for administration. The physician order dated, 7/5/2022, documented, Sertraline Tablet (used to treat depression) (1) 50 MG (milligram); Give 1 tablet by mouth at bedtime for Depression. The March 2023 MAR (medication administration record) documented the above order. On 3/25/2023 and 3/27/2023 for the evening dose documented a 9. A 9 indicates, Other/See Nurse Notes. The nurse's note dated, 3/25/2023 at 8:32 p.m. documented, Pending delivery. The nurse's note dated, 3/27/2023 at 9:39 p.m. documented, Medication is on order with pharmacy and the nurse does not have (name of back up medication system) access. An interview was conducted with LPN (licensed practical nurse) #1, on 4/19/2023 at 2:14 p.m. When asked the process to follow when a medication is not in the medication cart to administer, LPN #1 stated, the nurse should first call the pharmacy to see when it is going to be delivered. Then check the (Name of automated medication dispensing system) and pull it out from there. She stated if it is not in the (name of back up medication system), you have to call the doctor or nurse practitioner to make them aware and to get further orders or instructions. When asked if all nurses have access to the (name of back up medication system), LPN #1 stated, yes. She further stated in March there was a problem with the (name of back up medication system). The caplock key was stuck and she stated she had gotten locked out of the system. The review of the list of medications available in the (name of back up automated medication system) was conducted. Sertraline 25 mg tablets and 100 mg tablets were available in the system. The facility policy, Providing Pharmacy Products and Services failed to document the process a nurse should take when a medication is not available for administration. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/19/2023 at 4:41 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain two of two shower rooms in a sanitary manner, Rosewood and Dogwood hall shower rooms. The findings include: On 4/18/2023 at 11:03 a.m. OSM (other staff member) #7, the director of maintenance, was asked if the facility had any concerns with reported black mold the summer of 2022. OSM #7 stated, no. Observation was made of the shower rooms on both hallways on 4/19/2023 at approximately 2:45 p.m. On the Dogwood Hall there were two shower stalls in the shower room. There was a brown and black substance the junction of the walls and floors on both sides of the shower room. On the Rosewood Hall there were two shower stalls observed. There was a brown and black substance noted on both sides of the stall where the floor meets the walls. There was also a brown substance covering the grout on the left side where the side wall met the back wall. A brown and black substance was noted on the right side, where the side wall meets the back wall. On 4/19/2023 at 2:01 p.m. Observation of the shower rooms was conducted with OSM (other staff member) #7, the regional facilities Manager, OSM #8, the director or maintenance, and OSM #9, the director of environmental services. When asked what the brown and black substance was on the walls and floors, OSM #8 stated, That's mold. OSM #9 was asked how often the shower stalls were cleaned. OSM #9 stated they are cleaned at the end of the staff's shift. OSM #7 concurred that the brown and black areas didn't develop overnight. A request was made for the maintenance request logs for June, July, and August 2022. On 4/19/2023 at approximately 4:00 p.m. OSM #9 was asked how often the shower walls are scrubbed down, OSM #9 stated, once a month. The maintenance request logs were reviewed for June, July, and August 2022. There were no documented concerns for mold. The facility policy, Job to be Done: Scrub Ceramic Tile, documented in part, Steps to do job: Assemble equipment. Close off area to be scrubbed. Make a solution of hot water & germicide or degreaser. Apply solution along edges & use wire brush to scrub by wall. Apply solution to center area & use side by side machine to scrub floor. Try to use a wet wet-vac to get up dirty solution. Dirty water tends to settle into grout. It is difficult to get up with a mop. Allow floor to dry before use. Additional information: Try to use wire block to scrub. A black pad on block will glide over tile and not get into grout .Use a grout brush to clean between tiles. On 4/19/2023 at 4:41 p.m. ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, Administrative Market Leader, and ASM #4, the regional nurse consultant, were made aware of the above concern. No further information was provided prior to exit.

Oct 2021 28 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0740 (Tag F0740)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, clinical record review, and during the course of a complaint investigation, it was determined that the facility staff failed to provide behavioral health services such as conducting individualized assessments and person centered planning, related to residents who demonstrated or expressed suicidal ideation, for six of 41 residents in the survey sample, Resident #230, Resident #59, Resident #20, Resident #24, Resident #61 and Resident #13. On 8/25/21, Resident #230 expressed thoughts of self- injury documented on the MDS-Section D-Letter I., and was not further assessed by facility staff. Safety interventions and behavioral health services were not put in place. On 8/31/21, Resident #230 was found by staff at approximately 3: 00 a.m., with a call bell cord wrapped around his neck, self-injurious behavior that is likely to cause serious injury, harm, impairment, or death to the resident, resulting in transportation to the emergency room for further evaluation. The hospital documented the resident was being discharged back to the facility with a safety plan; however, there was no documented plan in place upon the resident's return to the facility, and no care plan addressing suicidal ideation developed until 9/2/21. On 10/21/21 at 1:10 PM a request was made to ASM (administrative staff member) #1, the executive director for a list of residents receiving psychiatric services, and a list of residents who had expressed thoughts of self- injury documented on the MDS-Section D-Letter I. Seven other residents were identified by the facility as having been assessed on the MDS-Section D-Letter I., as having expressed thoughts of self- injury. Five of the seven, (Residents # 59, 20, 24 61 and 13), had no further immediate assessments, safety interventions and /or behavioral health services provided resulting in the findings of Immediate Jeopardy on 10/21/21 at 4:28 p.m. The IJ was abated on 10/22/2021 at 6:37 p.m. and lowered to an E. The findings include: 1. Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (inability of insulin to function normally in the body) (1), chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease) (2), end stage renal disease 'ESRD' (inability of the kidneys to excrete waste and to function in the maintenance of electrolyte balance in the body) (3) and abscess of testis and buttocks (accumulation of pus in the testis and buttocks) (4). The most recent MDS (minimum data set) assessment, a five day Medicare assessment with an ARD (assessment reference date) of 8/26/21, coded Resident #230 as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating Resident #230 was cognitively intact. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead or of hurting yourself in some way coded Resident #230 as Yes for these questions and coded the frequency of symptoms for the resident as 2-6 days. Resident #230 was reviewed as part of a complaint regarding a concern of attempted suicide. A review of the physician orders dated 8/20/21, documented in part Psychiatry as needed. Psychology as needed. Further review of Resident #230's clinical record failed to reveal any evidence psychiatric consults or services were provided. A review of Resident #230's clinical record failed to evidence the development of a baseline care plan to address psychosocial needs and mood, including thoughts of self injury/suicide. On 9/2/21, the comprehensive care plan documented in part, FOCUS-Resident is at risk for a decline in mood related to medical condition and current living arrangements. INTERVENTIONS-Arrange for psych [psychiatric] consult follow up as indicated. A review of the nursing progress notes documented in part the following: - 8/24/21 at 1:11 PM, Level of consciousness noted as oriented to person oriented to place oriented to time. Mood status is happy pleasant smiling. Behavioral problems are not noted. - 8/25/21 at 4:27 PM, Level of consciousness noted as oriented to person. Mood status is angry negative statements fidgety. Behavioral problems are not noted. 8/27/21 at 8:49 AM, Level of consciousness noted as oriented to person oriented to place oriented to time. Mood status is depressed happy pleasant smiling negative statements flat affect. Behavioral problems are not noted. A review of the social services progress note dated 8/27/21 at 2:54 PM, documented in part, Resident answered yes to thoughts of hurting himself. Asked resident is [Sic.] he had any plans of hurting himself he stated he was in a bad mood the day of PHQ9 interview. A facility hospital transfer form dated 8/31/21 at 2:58 AM, documented in part, Suicide attempt. Reason for transfer: Resident was found with light cord wrapped around his neck and when asked what he was doing he stated, 'trying to f .[expletive] hand (Sic. [hang]) myself'. The hospital emergency department physician history and physical exam dated 8/31/21 at 3:55 AM, documented in part, Chief complaint: Psychiatric evaluation. Context: Resident is an [AGE] year old male who presents from nursing home because of suicidal ideations. The patient apparently is upset with the nursing home and upset with his medical care to the point that he states he would like to be put out of his misery. He asked one of the nurses if they could shoot him. He also tried to wrap a small piece of string around his neck. The patient tells me that he would like to be put out of is misery. Review of Systems: Psychiatric/Behavioral: positive for suicidal ideas. Neuro/Psych: Normal affect and agitated mood. Patient is alert, and oriented to person place and circumstance. Critical Care: Differential diagnosis considered includes: situational anxiety/frustration versus a true suicidal ideations. A hospital emergency department nursing note dated 8/31/21, documented in part, Disposition: Case discussed with patient, daughter and physician. Plan of Care: discharge with safety plan. A nursing home nurses progress noted dated 8/31/21 at 4:24 PM, documented in part, Patient returned from the hospital on stretcher accompanied by 2 EMT [emergency medical technicians], patient returned with no new order, all morning meds [medications] was administered at the hospital, new catheter and wound dress done while at the hospital. Vital signs: blood pressure 145/83, respirations 16, pulse 76, temperature 97.6. Patient continues to be monitored for suicidal idea. Patient was able to participate in Physical therapy activity. Currently in bed resting. A review of Resident #230's medical record failed to evidence that a safety plan was initiated for the resident upon return to the facility. On 10/20/21 at 4:05 PM, an interview was conducted with OSM (other staff member) #4, the social services manager. When asked about the discharge plan for Resident #230, OSM #4 stated, We had a pre-discharge meeting. It was not a care plan meeting. The resident was to be discharged on Tuesday 9/7. The daughter decided to take the resident home on 9/3/21, a Friday at 6:42 PM. An interview was conducted on 10/21/21 at 2:46 PM with Resident #230's daughter. When asked about the discharge date for her father, Resident #230's daughter stated, After his suicide attempt, I could not leave him in the facility over another weekend. I met with the social worker and she took notes on all kinds of scrap pieces of paper. I talked with the administrator about taking my dad home and he told me 'we really dropped the ball on this one including administration'. The administrator said they would release my dad with their wound vacuum since they had dropped the ball. I could not wait to get him out of there before something else happened to him. An interview was conducted on 10/20/21 at 1:15 PM with ASM (administrative staff member) #2, the director of clinical services [director of nursing]. When asked what actions would be done if a resident answered yes to thoughts that they would be better off dead, or of hurting themselves in some way, ASM #2 stated, We would remove everything out of room that they could do harm, give them plastic silverware, paper plates or Styrofoam containers for food. We would take away anything that could be wrapped around his neck. We would put them on 1:1. If situation escalated, we would send them out to the hospital. We would document behaviors and pass all this information on in report. When asked if she remembered the suicidal attempt by Resident #230, ASM #2 stated, No, I was moving from another part of the state and don't remember being informed. An interview was conducted on 10/20/21 at 2:55 PM, with OSM (other staff member) #4, the social services manager. When asked what process occurs when a resident answers yes to thoughts that they would be better off dead, or of hurting themselves in some way, OSM #4 stated, I wasn't aware of the answer until 8/27. I would call the director of clinical services and alert them. I ask the resident if they have a plan in place and notify the nurse. We would not leave the resident alone and would pull any items from the room the resident could harm themselves with. On 10/25/21 at 3:57 PM, another interview was conducted with OSM (other staff member) #4, the social services manager. When asked the about the process followed if a resident verbalized thoughts of self-harm, prior to education last week, OSM #4 stated, Prior to education last week, I would just inform the MDS coordinator and the nursing director. Now we stay with the resident and do not leave them. Before last week, normally I would follow up immediately and leave a note immediately. When asked where this information was documented and evidenced, OSM #4 stated, For Resident #230, I don't have any documentation or evidence. An interview was conducted on 10/21/21 at 6:47 AM with LPN (licensed practical nurse) #8. When asked if she remembered Resident #230, she asked to pull up his picture and then LPN #8 stated, Yes, I remember caring for him. When asked if she had been informed that he had verbalized thoughts of harm to himself, LPN #8 stated, No, I never knew that he was a risk to himself and that there was behavior issues. When asked what actions would be taken if a resident verbalized thoughts of harm to himself, LPN #8 stated, I would have them 1:1 and document it, inform the physician, nursing leaders, and family. An interview was conducted on 10/21/21 at 7:27 AM with LPN #5. When asked if she remembered Resident #230, LPN #5 stated, Yes I remember the resident and there was an issue where they sent him out to the hospital because I think he had a cord tied around his neck. I do not remember that he was put on 1:1. Normally our protocol is to put them on 1:1. When asked what interventions were put in place upon his return from the hospital, LPN #5 stated, I don't believe anything new was put in place. An interview was conducted by phone on 10/21/21 at 8:48 AM with LPN #9, the nurse on duty 8/31/21, night shift with Resident #230. When asked to describe the situation, LPN #9 stated, I found him [Resident #230] at about 3:00 AM. He knew what he was doing and he had the cord wrapped around his neck. I did my protocol. I had the CNA (certified nursing assistant) sit outside of his door and monitor him. I put him on frequent checks. Notified the nurse practitioner, the administrator and the nursing director. We were changing nursing directors I think at that time. I know the DON [director of nursing] and the administrator knew because they came in and talked with me the next day. When asked if she had been informed the resident had verbalized thoughts of harming himself, LPN #9 stated, No, I knew nothing about that before this situation, this took me by surprise. I did not know he was at risk. An interview was conducted on 10/21/21 at 10:20 AM with ASM #6, the nurse practitioner. When asked if she was informed that Resident #230 had verbalized thoughts of harming himself, ASM #6 stated, No, I did not know beforehand that he had suicidal tendency. There would have been orders to have him taken to the hospital if needed and seen by psychiatry. A second interview was conducted 10/21/21 at 12:11 PM, with Resident #230's daughter. When asked if her father had any history of self-harm or verbalizing thoughts of self-harm, the Resident #230's daughter stated, No, he has never tried to harm himself. That morning (8/31/21), the facility had my phone number wrong and my nephew had to call me to inform me that had taken my dad to the emergency room. When I went into see him, my dad said, Sis, I was in pain for two days and I couldn't sleep. So I see that cord and said I can wrap this cord around my neck and turn over in bed a few times it just might get tight enough. It's better than being here in this place. An interview was conducted on 10/21/21 at 1:09 PM with ASM #1, the administrator. When asked what he remembered about Resident #230's suicide attempt, ASM #1 stated, I would have to go back and look, but I remember being told that the cord was laying across his neck, not wrapped around his neck. When ASM #1 was informed of the interview conducted with the night nurse and that her recollection and the documentation in the medical record were consistent and documented, Resident was found with light cord wrapped around his neck and when asked what he was doing he stated, 'trying to f .[expletive] hand (Sic. [hang]) myself'. ASM #1 stated, I don't remember that. When asked if any interventions were initiated upon Resident #230's return from the emergency department and if an investigation had been initiated, ASM #1 stated, I don't think so. A review of the facility's Resident Expressing Suicidal Ideations policy dated 8/2017, documented in part, To ensure the safety of any resident that expresses the desire to harm themselves. The Director of Clinical Services and the Executive Director are to be notified immediately of any resident that expresses the desire to harm themselves. Once a resident expresses the desire to harm themselves, staff to do the following: staff to remain with resident until a physician or a qualified psychologist evaluates the resident and documents that the resident is not suicidal or at risk of harming self-OR until the resident is transferred to a higher level of care, the nurse to be notified immediately, the nurse to notify the physician and responsible party of the resident's condition, the nurse to notify the Director of Clinical Services and the Executive Director, the nurse to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. A review of the facility's Mental Health Referrals policy dated 11/2014, documented in part, Mental Health referrals will be utilized by the facility when a resident's behavior and affect appears disturbed or indicates distress. Resident's behavior and affect are observed by nursing home staff members and documented in the resident's chart. A list of any other residents who had verbalized self-injury was requested from ASM [administrative staff member) #1, the administrator, on 10/2/21 at approximately 1:01 p.m. On 10/21/21 at 2:15 p.m., ASM #1 provided a resident list based on MDS-Section D-Letter I Thoughts that you would be better off dead, or of hurting yourself in some way; that were coded as 'yes'. This list contained seven additional residents. The survey team reviewed the records of these additional seven residents, (Resident #'s 10, 50, 59, 20, 24, 61 and 13). The resident record review revealed five of the seven (Resident #'s 59, 20, 24, 61 and 13), failed to evidence any implementation of further assessments, safety interventions, and behavioral health services for these additional five residents with documented 'yes' answers to the MDS question about being better off dead or of hurting themselves. This resulted in a likely situation for serious psychosocial harm, serious injury, serious harm, serious impairment, or death to occur. On 10/21/21 at 3:41 PM, the Long Term Care supervisor, was notified of the facility's failure to implement immediate further assessments, safety interventions, and behavioral health services for these additional five residents as documented above. The Long Term Care supervisor consulted with three additional Long Term Care supervisors and the Division director and the team was notified of immediate jeopardy findings. On 10/21/21 at 4:28 PM, the survey team met with the executive director, director of clinical services and the vice president of operations, and informed them of the concern for Immediate Jeopardy. On 10/21/21, the facility submitted the following plan of correction that was accepted at approximately 8:05 p.m. 1. Resident #230 triggered for self-injury on the PHQ-9 completed on August 25, 2021. The resident was found with his call bell around his neck on 8/31/21 and was sent to the emergency room. The facility failed to implement behavioral health services for Residents #230, #61, #50, #59, #24, #10, #13, and #20. On October 21, 2021, it was identified residents #61, #50, #59, #24, #10, #13, and #20 triggered for self-injury on the PHQ-9. Resident #230 was discharged on 9/3/21. Residents #61, #50, #59, #24, #10, #13, and #20 had call bells removed from their room, plastic silverware implemented until assessed by a Registered Nurse on 10/21/21. 2. The Director of Nursing (DON) or designee will complete PHQ-9 for all residents with BIM score of 8 and above. Residents with a BIMS of 7 or below will have nursing and social services documentation reviewed for the last 30 days for thoughts of self-injury or other present symptoms. Residents identified with feelings of self-injury as recorded on PHQ-9 or through documentation review will have MD/NP/RP notification and appropriate interventions in place and plan of care updated. MD/NP will be consulted on appropriate immediate interventions until psych [psychiatric] services can be rendered in house or transferred to a higher level of care as appropriate. Plan of care will be updated by licensed nurse. 3. Regional [NAME] President of Operations/Regional Director of Clinical Services will re-educate Social Services Director, MDS Coordinators, and Nurse Management on policy and procedures related to completing PHQ-9 per the RAI Manual Guidelines and correctly identifying thoughts of self-injury and policy for addressing change in condition. Correctly identifying thoughts of self-injury include a resident verbalizing the following: 1. Feeling bad about yourself - or that you are a failure or have let yourself or your family down 2. Thoughts that you would be better off dead, or of hurting yourself in some way. Addressing a change in condition is done by identifying a resident's change in their physical, mental, or psychosocial status. DON [director of nursing] or designee will re-educate all staff on identifying changes in psychosocial behavior. Staff education to include identifying a resident expressing the desire to harm themselves and completing the following: 1. Staff to remain with resident until a physician or a qualified psychologist evaluates the resident and documents that the resident is not suicidal or at risk of harming self or until the resident is transferred to a higher level of care. 2. The nurse to be notified immediately 3. The nurse to notify the physician and responsible party of the resident's condition. 4. The nurse to notify the Director of Clinical Services and the Executive Director 5. The nurse to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. No staff will be allowed to work until education is completed. IDT [interdisciplinary team] will review 24 hour report and nurse notes of residents triggering for self-injury and any other symptom presence during the morning clinical meeting to ensure appropriate interventions are in place, MD/NP/RP [medical doctor/nurse practitioner/ responsible party] notification and care plans reflect appropriate interventions. DON/designee to review completed PHQ-9's to identify residents who may have triggered for self-injury during morning clinical meeting Monday through Friday. Weekend staff identifying residents who express the desire to harm themselves will follow the suicidal ideation policy. This will be an ongoing intervention. 4. DON to report findings from QI [quality improvement] monitoring at the QI committee meeting monthly for 12 months for further compliance and/or revision. 5. Date of compliance 10/22/21 at 3:00pm. On 10/23/21 from 8:00 AM-10:00 AM, the facility plan of correction was verified onsite by the following: 1. Review of the all resident's PHQ-9 and/or documentation of MD/NP/RP notification and appropriate interventions. 2. Review of all psychiatric evaluations of residents who were identified as wanting to harm themselves as coded on the PHQ-9. 3. Review of all resident care plans that required a revision/update regarding psychiatric services. 4. Review of all credible evidence for training provided, education content and staff sign in sheets for all shifts and staff. 5. Interviews, in-person and telephone, with numerous facility staff, including contract staff, from varying shifts and disciplines in regard to identifying changes in resident's psychosocial behavior or expressing the desire to harm themselves and the steps they need to follow: a. Staff to remain with resident until a physician or a qualified psychologist evaluates the resident and documents that the resident is not suicidal or at risk of harming self or until the resident is transferred to a higher level of care. b. The nurse to be notified immediately c. The nurse to notify the physician and responsible party of the resident's condition. d. The nurse to notify the Director of Clinical Services and the Executive Director e. The nurse to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. In addition to the seven resident's originally identified, the facility identified three additional residents as wanting to harm themselves. These residents were also included in the verification review. All ten resident were evaluated by psychiatric services and deemed safe before the immediate jeopardy abatement on 10/22/21 at 6:37 PM. No further information was provided prior to exit. 2. The facility staff failed to assess and implement a plan of care for Resident #59 who stated he had thoughts that he would be better off dead, or of hurting himself in some way on a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 9/29/21. The facility staff failed to evidence that behavioral health services were offered to Resident #59 between 9/29/21 and 10/21/21. Resident #59 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (1), chronic obstructive pulmonary disease 'COPD' (2) and chronic respiratory failure. (3) The most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 9/29/21, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead, or of hurting yourself in some way coded the resident as Yes and frequency of symptoms coded the resident as 2-6 days. A review of the comprehensive care plan dated 7/8/21, documented in part, FOCUS-Resident has a decline in mood problem related to terminal prognosis. INTERVENTIONS-Behavioral health consults as needed. Seen by psych [psychiatric] services (initiated 10/22/21). Facility/hospice staff to provide emotional support as needed. Review of the physician's orders failed to evidence any current order for Psychiatry as needed or Psychology as needed. A past order had a discontinuation date of 1/30/21. A review of the social services progress note dated 9/29/21 at 11:07 AM, documented in part, On PHQ9 resident answered yes to thoughts about being dead/harming self, he stated that he has no plan in place and the thoughts come and go. There was no evidence in the medical record of additional monitoring or notification of nursing. There was no evidence of removing items from the resident's room or psychiatric consult for Resident #59, prior to identification of immediate jeopardy on 10/21/21, as documented above. On 10/21/21 at 4:28 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3, the regional vice president of operations were informed of the Immediate Jeopardy findings at this time. A review of the resident safety check form dated 10/21/21 3:00 PM through 10/21/21 6:45 PM documented every 15 minute checks. On 10/21/21 at 5:10 PM an interview was conducted with Resident #59. When asked if he remembered being asked about thoughts of self-harm, Resident #59 stated, Yes, I remember the conversation and remember saying that. Nothing else has been done, I have not talked with anyone. A review of the nurse practitioner progress note dated 10/22/21 at 10:30 AM, documented in part, Suicide screening: Psychiatric: Insight: good judgement. Mental status: confused and abnormal affect, hallucinations. Orientation: not oriented to time, place and person. Memory: recent memory abnormal and remote memory abnormal. Patient with no voiced suicidal ideations or thoughts per staff. Psych [psychiatric] to evaluate patient as well. On 10/25/21 at 3:57 PM, an interview was conducted with OSM (other staff member) #4, the social services manager. When asked to provide any information regarding notification to the Director of Clinical Services regarding Resident #59's assessed thoughts of self-harm, OSM #4 stated, I'm not sure, I will have to check and get back with you. When asked about the process staff follows if a resident verbalized thoughts of self-harm, prior to education last week, OSM #4 stated, Prior to education last week, I would just inform the MDS coordinator and the nursing director. Now we stay with the resident and don't leave them. Before last week, normally I would follow up immediately and leave a note immediately. On 10/25/21 at 4:06 PM, an interview was conducted with ASM (administrative staff member) #2, the director of clinical services [director of nursing]. When asked the process followed if the mood assessment identifies thoughts of self-harm, ASM #2 stated, Normally the social services manager reports it to me prior to education last week. When asked what the revised process included, ASM #2 stated, We assess the resident and put them on every 15 minute checks until the physician can see them. If suicidal, take call bell out of room and put them on 1:1. This process was started last week. We had someone in social services that was not reporting this information to us. That person is no longer here. Since, I have been here (8/26/21 as interim, 9/16/21 as permanent), I have never had anyone report a resident with thoughts of self-harm to me. On 10/26/21 at 8:25 AM, OSM #4 provided email dated 9/29/21 at 8:05 AM to the ASM (administrative staff member) #2, the director of clinical services, which documented in part, Resident #59 also answered yes to having thoughts about hurting himself or being better off dead but stated he had no plan in place. He seems very depressed now that he is in isolation, more so then before, seems to have a hard time understanding why he is in quarantine. No further information was provided prior to exit. References: (1) Diabetes mellitus inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (2) Chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. (3) Chronic respiratory failure (chronic inability of the heart and lungs to maintain and adequate level of gas exchange. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 502. 3. The facility staff failed to assess and implement a plan of care for Resident #20 who stated he had thoughts that he would be better off dead, or of hurting himself in some way on a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/19/21. The facility staff failed to evidence that behavioral health services were offered to Resident #20 between 8/19/21 and 10/21/21. Resident #20 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (1), chronic kidney disease (decreased function of the kidneys frequently as a complication of diabetes) (2) and cerebrovascular accident (hemorrhage or blockage of the blood vessels of the brain leads to lack of oxygen and resulting symptoms) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 8/19/21, coded Resident #20 as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead, or of hurting yourself in some way coded Resident #20 he resident as Yes and frequency of symptoms coded the resident as 2-6 days. A review of the comprehensive care plan dated 8/23/21, documented in part, FOCUS-Potential for psychosocial well-being. INTERVENTIONS-Observe for psychosocial and mental status changes. Document and social work report as indicated. Provide emotional support and allow residents to express feelings, fears and concerns. A review of the physician orders dated 3/16/21, documented in part Psychiatry as needed. Psychology as needed. A review of the MDS coordinator note dated 8/23/21 at 1:17 PM, documented in part, MDS 8/13 Mood interviews. Mood is fluctuating daily. Recent SCIC (significant change in condition) due to coming off hospice. There was no evidence in the medical record of additional monitoring or notification of nursing regarding Resident #20's 8/19/21, assessment for thoughts of being better off dead, or of hurting yourself in some way . There was no documented evidence of removing items from the resident's room or of psychiatric consult, prior to the identification of immediate jeopardy on 10/21/21, as documented above. On 10/21/21 at 4:28 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3, the regional vice president of operations were informed of the Immediate Jeopardy findings at this time. A review of the resident safety check form dated 10/21/21 11:00 PM through 10/22/21 11:45 AM documented every 15 minute checks. On 10/21/21 at 5:00 PM, an interview was attempted with Resident #20, but was not completed. A review of the nurse practitioner progress note dated 10/22/21 at 12:00 PM, documented in part, Suicide screening: Psychiatric: Insight: poor insight. Mental status: lethargic, confused and abnormal affect, hallucinations. Orientation: not oriented to time, place and person. Memory: recent[TRUNCATED]

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to provide care in a manner to ensure dignity for one of 41 residents in the survey sample, Resident #28. The facility staff failed to maintain Resident #28's Foley urinary catheter (1) in a dignified manner. Urine in the catheter bag was observed from the hall while Resident #28 was lying in bed. The findings include: Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to congestive heart failure, muscle weakness and dementia. Resident #28's quarterly minimum data set assessment with an assessment reference date of 8/31/21, coded the resident's cognition as moderately impaired. Review of Resident #28's clinical record revealed a physician's order dated 3/23/21 for a Foley catheter due to urinary retention. Resident #28's comprehensive care plan dated 3/15/21 documented, (Resident #28) has Indwelling Foley Catheter r/t (related to) obstructive uropathy .Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 10/19/21 at 8:48 a.m. and 9:49 a.m., Resident #28 was observed in bed and was not able to be interviewed. The resident's Foley catheter bag was observed attached to the bed frame and was located on the side of the bed that was facing the door. The urine in the catheter bag was visible from the hall. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated a privacy bag should cover a resident's Foley catheter bag and she would feel embarrassed if she had a catheter and the urine in the bag was visible to others. On 10/20/21 at 2:32 p.m., an interview was conducted with RN (registered nurse) #1, the employee who documented Resident #28's care plan. RN #1 stated she documented to keep Resident #28's catheter bag and tubing aware from the entrance room door for privacy. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services, [director of nursing]) were made aware of the above concern. The facility policy regarding urinary catheter care failed to document information regarding catheters and dignity. No further information was presented prior to exit. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide accommodation of needs for two of 41 residents in the survey sample, Residents #8 and #28. The facility staff failed to ensure Resident #8 and Resident #28's call bell or ring bell was within reach. The findings include: 1. The facility staff failed to ensure Resident #8's hand held ring bell was within the resident's reach. Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to major depressive disorder, diabetes and muscle weakness. Resident #8's annual minimum data set assessment with an assessment reference date of 8/2/21, coded the resident as being cognitively intact. Section G coded Resident #8 as requiring extensive assistance of two or more staff with bed mobility. Resident #8's electric call bell was not operational during the survey. On 10/19/21 at 10:09 a.m., Resident #8 was lying in bed. An interview was conducted with the resident who stated that he sometimes uses his call bell. On 10/19/21 at 10:50 a.m. and 3:45 p.m., Resident #8 was lying in bed. A hand held ring bell was observed on a night stand that was positioned against the wall, to the side and behind the head of Resident #8's bed. The ring bell was not within Resident #8's reach. Resident #8's comprehensive care plan dated 8/26/20 documented, (Resident #8) is at risk for falls r/t (related to) impaired mobility .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated residents should have call bells or ring bells within reach so they have an easy way to get a hold of staff. On 10/19/21 at 3:47 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated she checks to ensure call bells are within residents' reach when she completes her rounds. CNA #1 stated call bells should be within residents' reach in case there is an emergency and because some residents are not mobile. CNA #1 was shown the ring bell on Resident #8's nightstand. CNA #1 stated the ring bell was not within the resident's reach and placed it on an over bed table within the resident's reach. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy regarding the call bell system documented, Resident must have, at all times, a system to notify staff when assistance is needed. Hand bells or tap type bells will be placed within reach of any resident affected by an inoperable call bell . No further information was presented prior to exit. 2. The facility staff failed to ensure Resident #28's call bell was within reach. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to congestive heart failure, muscle weakness and dementia. Resident #28's quarterly minimum data set assessment with an assessment reference date of 8/31/21, coded the resident's cognition as moderately impaired. Section G coded Resident #28 as requiring extensive assistance of one staff with bed mobility. On 10/19/21 at 8:48 a.m. and 11:07 a.m., Resident #28 was observed in bed. The resident's call bell was on the floor on the left side of the resident's bed and was not within the resident's reach. Resident #28 was not able to be interviewed during the survey. Resident #28's comprehensive care plan dated 4/29/20 documented, (Resident #28) is at risk for falls r/t (related to) a h/o (history of) falls .Be sure his call light is within reach and encourage him to use it for assistance as needed. Due to blindness, be sure you tell him where the call bell is. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated residents should have call bells or ring bells within reach so they have an easy way to get a hold of staff. On 10/19/21 at 3:47 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated she checks to ensure call bells are within residents' reach when she completes her rounds. CNA #1 stated call bells should be within residents' reach in case there is an emergency and because some residents are not mobile. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to notify the physician of a possible need to alter treatment for two of 41 residents in the survey sample, Residents #24 and #129. The facility staff failed to notify Resident #24's physician when the medication Eliquis was not available for administration on 7/5/21 and 7/29/21, and failed to notify Resident #129's physician when the medication guaifenesin was not available for administration on 9/28/21, 9/29/21 and 9/30/21. The findings include: 1. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes, atrial fibrillation (1) and a history of stroke. Resident #24's quarterly minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognitive skills for daily decision making as modified independence. Review of Resident #24's clinical record revealed a physician's order dated 3/12/21 for Eliquis (1) 2.5 mg (milligrams) - one tablet by mouth two times a day for peripheral vascular disease (2). Resident #24's July 2021 MAR (medication administration record) documented the order for Eliquis 2.5 mg- one tablet by mouth two times a day. On 7/5/21 at 5:00 p.m. and 7/29/21 at 5:00 p.m., the nurse did not document the medication as being administered. The MAR documented the code, 9=other/See Nurse Notes. A nurse's note dated 7/5/21 documented, out of medication and was reordered. A nurse's note dated 7/29/21 documented, not available. Further review of Resident #24's clinical record failed to reveal the physician was notified on the above dates when Eliquis was not administered. Resident #24's comprehensive care plan dated 8/2/20 documented, (Resident #24) has Peripheral Artery Disease. Give medications for improved blood flow or anticoagulants as ordered . The care plan failed to document information regarding physician notification if the medication was not administered. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the physician should be notified when a medication is not available for administration to a resident because the physician may want to change the order. On 10/21/21 at 8:30 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policies regarding medical care and medication administration failed to document specific information regarding physician notification for medications not available for administration. No further information was presented prior to exit. References: (1) Apixaban (Eliquis) is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a613032.html (2) Peripheral vascular disease is a condition of the blood vessels that supply the feet and legs. This information was obtained from the website: https://medlineplus.gov/ency/article/000170.htm 2. Resident #129 was admitted to the facility on [DATE]. Resident #129's diagnoses included but were not limited to high blood pressure, diabetes and COVID-19. Resident #129's quarterly minimum data set assessment with an assessment reference date of 10/3/21, coded the resident's cognition as severely impaired. Review of Resident #129's clinical record revealed a physician's order dated 9/27/21 for guaifenesin (1) liquid 100 mg (milligrams)/5 ml (milliliters). Give 10 ml by mouth every four hours for a cough for 15 days. Resident #129's September 2021 MAR (medication administration record) documented the order for guaifenesin liquid 100 mg (milligrams)/5 ml (milliliters). Give 10 ml by mouth every four hours for a cough for 15 days. On 9/28/21 at 12:00 p.m. and 4:00 p.m., 9/29/21 at 4:00 a.m. and 8:00 p.m., and 9/30/21 at 12:00 a.m. and 4:00 a.m., the nurse did not document the medication as being administered. The MAR documented the code, 9=other/See Nurse Notes. A nurse's note dated 9/28/21 documented, on order from supply. Another nurse's note dated 9/28/21 documented, on supply order. A nurse's note dated 9/29/21 documented, drug not available. Another nurse's note dated 9/29/21 documented, drug not available. A nurse's note dated 9/30/21 documented, drug not available. Further review of Resident #129's clinical record (including nurses' notes) failed to reveal the physician was notified on the above dates when guaifenesin was not administered. Resident #129's comprehensive care plan dated 6/25/21 failed to document information regarding physician notification if guaifenesin was not administered. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the physician should be notified when a medication is not available for administration to a resident because the physician may want to change the order. On 10/21/21 at 8:30 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. No further information was provided. Reference: (1) Guaifenesin is used to treat chest congestion. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682494.html

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #229 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Diabetes mellitus (inability of insulin to function normally in the body) (1), fracture right fibula (break in the outer bone of the leg) (2), chronic respiratory failure (chronic inability of the heart and lungs to maintain and adequate level of gas exchange) (3) and epilepsy (neurological disorder characterized by recurrent episodes of convulsive seizures) (4). The most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an ARD (assessment reference date) of 10/20/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, hygiene/bathing, dressing and as independent for eating. A review of MDS Section H- Bowel and Bladder coded the resident as always incontinent for bowel and for bladder. Review of Resident #229's clinical record failed to evidence a completed baseline care plan prior to 10/19/21. An interview was conducted on 10/19/21 at 2:40 PM with LPN (licensed practical nurse) #4. When asked to review the baseline care plan for Resident #229, LPN #4 stated, I will look in the EMR (electronic medical record). It says there is no care plan. There may be one in her paper chart. LPN #4 was then observed reviewing Resident #229's paper clinical record, and stated, Yes, this is the form and it is blank. I believe she came later in the evening. When asked about the purpose of the baseline care plan, LPN #4 stated, It is to develop goals for the resident based on their individual needs, and orders. When asked who is responsible for the baseline care plan, LPN #4 stated, The nurse is responsible to develop the baseline care plan. An interview was conducted on 10/20/21 at 2:32 PM with RN (registered nurse) #1, the MDS coordinator. When asked who is responsible for developing baseline care plans, RN #1 stated, The nurses on the floors initiate the baseline care plans and we do the comprehensive. The nurse who admits the patients starts the baseline care plan. The baseline care plan should be done within 48 hours of admission but is a work in progress until the comprehensive is completed. On 10/20/21 at 5:10 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3 the regional vice president of operations and ASM #4 the regional clinical nurse were made aware of the concerns. No further information was provided prior to exit References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 232, 234. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 502. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 199. 3. The facility staff failed to develop a baseline care plan to address Resident #230's mood and statements regarding self harm. Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (inability of insulin to function normally in the body) (1), chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease) (2), end stage renal disease 'ESRD' (inability of the kidneys to excrete waste and to function in the maintenance of electrolyte balance in the body) (3) and abscess of testis and buttocks (accumulation of pus in the testis and buttocks) (4). The most recent MDS (minimum data set) assessment, a five day Medicare assessment with an ARD (assessment reference date) of 8/26/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead, or of hurting yourself in some way coded the resident as Yes and frequency of symptoms coded the resident as 2-6 days. This was reviewed as part of a complaint for Resident #230. Review of Resident #230's clinical record failed to reveal a baseline care plan addressing Resident #230's expressed thoughts of self- injury documented on the MDS-Section D-Letter I., that was completed on 8/25/21 by the social worker no longer employed at the facility. A review of the physician orders dated 8/20/21, documented in part Psychiatry as needed. Psychology as needed. Further review of the clinical record failed to evidence any psychiatric and or psychology visits were provided for Resident #230. A facility hospital transfer form dated 8/31/21 at 2:58 AM, documented in part, Suicide attempt. Reason for transfer: Resident was found with light cord wrapped around his neck and when asked what he was doing he stated, 'trying to f .[expletive] hand (Sic. [hang]) myself'. Further review of the clinical record revealed a comprehensive care plan dated 9/2/21, that documented in part, FOCUS-Resident is at risk for a decline in mood related to medical condition and current living arrangements. INTERVENTIONS-Arrange for psych [psychiatric] consult follow up as indicated. An interview was conducted on 10/19/21 at 2:40 PM with LPN (licensed practical nurse) #4. When asked about the purpose of the baseline care plan, LPN #4 stated, It is to develop goals for the resident based on their individual needs, and orders. When asked who is responsible for the baseline care plan, LPN #4 stated, The nurse is responsible to develop the baseline care plan. An interview was conducted on 10/20/21 at 6:55 AM with LPN (licensed practical nurse) #8. When asked the purpose of the base line care plan, LPN #8 stated, To have a plan to meet the resident needs that everyone can see. When asked if mood and behavior issues should be included on the baseline plan, LPN #8 stated, Yes, they should be included. An interview was conducted on 10/20/21 at 2:40 PM with LPN #6, MDS coordinator. When asked the purpose of the baseline care plan, LPN #6 stated, The purpose is to develop the plan of care for the resident to meet their needs. When asked about the MDS Section D Letter I coding completed on 8/25/21 and development of a care plan for Resident #230, LPN #6 stated, Yes, that [comprehensive care plan] wasn't developed till 9/2/21. When asked if there was any documentation that a baseline care plan had been developed to address Resident #230's mood and self injury statements before that date [9/2/21], LPN #6 stated, None that I can see. On 10/26/21 at 3:52 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3 the regional vice president of operations were made aware of the concerns. The facility policy titled, Plans of Care documented, Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR (pre-admission screening and resident review) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. A review of the facility's Mental Health Referrals policy, dated 11/2014, documented in part, Resident's behavior and affect are observed by nursing home staff members and documented in the resident's chart. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 4. Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for three of 41 residents in the survey sample, Residents #130, #229 and Resident #230. 1. The facility staff failed to develop a baseline care plans for Resident #130 who was admitted to the facility on [DATE]. 2. The facility staff failed to develop a baseline care plans for Resident #229 admitted to the facility on [DATE]. 3. The facility staff failed to develop a baseline care plan to address Resident #230's mood and statements regarding self harm. The findings include: 1. Resident #130 was admitted to the facility on [DATE]. Resident #130's diagnoses included but were not limited to congestive heart failure, diabetes and chronic kidney disease. Resident #130's admission MDS (minimum data set) assessment with an assessment reference date of 10/21/21, coded the resident as being cognitively intact. On 10/20/21, Review of Resident #130's clinical record failed to reveal a baseline care plan. A blank baseline care plan was present in Resident #130's paper clinical record but was not filled out. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the nurses complete assessments and provide information for baseline care plans but do not develop baseline care plans. On 10/20/21 at 2:32 p.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator. RN #1 stated the nurse who admits a resident is supposed to initiate a baseline care on admission. RN #1 stated there is a blank baseline care plan form that should be completed within 48 hours of admission. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Plans of Care documented, Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR (pre-admission screening and resident review) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to maintain the highest level of well-being for two of 41 residents in the survey sample, Residents #26 and #129. 1. The facility staff failed to monitor Resident #26's fluid intake as ordered by the physician. 2. a. The facility staff failed to ensure the medication guaifenesin (1) was available for administration to Resident #129 on 9/28/21, 9/29/21 and 9/30/21. 2. b. The facility staff failed to obtain Resident #129's weekly weight per physician's order on 8/16/21. The findings include: 1. Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having received dialysis services during the look back period. A review of Resident #26's physician's orders, revealed the following order, dated 12/9/20: Fluid restriction: 1200 ml/day (milliliters per day). Dietary: Breakfast 240 ml, lunch 240 ml, dinner 240 ml = 720 with meals. Nursing 7a - 7p = 240. 7p - 7a = 240 = 480 ml with meds (medications) every shift for fluid restriction. A review of Resident #26's MARs [medication administration record] and Point of Care records for October 2021 failed to reveal evidence of the exact amount of fluids Resident #26 received on any shift, or for any 24 hour period in total. A review of a dietary instruction slip for dinner on 10/21/21 revealed, in part: 6 oz (ounce) tea of choice .1200 ml fluid restriction. A review of Resident #26's comprehensive care plan dated 7/27/20 and updated 8/11/20, revealed, in part: [Resident #26] needs dialysis r/t (related to) renal (kidney) failure .monitor vital signs .1200 ml/day fluid restriction. He is noncompliant at times. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked how she calculates if a resident is compliant with a fluid restriction, she stated she only documents how much fluid she is giving with medications, or if she is offering the resident something to drink. When asked who documents how much fluid a resident receives on a meal tray, LPN #1 stated the CNAs document this information on the point of care records. When asked who is responsible for calculating a total amount of fluids consumed by a resident for a 24 hour period, LPN #1 stated, That's an excellent question. LPN #1 stated someone should be, but she doesn't know who is actually doing it. When asked why it would be important to know exactly how much fluid a resident is drinking, she stated if the resident is on dialysis, too much fluid could harm their kidneys even more. On 10/20/21 at 3:12 p.m., CNA (certified nursing assistant) #2 was interviewed. When asked what she documents for residents who are on a fluid restriction, she stated she can only document the percentage of a meal the resident has eaten. CNA #2 stated there is no place on the point of care system to document an exact amount of fluid a resident receives with meals. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. The facility staff were asked to provide evidence of Resident #26's recorded fluid intake for the gaps identified above. A review of the facility policy, Fluid Restrictions, revealed, in part: Residents receive adequate fluid intake within the limitations determined by the attending physician .Caregivers will be notified on limitations. No further information was provided prior to exit. 2. a. Resident #129 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #129's diagnoses included but were not limited to high blood pressure, diabetes and COVID-19. Resident #129's quarterly minimum data set assessment with an assessment reference date of 10/3/21, coded the resident's cognition as severely impaired. Review of Resident #129's clinical record revealed a physician's order dated 9/27/21 for guaifenesin liquid 100 mg (milligrams)/5 ml (milliliters). Give 10 ml by mouth every four hours for a cough for 15 days. Resident #129's September 2021 MAR (medication administration record) documented the order for guaifenesin liquid 100 mg (milligrams)/5 ml (milliliters). Give 10 ml by mouth every four hours for a cough for 15 days. On 9/28/21 at 12:00 p.m. and 4:00 p.m., 9/29/21 at 4:00 a.m. and 8:00 p.m., and 9/30/21 at 12:00 a.m. and 4:00 a.m., the nurse did not document the medication as being administered. The MAR documented the code, 9=other/See Nurse Notes. A nurse's note dated 9/28/21 documented, on order from supply. Another nurse's note dated 9/28/21 documented, on supply order. A nurse's note dated 9/29/21 documented, drug not available. Another nurse's note dated 9/29/21 documented, drug not available. A nurse's note dated 9/30/21 documented, drug not available. Resident #129's comprehensive care plan dated 6/25/21 failed to document information regarding guaifenesin administration. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse who documented the 9/28/21 nurses' notes). LPN #1 stated guaifenesin is an over the counter medication that is kept in stock in the facility. LPN #1 stated if an over the counter medication is due for administration and is not on the medication cart then the medication can be obtained from another medication cart or in the over the counter medication supply closet. In regards to Resident #129's guaifenesin not being available for administration in September 2021, LPN #1 stated Resident #129 had been readmitted to the facility and there was no guaifenesin stocked in house at the time so she was waiting to obtain the medication from the pharmacy. Review of the facility over the counter medication stock list revealed guaifenesin was kept in stock in house. On 10/21/21 at 8:30 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy for medication administration failed to document instructions for obtaining over the counter medications that are supposed to be kept in house. No further information was presented prior to exit. Reference: (1) Guaifenesin is used to treat chest congestion. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682494.html 2. b. Review of Resident #129's clinical record revealed a physician's order dated 6/19/21 for a weekly weight every day shift every Monday. Resident #129's comprehensive care plan dated 6/25/21 documented, (Resident #129) is at risk for weight changes and altered nutritional/fluid status r/t (related to) dx (diagnosis) COVID, PNA (pneumonia, respiratory failure, diabetes .Weights and labs per order/protocol . Review of Resident #129's August 2021 weight list and August 2021 MAR (medication administration record) revealed the resident's weight was obtained on 8/9/21 and 8/23/21 but not on 8/16/21, or any other date during that week. A nurse's note dated 8/16/21 documented the facility staff were unable to obtain Resident #129's weight on that date due to staffing issues. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1, the nurse who documented the above note. LPN #1 stated the CNAs (certified nursing assistants) are responsible for obtaining resident weights but she tries to help when she can. LPN #1 stated 8/16/21 was a really bad day due to a lack of staffing and the staff was unable to obtain Resident #129's weight. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Weighing the Resident documented, Residents will be weighed unless ordered otherwise by the physician: -Admission/re-admission x3 days -Weekly x 4 weeks -Monthly thereafter -As needed. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #331 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including a broken right arm, diabetes, and history of a stroke. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/30/21, Resident #331 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status. Resident #331 was coded as not having a catheter in her bladder for urination during the look back period. She was coded as always incontinent of urine during the look back period. On 10/19/21 at 11:15 a.m., Resident #331 was observed as she was being pushed in her wheelchair down the hall by a staff member. A catheter collection bag, covered with a privacy cover, was observed hanging on the wheelchair rim. A review of Resident #331's physician's orders revealed, in part: Foley catheter 16 FR (French, designating catheter size)/10 cc (cubic centimeters) balloon. The order was written 10/13/21, and did not include a diagnosis for the need for the urinary catheter. A review of Resident #331's comprehensive care plan dated 6/9/21 failed to reveal any information related to the resident having a urinary catheter. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. On 10/21/21 at 8:36 a.m., ASM (administrative staff member) #2, the director of clinical services, was interviewed. When asked why it is important to have a diagnosis that would indicate a need for a urinary catheter, ASM #2 stated catheters carry a risk of causing urinary tract infections for residents. She stated when a resident is readmitted from the hospital with a new catheter, the facility staff should look for an appropriate diagnosis. ASM #2 stated when Resident #331 was discharged to the hospital from the facility, she did not have a urinary catheter. When she returned from the hospital on [DATE], she had a urinary catheter in place. She stated the nurse practitioner looks through the chart and assesses the resident for the appropriate use of the catheter. If there is not an appropriate diagnosis, the catheter should be removed. On 10/21/21 at 10:10 a.m., ASM #6, the nurse practitioner, was interviewed. When asked about the use of a urinary catheter, ASM #6 stated, I know what the regulations say about that. She stated the use of the catheter is dependent on the reason for discharge to the hospital, and the resident's condition on readmission to the facility. She stated she had reviewed Resident #331's clinical record, and did not see any evidence of a qualifying diagnosis for the urinary catheter. She stated the catheter should have already been removed. A review of the facility policy, Catheter Care, Urinary, revealed no information related to qualifying diagnoses for residents to utilize a urinary catheter. No further information was provided prior to exit. REFERENCES 1. A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm. Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to provide care and services for a Foley catheter for two of 41 residents in the survey sample, Residents #28 and #331. 1. The facility staff failed to maintain Resident #28's Foley urinary catheter (1) tubing and bag in a manner to prevent infections. The resident's tubing and bag were observed directly touching the floor on 10/20/21. 2. The facility staff failed to ensure medical justification for Resident #331's indwelling catheter and failed to ensure the catheter was discontinued as soon as clinically warranted. The findings include: 1. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to congestive heart failure, muscle weakness and dementia. Resident #28's quarterly minimum data set assessment with an assessment reference date of 8/31/21, coded the resident's cognition as moderately impaired. Review of Resident #28's clinical record revealed a physician's order dated 3/23/21 for a Foley catheter due to urinary retention. Resident #28's comprehensive care plan dated 3/15/21 documented, (Resident #28) has Indwelling Foley Catheter r/t (related to) obstructive uropathy .Position catheter bag and tubing below the level of the bladder and away from entrance room door. The care plan did not document information regarding the catheter tubing and bag position in relation to the floor. On 10/20/21 at 11:29 a.m., Resident #28 was observed in a low bed. The resident's catheter tubing and bag was directly touching the floor. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated a resident's catheter tubing and bag should not touch the floor because of infection control reasons and it is a tripping hazard. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy regarding urinary catheter care failed to document specific information regarding catheter placement. No further information was presented prior to exit. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record, it was determined that the facility staff failed to provide respiratory services consistent with professional standards for one of 41 residents in the survey sample, Resident #129. The facility staff administered oxygen to Resident #129 without a physicians order. The findings include: Resident #129 was admitted to the facility on [DATE]. Resident #129's diagnoses included but were not limited to high blood pressure, diabetes and COVID-19. Resident #129's quarterly minimum data set assessment with an assessment reference date of 10/3/21, coded the resident's cognition as severely impaired. Review of Resident #129's current physician orders failed to reveal a physician's order for oxygen. Resident #129's comprehensive care plan dated 6/25/21 failed to reveal documentation regarding oxygen administration. On 10/19/21 at 8:52 a.m. and 10:09 a.m., Resident #129 was observed in their room, receiving oxygen at 1.5 liters per minute via nasal cannula connected to an oxygen concentrator that was running. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated nurses must obtain an order for oxygen administration because oxygen is a medication that enters the body. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Medical Care/Standards of Practice documented, No medications or treatments shall be given without a doctor's order. The facility policy titled, Oxygen Therapy documented, Physician's order for oxygen therapy shall include: -Administration modality -FiO2 (fraction of inspired oxygen) or liter flow -Continuous or PRN (as needed) -PRN orders must include specific guidelines as to when the resident is to use oxygen. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement a complete pain management program for one of 41 residents in the survey sample, Resident #70. The facility staff failed to attempt non-pharmacological interventions for Resident #70 prior to the administration of as needed acetaminophen (Tylenol) on 9/19/21, 10/6/21, 10/12/21 and 10/16/21. The findings include: Resident #70 was admitted to the facility on [DATE]. Resident #70's diagnoses included but were not limited to high blood pressure, diabetes and chronic pain syndrome. Resident #70's quarterly minimum data set assessment with an assessment reference date of 10/10/21, coded the resident as being cognitively intact, scoring a 15 on a scale from 0 to 15 on the brief interview for mental status. Section J documented Resident #70 reported occasional pain. Review of Resident #70's clinical record revealed a physician's order for acetaminophen 500 mg (milligrams) - one tablet by mouth every six hours as needed for pain. Review of Resident #70's September 2021 and October 2021 MARs (medication administration records) revealed the resident was administered as needed acetaminophen on 9/19/21, 10/6/21, 10/12/21 and 10/16/21. Further review of Resident #70's September 2021 and October 2021 MARs and nurses' notes failed to reveal evidence that the facility staff attempted non-pharmacological interventions prior to the administration of as needed acetaminophen on the above dates. Resident #70's comprehensive care plan dated 4/22/21 documented, (Resident #70) has chronic pain r/t (related to) neuropathy. Encourage intermittent rest and LE (lower extremity) elevation as needed for pain relief . On 10/20/21 at 11:22 a.m., an interview was conducted with Resident #70. Resident #70 stated a CNA (certified nursing assistant) massaged her leg one time but the nurses do not offer non-pharmacological interventions prior to the administration of as needed acetaminophen. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1, a nurse who administered as needed acetaminophen to Resident #70 on one of the above dates. When asked what should be done prior to administering an as needed pain medication, LPN #1 stated she encourages repositioning and a lot of it has to do with knowing the resident. LPN #1 stated she sometimes offers snacks to Resident #70. LPN #1 stated she could not recall if she attempted non-pharmacological interventions with Resident #70 prior to the administration of as needed Tylenol in September 2021 or October 2021. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Pain Management Guideline documented, Treatment: Develop patient centered interventions (pharmacologic and non-pharmacologic) to manage pain. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet the needs of two of 41 residents in the survey sample, Residents #53 and #129. 1. The facility did not provide sufficient staffing to ensure a shower/bath was provided on multiple occasions in August and September 2021, to Resident #53, who was assessed as being dependent on the assistance of staff for personal hygiene and bathing. 2. The facility staff failed to provide sufficient staffing to obtain Resident #129's weight per the physician's order on 8/16/21. The findings include: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, hardening and disintegration of the spinal cord bones, quadriplegia and nerve pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, the resident was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). He was coded as being completely dependent on the assistance of staff for personal hygiene and bathing. On 10/24/21 at 4:26 p.m., Resident #53 and his parents requested to meet with the survey team. Resident #53's mother reported concerns regarding the staff's lack of ADL care for the resident, particularly in bathing/showering the resident. She stated the resident has gone a week or more without showering. She stated there were times when the staff had not washed the resident's hair for such a long time that the resident would have acne breakouts along his forehead because his hair was so dirty and greasy. She stated she has reported these concerns to both ASM (administrative staff member) #1, the executive director, and ASM #2, the DCS (director of clinical services). She stated there has been turnover in the DCS position, and the facility just cannot keep any help. Resident #53 confirmed these statements, and stated there are times when nobody is working the floor. Resident #53 stated that he has gone through stretches of more than a week without being offered a shower, and without getting a bed bath. He stated he was not certain which days were his assigned bath days. A review of Resident #53's bathing records revealed no evidence of the resident being bathed and showered between the following dates: 8/12/21 through 8/23/21; 9/1/21 through 9/6/21; 9/10/21 through 9/15/21; 9/17/21 through 10/6/21. A review of Resident #53's progress notes revealed the following note, written on 10/7/21 by RN (registered nurse) #5: PC (phone call) from mother .proceeded to tell me about her calling early regarding [Resident #53] needing a bath. Advised her that I heard about the call and it was already taken care of before she called in. A review of Resident #53's comprehensive care plan dated 3/11/21, and most recently updated on 4/30/21, revealed, in part: [Resident #53] has an ADL self-care performance deficit .Bathing/Showering: Check nail length and trim and clean on bath day and as necessary .provide sponge bath when a full bath or shower cannot be tolerated .the resident requires full assistance by staff with showering twice weekly/prn [as needed]. On 10/25/21 at 3:23 p.m., RN (registered nurse) #5 was interviewed. She stated the resident had recently reported to her that he had not been showering because there was not enough staff. She stated, as far as she knew, this was true. RN #5 stated Resident #53's unit has an assigned shower aide, but the aide is most often pulled to work a regular assignment, due to lack of staff. RN #5 stated when this happens, residents do not receive a bath or shower. She stated for residents to get basic care, the unit requires at least three CNAs. RN #5 stated she had spoken multiple times to the CNAs (certified nursing assistants) about bathing Resident #53, but they only have so much time in their day. She stated that on 10/7/21, Resident #53's mother had called to complain about Resident #53's not having received a bath/shower recently. She stated she had already spoken to the aides about this. When shown Resident #53's bath records, RN #5 stated the records looked about right, and she could not verify that the resident had received a bath during the long gaps of blanks on the shower records. On 10/25/21 at 3:42 p.m., CNA #12 was interviewed. She stated she has worked with Resident #53 since he was admitted to the facility. CNA #12 stated the resident has for sure gone for long stretches of time without a shower or bath. She stated she did not usually have the time to give him a bed bath. She stated if she did so, she would document it on the bath record. CNA #12 stated there was frequently not enough staff working the unit to give Resident #53 a bath or shower. She stated the optimal number of CNAs for the unit is three, plus a bath aide. CNA #12 stated residents are not limited to only their assigned shower days, and, after reviewing Resident #53's shower records, stated he had received showers on days other than Mondays and Thursdays, his regular shower days. CNA #12 stated there is CNA who is tasked with giving all the showers, but that CNA is most often pulled to do regular CNA duties on her unit, or on the facility's other unit because of low staffing. A review of the as-worked schedule for Resident #53's unit during August and September 2021 revealed, in part: - On 8/16/21, only one CNA (certified nursing assistant) was documented working Resident #53's unit, and this staff member worked from 7:00 am just until 12:45 p.m. No CNA was documented as working the unit between 12:45 p.m. and 3:00 p.m. - On 9/18/21, only one CNA (certified nursing assistant) was documented as working Resident #53's unit on all three shifts. On 10/26/21 at 3:42 p.m., ASM #2 was interviewed. She stated all residents have a shower schedule, but sometimes, baths or showers need to be given on a different day, cue to either resident or staffing needs. She stated residents should be offered a bath or shower two days each week. ASM #2 stated the CNAs are responsible for giving showers, and for recording the baths as given in the resident's clinical record. She stated Resident #53's unit has a shower aide, and the shower aide is responsible for giving most of the showers on the unit. ASM #2 stated if showers are not accomplished, the CNA should report this to the nurse, and the nurse should document this in the resident's clinical record. She stated she was aware of some occasions when the shower aide had been assigned to other duties because of the need for additional staff. ASM #2 stated she could not add any information than what was documented in the clinical record and on the as worked schedules. On 10/26/21 at 3:50 p.m., ASM #1 and ASM #2 were informed of these concerns. Additional evidence verifying the facility had provided sufficient staffing to meet Resident #53's showering needs was requested. On 10/20/21 at 5:30 p.m., ASM #1 was asked to provide a policy related to sufficient staffing to meet the needs of residents. On 10/26/21 at 2:11 p.m., ASM #1 stated the facility did not have such a policy. No further information was provided prior to exit. 2. Resident #129 was admitted to the facility on [DATE]. Resident #129's diagnoses included but were not limited to high blood pressure, diabetes and COVID-19. Resident #129's quarterly minimum data set assessment with an assessment reference date of 10/3/21, coded the resident's cognition as severely impaired. Review of Resident #129's clinical record revealed a physician's order dated 6/19/21 for a weekly weight every day shift every Monday. Resident #129's comprehensive care plan dated 6/25/21 documented, (Resident #129) is at risk for weight changes and altered nutritional/fluid status r/t (related to) dx (diagnosis) COVID, PNA (pneumonia, respiratory failure, diabetes .Weights and labs per order/protocol . Review of Resident #129's August 2021 weight list and August 2021 MAR (medication administration record) revealed the resident's weight was obtained on 8/9/21 and 8/23/21 but not on 8/16/21 (or any other date during that week). A nurse's note dated 8/16/21 documented the facility staff were unable to obtain Resident #129's weight on that date due to staffing issues. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1, the nurse who documented the above note. LPN #1 stated 8/16/21 was a really bad day. LPN #1 stated the CNAs (certified nursing assistants) are responsible for obtaining residents' weights but she tries to help when she can. LPN #1 stated if she documented the above note then there was probably only one or two CNAs either on the unit or in the building. LPN #1 stated Resident #129's weight was not obtained due to staffing and all the staff could do was to make sure the residents got their meals, were clean and dry, and not on the floor. Review of the facility nursing staff schedule dated 8/16/21 revealed nurses worked 12 hour shifts and CNAs worked either 12 hour shifts or eight hour shifts. Further review of the facility nursing staff schedule for 8/16/21 revealed four nurses worked from 6:45 a.m. to 7:15 p.m., two CNAs worked from 7:00 a.m. to 3:00 p.m., one CNA worked from 7:00 a.m. to 12:45 p.m., two CNAs worked from 3:00 p.m. to 11:00 p.m., one nurse worked from 6:45 p.m. to 7:15 a.m., one nurse worked from 6:45 p.m. to 11:00 p.m., one nurse worked from 11:00 p.m. to 7:15 a.m., one CNA worked from 7:00 p.m. to 7:00 a.m. and one CNA worked from 11:00 p.m. to 7:00 a.m. On 10/20/21 at 5:10 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that depending on the facility census, four or three nurses should work during the day and night shift, four CNAs should work during the day shift, three CNAs should work during the evening shift and two CNAs should work during the night shift. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for one of three CNA record reviews, (CNA #6) The facility staff failed to complete an annual performance review for CNA #6. The findings include: CNA #6 was hired on 5/8/04. Review of CNA #6's record revealed the last performance review was completed on 7/1/10. On 10/20/21 at 9:36 a.m., an interview was conducted with OSM (other staff member) #3 (the human resources coordinator). OSM #3 stated performance reviews are supposed to be done annually. OSM #3 stated she began employment on 5/31/21 or 6/1/21. OSM #3 stated she audited employee files and noticed performance reviews had not been done. OSM #3 stated she has been trying to implement action for this but there has been so many other things to do. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Employee Job Performance Evaluations documented, It is the policy of The Company to evaluate each employee's job performance on a continual and on-going basis. Employees will receive an evaluation of their performance prior to the completion of their Introductory Period and annually thereafter. No further information was presented prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #53 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, hardening and disintegration of the spinal cord bones, quadriplegia and nerve pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, the resident was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). He was coded as receiving a medication to treat anxiety on all seven days of the look back period. On 10/24/21 at 4:26 p.m., Resident #53 and his parents requested to meet with the survey team. Resident #53's mother reported concerns regarding Resident #53 not receiving his medications as ordered. She stated Resident #53 had not received Diazepam since Wednesday, 10/20/21. Resident #53 confirmed his mother's statement. He stated he had been miserable since that time. A review of Resident #53's physician's orders revealed, in part, the following: Diazepam Tablet 5 mg (milligrams. Give 2 tablets by mouth at bedtime .related to anxiety disorder. A review of Resident #53's October 2021 MAR (medication administration record) revealed the number 9 in the square for the Diazepam administration on 10/21/21, 10/22/21, and 10/23/21. The legend for the October 2021 MAR documented: 9 =Other/See Nurse Note. A review of Resident #53's progress notes revealed, in part: 10/21/2021 11:23 p.m .Medication Administration Note Text: medication not available. 10/22/2021 10:47 p.m .Medication Administration Note Text: medication not available. 10/23/21 10:11 p.m .Medication Administration Note Text: medication not available. Further review of Resident #53's progress notes revealed, in part, the following: 10/23/2021 18:00 (6:00 p.m.) Nursing Progress Note: Attempted calls to [ASM (administrative staff member) #8 (medical director and Resident #53's attending physician)] on numerous occasions to get Valium (Diazepam) .to be called to pharmacy for this resident. 1430 (2:30 p.m.), 1450 (2:50 p.m.), 1530 (3:30 p.m.), 1635 (4:35 p.m.) no answer, goes to voicemail that says that mailbox is full. The nurse who wrote this note was unavailable for interview at the time of the survey. A review of Resident #53's comprehensive care plan dated 3/11/21 revealed, in part: [Resident #53] uses anti-anxiety medications .Administer anti-anxiety medications as ordered by physician. On 10/25/21 at 3:23 p.m., RN (registered nurse) #5 was interviewed. She stated she was taking care of Resident #53 that morning and that he is upset because he has not received his Diazepam the past few nights. She stated she had personally faxed the refill request to the NP (nurse practitioner), ASM (administrative staff member) #6, on Thursday, 10/21/21. She stated she had called ASM #6 and told her Resident #53 would soon be completely out of the Diazepam, and needed a refill. She stated because Diazepam is a controlled substance, a refill required the NP or physician to directly contact the pharmacy to authorize it. She stated she did not work between Thursday, 10/21/21 and that morning (10/25/21), she had not had the opportunity follow up on this refill. She stated when she arrived at work at 7:00 a.m. on 10/25/21, she discovered the medication had finally been re-ordered on 10/24/21, but still had not been delivered to the facility. RN #5 stated she had looked for, but had not been able to locate the refill requests she had faxed to ASM #6 on 10/21/21. Review of the facility STAT (immediate) box revealed that Diazepam 5 mg was not available in the box for administration. On 10/26/21 at 9:34 a.m., ASM #8, the medical director and Resident #53's attending physician, was interviewed. When asked the process for authorizing refills for controlled medications, he stated the facility nurses should communicate the refill needs a week before the medication runs out. He stated if he receives a request for a refill, he can send an electronic order directly to the pharmacy, or he can call the pharmacy to refill the medication. When asked what happens if the refill is urgently needed on a weekend, he stated the nurses at the facility have his phone number, as well as the phone numbers for both nurse practitioners, and they should call one of the providers. When asked if he was aware that facility staff had attempted to call him over the weekend, he stated he was not. He stated his voicemail had not been full over the weekend. On 10/26/21 at 12:19 p.m., ASM #6, the nurse practitioner, was interviewed. She stated if a resident needs a refill for a controlled medication, the staff prints out the paper prescription for the provider to sign on their next visit to the facility. She stated if the refill is needed urgently, the staff may call her, and she can directly transmit an electronic refill request to the pharmacy. She stated she had not received any phone calls or faxes from facility nurses regarding Resident #53's Diazepam prescription. On 10/26/21 at 3:42 p.m., ASM #2, the director of clinical services, was interviewed. She stated if a resident needs an urgent refill for a controlled substance, the nursing staff may all a provider and request the provider to transmit the refill request directly to the pharmacy. She stated she was not aware of any concerns regarding Resident #53's Diazepam. On 10/26/21 at 3:50 p.m., ASM #1, the executive director, and ASM #2 were informed of these concerns. Additional evidence that Resident #53 had received the Diazepam as ordered was requested. A review of the facility policy, Medication Shortages/Unavailable Medications, failed to reveal any information related to the facility staff attempting unsuccessfully to reach the physician for a controlled substance refill while the provider states he/she was never contacted about the refill. No further information was provided prior to exit. REFERENCES (1) Diazepam is used to relieve anxiety and to control agitation caused by alcohol withdrawal. It is also used along with other medications to control muscle spasms and spasticity caused by certain neurological disorders such as cerebral palsy (condition that causes difficulty with movement and balance), paraplegia (inability to move parts of the body), athetosis (abnormal muscle contractions), and stiff-man syndrome (a rare disorder with muscle rigidity and stiffness). This information is taken from the website https://medlineplus.gov/druginfo/meds/a682047.html. Based on staff interview and clinical record review, it was determined that the facility staff failed to provide pharmacy services for two of 41 residents in the survey sample, Resident #24 and Resident #53. 1. The facility staff failed to assure the medication Eliquis (1) was available for administration to Resident #24 on 7/5/21 and 7/29/21. 2. The facility staff failed to assure the medication Diazepam was acquired, and received for administration to Resident #53, per the physician order on 10/21/21 through 10/23/21. The findings include: Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes, atrial fibrillation (1) and a history of stroke. Resident #24's quarterly minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognitive skills for daily decision making as modified independence. Resident #24's comprehensive care plan dated 8/2/20 documented, (Resident #24) has Peripheral Artery Disease. Give medications for improved blood flow or anticoagulants as ordered . Review of Resident #24's clinical record revealed a physician's order dated 3/12/21 for Eliquis 2.5 mg (milligrams) - one tablet by mouth two times a day for peripheral vascular disease (2). Resident #24's July 2021 MAR (medication administration record) documented the order for Eliquis 2.5 mg- one tablet by mouth two times a day. On 7/5/21 at 5:00 p.m. and 7/29/21 at 5:00 p.m., the nurse did not document the medication as being administered. The MAR documented the code, 9=other/See Nurse Notes. A nurse's note dated 7/5/21 documented, out of medication and was reordered. A nurse's note dated 7/29/21 documented, not available. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated nurses can fax medication refill requests to the pharmacy or request a refill directly through the computer system. LPN #1 stated if a medication is needed and not available then she calls the pharmacy or obtains the medication from the STAT box (a box containing various medications) if the medication is in the STAT box. Review of the list for the STAT box in the facility during July 2021 failed to reveal Eliquis was contained in the box. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility pharmacy policy titled, Reordering, Changing and Discontinuing Orders failed to specifically document steps to take if a medication is not available and not in the STAT box. No further information was presented prior to exit. References: (1) Apixaban (Eliquis) is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a613032.html (2) Peripheral vascular disease is a condition of the blood vessels that supply the feet and legs. This information was obtained from the website: https://medlineplus.gov/ency/article/000170.htm

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure a resident was free from a significant medication error for one of 41 residents in the survey sample, Resident #24 The facility staff failed to administer the blood thinning medication Eliquis (1) to Resident #24 on 7/5/21 and 7/29/21. The findings include: Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes, atrial fibrillation (1) and a history of stroke. Resident #24's quarterly minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognitive skills for daily decision making as modified independence. Resident #24's comprehensive care plan dated 8/2/20 documented, (Resident #24) has Peripheral Artery Disease. Give medications for improved blood flow or anticoagulants as ordered . Review of Resident #24's clinical record revealed a physician's order dated 3/12/21 for Eliquis 2.5 mg (milligrams) - one tablet by mouth two times a day for peripheral vascular disease (2). Resident #24's July 2021 MAR (medication administration record) documented the order for Eliquis 2.5 mg- one tablet by mouth two times a day. On 7/5/21 at 5:00 p.m. and 7/29/21 at 5:00 p.m., the nurse did not document the medication as being administered. The MAR documented the code, 9=other/See Nurse Notes. \ A nurse's note dated 7/5/21 documented, out of medication and was reordered. A nurse's note dated 7/29/21 documented, not available. On 10/20/21 at 1:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated nurses can fax medication refill requests to the pharmacy or request a refill directly through the computer system. LPN #1 stated if a medication is needed and not available then she calls the pharmacy or obtains the medication from the STAT [immediate] box (a box containing various medications) if the medication is in the STAT box. Review of the list for the STAT box in the facility during July 2021 failed to reveal Eliquis was contained in the box. On 10/20/21 at 4:02 p.m., an interview was conducted with LPN #2. LPN #2 stated Eliquis is a blood thinning medication that is usually prescribed for atrial fibrillation. LPN #2 stated it is important to administer Eliquis as prescribed by the physician because a missed dose can cause a blood clot or put a resident at risk for a stroke. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. On 10/20/21 at 5:30 p.m., ASM #1 was asked to provide a policy regarding significant medication errors. On 10/26/21 at 2:11 p.m., ASM #1 stated the facility did not have the requested policy. The Eliquis manufacturer's website documented, Do not stop taking ELIQUIS without talking to the doctor who prescribed it to you. For patients taking ELIQUIS for atrial fibrillation: stopping ELIQUIS increases your risk of having a stroke. This information was obtained from the website: https://www.eliquis.bmscustomerconnect.com/ No further information was presented prior to exit. References: (1) Apixaban (Eliquis) is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a613032.html (2) Peripheral vascular disease is a condition of the blood vessels that supply the feet and legs. This information was obtained from the website: https://medlineplus.gov/ency/article/000170.htm

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide laboratory testing for one of 41 residents in the survey sample, Resident #26. The facility staff failed to provide laboratory testing ordered for Resident #26 on 9/30/20. The findings include: Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). The resident was coded as requiring the assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. He was coded as having received dialysis services during the look back period. A review of Resident #26's physician's orders revealed the following: CBC (complete blood count) with diff (differentiation), BMP (basic metabolic panel), CRP (C-reactive protein), Ferritin (Iron level), D-dimer (clotting level), Fibrinogen (helps clotting) one time a day every Thursday for 14 days. Start date 9/23/21. Further review of Resident #26's September 2021 TARs (treatment administration records) and laboratory results revealed no results for the laboratory [lab] tests ordered for 9/30/21. A review of Resident #26's comprehensive care plan dated 7/27/20 revealed, in part: Obtain and monitor lab/diagnostic work as ordered. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the information for lab (laboratory) tests that need to be done is kept in a book at the nurses' desk. LPN #1 stated the nurse who receives an order for a lab test fills out a request slip, and puts in the book. When the outside lab company staff arrive at the facility, they check the book and obtain blood specimens as ordered. She stated she is not sure why Resident #26's lab tests were not performed for 9/30/21, but she could not find any evidence that the tests were done. On 10/21/21 at 8:36 a.m., ASM (administrative staff member) #2, the director of clinical services, confirmed the lab tests had not been done for Resident #26 on 9/30/21. She stated the night shift nurse is responsible for double checking that all lab requests for a particular day are accurate and in the book for the outside lab company. ASM #2 stated she could not locate a lab test request sheet for Resident #26 for 9/30/21. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. A review of the facility policy, Laboratory, Diagnostic and X-ray, revealed, in part: Obtain a physician's order for laboratory work, diagnostic testing, and X-ray. Complete the required requisition form (s). Schedule laboratory work .as indicated. No further information was provided prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate medical record for two of forty-one residents in the survey sample, Resident #230 and Resident #2. 1. The facility failed to provide a complete and accurate medical record for Resident #230, for documentation on the TAR (treatment administration record) for the wound vacuum continuously running as ordered on 8/24/21 night shift and 8/30/21 day shift, and ostomy care every shift as ordered on 8/24/21, 8/25/21 and 8/26/21 as well as day shift on 8/30/21. 2. The facility failed to provide a complete and accurate medical record for the documentation of pain levels prior to the administration of pain medication on the MAR (medication administration record) for Resident #2. The findings include: 1. Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (inability of insulin to function normally in the body) (1), chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease) (2), end stage renal disease 'ESRD' (inability of the kidneys to excrete waste and to function in the maintenance of electrolyte balance in the body) (3) and abscess of testis and buttocks (accumulation of pus in the testis and buttocks) (4). The most recent MDS (minimum data set) assessment, a five day Medicare assessment with an ARD (assessment reference date) of 8/26/21, coded Resident #230 as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, locomotion, and dressing and bathing; total dependence for hygiene and supervision for eating. A review of MDS Section H- bowel and bladder coded the resident as having an ostomy for bowel and an indwelling catheter for bladder. A review of Resident #230's comprehensive care plan dated 9/2/21, the comprehensive care plan documents in part, FOCUS-Resident has scrotal and right gluteal abscess. Decline in mobility and ADL (activities of daily living). INTERVENTIONS-Treatment per order. Toilet use: He is not toileted. He has a catheter and colostomy and is dependent on staff for care of these devices. A review of the physician orders dated 8/20/21, documented in part, Wound vacuum continuously running every shift. Colostomy care every shift and as needed. A review of Resident #230's TAR (treatment administration record) failed to evidence documentation of wound vacuum continuously running every shift on 8/24/21 night shift and 8/30/21 day shift. A review of Resident #230's TAR failed to evidence documentation of colostomy care every shift and as needed on the night shifts on: 8/24/21, 8/25/21 and 8/26/21 as well as day shift on 8/30/21. An interview was conducted on 10/21/21 at 7:00 AM with LPN (licensed practical nurse) #8. When asked what blanks on the TAR indicates, LPN #8 stated, Well, it could mean the treatment didn't happen, but it could also mean you didn't finish charting. When asked if she remembered providing care to Resident #230, LPN #8 stated, Yes, I remember caring for him and I don't remember missing any treatments. An interview was conducted on 10/26/21 at 9:46 AM with LPN #10. When asked what blanks on the TAR indicates, LPN #10 stated, Usually it means we didn't get it charted. When asked if he remembered caring for Resident #230, LPN #10 stated, Yes, I do. When asked what the blanks on the TAR, shown to LPN #10 meant, LPN #10 stated, I believe it is charting error. A review of the facility's Clinical/Medical Records policy, dated 8/2017, documented in part, Clinical Records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. On 10/26/21 at 3:52 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3 the regional vice president of operations were made aware of the concerns. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 4. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (inability of insulin to function normally in the body) (1), chronic kidney disease (decreased function of the kidneys frequently as a complication of diabetes) (2) and right below the knee amputation 'RBKA' (surgical removal of right leg below the knee) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/19/21, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for hygiene, supervision for bathing and dressing and independent for eating, bed mobility and transfers. Ambulation did not occur. A review of MDS Section H- bowel and bladder coded the resident as always continent for bowel and for bladder. On 7/27/21 the comprehensive care plan documents in part, FOCUS-Resident has history of chronic back pain. INTERVENTIONS-Meds [medications] per order. A review of the physician orders dated 4/20/21, documented in part Oxycodone (opioid analgesic) (4) tablet 5 milligram, give 1 tablet by mouth every 6 hours as needed for pain. A review of Resident #2's MAR revealed the following: The September 2021 MAR evidenced documentation of Oxycodone 5 milligram tablet administration for a documented pain level of '0' on 9/24/21 at 9:07 PM, 9/26/21 at 5:34 AM. The October 2021 MAR evidenced documentation of Oxycodone 5 milligram tablet administration for the documented pain level of '0' on 10/2/21 4:12 AM, 10/3/21 9:01 PM, 10/7/21 at 10:08 PM, 10/15/21 at 11:51 PM, 10/16/21 at 5:52 AM, 10/17/21 at 12:05 AM, 10/18/21 at 5:55 AM, 10/19/21 at 8:44 PM, 10/20/21 at 6:08 AM and 10/21/21 at 12:18 AM. An interview was conducted on 10/21/21 at 6:47 AM with LPN (licensed practical nurse) #8. When asked how pain level was determined, LPN #8 stated, I ask them their pain level on a scale of 0-10, or their facial expressions. When ask to review the documentation of the MAR for Resident #2, LPN stated, Yes that would be helpful. When asked why Oxycodone 5 milligram would be given for a pain level of 0, LPN #8 stated, I would not give Oxycodone for a pain level of 0. When shown her documentation on the MAR, LPN #8 stated, No, that's not right. LPN #8 pulled up her administration view and showed that on one section 0 = administration. I was documenting that I administered the pain medication. His pain level was always a 6-7. It was never lower than a 6. I would never give Oxycodone, a narcotic, for a pain level of '0'. When asked if this documentation was accurate, since the '0' appeared next to pain level, LPN #8 stated, No, this is not accurate documentation. An interview was conducted on 10/21/21 at 7:27 AM with LPN #5, the director of clinical services. When asked about the wrong code being on the MAR for pain medication, LPN #5 stated, The documentation is not accurate and doesn't tell the story. On 10/26/21 at 3:52 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3 the regional vice president of operations were made aware of the concerns. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 119. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 29. (4) 2019 [NAME] Drug Guide for Nurses, Wolters Kluwer, page 283.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

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Based on staff interview and facility document review, it was determined that the facility staff failed to ensure CNAs (certified nursing aides) completed required annual in-service trainings for two of three CNA record reviews, (CNA #5 and CNA #6). The facility staff failed to ensure CNA #5 completed annual abuse training and failed to ensure CNA #6 completed annual dementia or abuse training. The findings include: CNA #5 was hired on 8/6/13. Review of CNA #5's record failed to reveal evidence that the CNA had completed annual abuse training. CNA #6 was hired on 5/8/04. Review of CNA #6's record failed to reveal evidence that the CNA had completed annual dementia or annual abuse training. On 10/20/21 at 9:36 a.m., an interview was conducted with OSM (other staff member) #3 (the human resources coordinator). OSM #3 stated all training are completed through a computer program and the system prompts employees for trainings that must be completed. OSM #3 stated she thought abuse and dementia trainings must be done annually. OSM #3 stated she printed out each employee's trainings after she began employment on 5/31/21 or 6/1/21. OSM #3 stated she told employees they had to be caught up on their trainings by 9/30/21 and whoever was 30 days behind on trainings would be provided corrective action. OSM #3 stated she could not locate abuse training for CNA #5 or dementia or abuse training for CNA #6 who only works one or two days a month. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, In-Service Training- General documented, Employees will be provided in-service training on required topics on an annual basis .2. Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, and may include Company required in-service education topics. Each Care Center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly . No further information was presented prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to: chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease) (1), cellulitis (inflammation of the skin beneath the tissue) (2), cirrhosis of the liver (chronic condition in which the normal liver tissue is replaced by fibrous tissue and nodules interfering with normal blood flow and function) (3) and bundle branch block (defect in the electrical tissues of the heart that results in abnormal conduction) (4). Resident #71's most recent MDS (minimum data set) assessment, a five day Medicare admission assessment, with an assessment reference date of 9/15/21, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. Review of Resident #71's clinical record revealed the resident was transferred to the hospital on 9/26/21 for shortness of breath and hypoxia. On 10/20/21 at 7:36 AM, ASM (administrative staff member) #1, the executive director, brought in requested paperwork for Resident #71, with note documenting, Resident #71, no ombudsman notification found. An interview was conducted on 10/20/21 at 2:55 PM with OSM (other staff member) #4, the social services manager regarding notification to the ombudsman for Resident discharges/transfers. OSM #4 stated, There is transfer paperwork, RP (responsible party), ombudsman notification and bed hold. When asked when she had taken on this role, OSM #4 stated, I was in activities in July, then both social workers walked out and they put me in that position to keep up with the discharges. An interview was conducted on 10/21/21 at 7:15 AM with OSM #4. When asked the if the ombudsman notification for Resident #71 had been found, OSM #4 stated, There is no ombudsman notification for this resident. On 10/20/21 at 5:10 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3 the regional vice president of operations and ASM #4 the regional clinical nurse were made aware of the concerns. No further information was provided prior to exit References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 108. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 121. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 91. Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence notification to the ombudsman of hospital transfer/discharges for four of 41 residents in the survey sample, Residents #331, #71, #129, and #45. 1. The facility staff failed to notify the ombudsman of Resident #331's discharge to the hospital on 9/17/21. 2. The facility staff failed to provide written notification of transfer to the ombudsman for Resident #71, when the resident was transferred to the hospital on 9/26/21. 3. Resident #129 was transferred to the hospital on 9/20/21. The facility staff failed to provide written notification of the transfer to the ombudsman. 4. The facility staff failed to evidence that the ombudsman was notified of a facility-initiated transfer on 08/05/2021 for Resident # 45. The findings include: 1. Resident #331 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including a broken right arm, diabetes, and history of a stroke. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/30/21, the resident was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status. A review of Resident #331's clinical record revealed the following progress note: 9/17/21 Nursing Progress Note Text: This nurse was called to the resident room by NP (nurse practitioner) because resident was choking on non-thickened ginger ale that was given to her by her family. On arriving to the resident room, resident had been placed on her side .The rescue squad was called. The rescue squad came and transported the resident to the hospital. Further review of the resident's census information provided by the facility revealed she was hospitalized from [DATE] until she was readmitted to the facility on [DATE]. On 10/20/21 at 3:12 p.m., OSM (other staff member) #4, the social services manager, was interviewed. She stated it is her responsibility to email the ombudsman when a resident is discharged to the hospital. OSM #4 also stated she has the option of sending a fax to the ombudsman to notify of a resident discharge. She stated she keeps copies of these ombudsman notifications in a book. OSM #4 was asked to provide evidence the ombudsman had been notified in writing regarding Resident #331's discharge to the hospital on 9/17/21. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. On 10/21/21 at 8:36 a.m., ASM #2 stated the facility did not have evidence of the ombudsman notification of Resident #331's discharge to the hospital on 9/17/21. A review of the facility policy, Transfer/Discharge Notification and Right to Appeal, revealed, in part: Before a center transfers or discharges a resident the center must .send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. No further information was provided prior to exit. 3. Resident #129 was admitted to the facility on [DATE]. Resident #129's diagnoses included but were not limited to high blood pressure, diabetes and COVID-19. Resident #129's quarterly minimum data set assessment with an assessment reference date of 10/3/21, coded the resident's cognition as severely impaired. Review of Resident #129's clinical record revealed a nurse's note dated 9/20/21 that documented the resident was discharged to the hospital on 9/20/21, due to an elevated temperature, an elevated heart rate and respiratory complications. Further review of Resident #129's clinical record failed to reveal written notification of the transfer was provided to the ombudsman. On 10/20/21 at 2:55 p.m., an interview was conducted with OSM (other staff member) #4, the social services manager. OSM #4 stated she faxes or emails the ombudsman with notice of resident transfers and places the notice in a binder. OSM #4 was asked to provide evidence of ombudsman notification when Resident #129 was transferred to the hospital on 9/20/21. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. No further information was presented prior to exit. 4. Resident # 45 was admitted to the facility with diagnoses included but were not limited to: low iron, intestinal bleeding and muscle weakness. Resident # 45's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/22/2021, coded Resident # 45 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. A nurse's note for Resident # 45 dated 08/05/2021 at 12:41 p.m., documented, resident to be admitted to [Name of Hospital] for GI [gastrointestinal] bleed [1]. Review of the clinical record and the EHR (electronic health record) for Resident # 45 failed to evidence notification to the ombudsman for the facility-initiated transfer on 08/05/2021 for Resident # 32. On 10/20/21 at 2:55 p.m., an interview was conducted with OSM (other staff member) #4, the social services manager. OSM #4 stated she faxes or emails the ombudsman with notice of resident transfers and places the notice in a binder. On 10/20/2021 at approximately 4:09 p.m., an interview was conducted with OSM [other staff member] # 4, social services manager. When asked about the documentation for the ombudsman notification regarding the facility-initiated transfer of Resident #45 on 08/05/2021, OSM # 4 stated that they did not have evidence of notification to the ombudsman. On 10/20/2021 at 4:50 p.m., ASM [administrative staff member] # 1, executive director, ASM # 2, director of clinical services, ASM # 3, regional vice president of operations, ASM # 4, clinical nurse, and ASM # 5, interim assistant director of nursing, were made aware of the above findings. No further information was provided prior to exit. Reference; [1] GI bleeding is not a disease, but a symptom of a disease. There are many possible causes of GI bleeding, including hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus. This information was obtained from the website: https://medlineplus.gov/gastrointestinalbleeding.html.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. The facility staff failed to develop the comprehensive care plan for bedrails for Resident #59. Resident #59 was observed in bed with 1/2 upper bedrails up on 10/19/21 at 10:15 AM and on 10/19/21 at 4:15 PM. Resident #59 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (inability of insulin to function normally in the body) (1), chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease) (2) and chronic respiratory failure (chronic inability of the heart and lungs to maintain and adequate level of gas exchange) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 9/29/21, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, supervision for eating and total dependence for dressing, bathing and hygiene. A review of MDS Section H- bowel and bladder coded the resident as always incontinent for bowel and for bladder. A review of the physician orders dated 9/14/21, documented in part 1/2 side rails to promote independence and bed mobility. A review of Resident #59's comprehensive care plan failed to evidence development of a care plan to address the use of bed rails until 10/20/21. On 10/20/21 the comprehensive care plan documents in part, FOCUS-Resident has an ADL (activities of daily living) self-care performance deficit related to multiple co-morbidities and end of life. INTERVENTIONS- 1/2 bilateral side rails to promote independence and bed mobility. An interview was conducted on 10/19/21 at 4:30 PM with LPN (licensed practical nurse) #5. When asked the purpose of the care plan, LPN #5 stated, It is the plan of care that everyone sees to address the resident's needs and orders. When asked if side rails should be included on the comprehensive care plan, LPN #5 stated, Yes, they should be included. An interview was conducted on 10/20/21 at 6:55 AM with LPN #8. When asked the purpose of the comprehensive care plan, LPN #8 stated, To have a plan to meet the resident needs that everyone can see. When asked if the use of side rails should be included on the comprehensive care plan, LPN #8 stated, Yes, they should be included. On 10/20/21 at 5:10 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3 the regional vice president of operations and ASM #4 the regional clinical nurse were made aware of the concerns. On 10/21/21 at 11:00 AM, ASM #1 provided a copy of the revised care plan for Resident #59, which included side rails. A review of the facility's Plans of Care policy, dated 9/2017, documented in part, Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. A review of the facility's Side Rail/Bed Rail policy, dated 4/2018, documented in part, Side rail/bed rail may include but not limited to: side rails, bed rails, safety rails, grab bars and assist bars. Update the care plan and kardex. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 502. Based on observation, resident interview, family interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 41 residents in the survey sample, Residents #53, #26, #33, #8, #24, #28, #129, and #59. The findings include: 1.a. The facility staff failed to implement Resident #53's comprehensive care plan to provide the resident a shower, multiple times in August and September 2021. Resident #53 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, hardening and disintegration of the spinal cord bones, quadriplegia and nerve pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, Resident #53 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). He was coded as being completely dependent on the assistance of staff for personal hygiene and bathing. On 10/24/21 at 4:26 p.m., Resident #53 and his parents requested to meet with the survey team. Resident #53's mother reported concerns regarding the staff's lack of ADL care for the resident, particularly in bathing/showering the resident. She stated the resident has gone a week or more without showering. She stated there were times when the staff had not washed the resident's hair for such a long time that the resident would have acne breakouts along his forehead because his hair was so dirty and greasy. She stated she has reported these concerns to both ASM (administrative staff member) #1, the executive director, and ASM #2, the DCS (director of clinical services). She stated there has been turnover in the DCS position, and the facility just cannot keep any help. Resident #53 confirmed these statements, and added there are times when nobody is working the floor. He confirmed that he has gone through stretches of more than a week without being offered a shower, and without getting a bed bath. He stated he was not certain which days were his assigned bath days. He stated that he was not offered any kind of bed bath on most days, and that he did not feel clean with just a bed bath. A review of Resident #53's comprehensive care plan dated 3/11/21, most recently updated on 4/30/21, revealed, in part: [Resident #53] has an ADL self-care performance deficit .Bathing/Showering: Check nail length and trim and clean on bath day and as necessary .provide sponge bath when a full bath or shower cannot be tolerated .the resident requires full assistance by staff with showering twice weekly/prn [as needed]. A review of Resident #53's bathing records revealed no evidence of the resident being bathed and showered between the following dates: 8/12/21 through 8/23/21; 9/1/21 through 9/6/21; 9/10/21 through 9/15/21; 9/17/21 through 10/6/21. A review of the bath day assignment sheet for Resident #53 revealed documentation stating he should ordinarily get a shower or bath on Mondays and Thursdays. A review of Resident #53's progress notes revealed the following note, written on 10/7/21 by RN (registered nurse) #5: PC (phone call) from mother .proceeded to tell me about her calling early regarding [Resident #53] needing a bath. Advised her that I heard about the call and it was already taken care of before she called in. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked the purpose of a care plan, she stated a care plan enables the staff to offer the best possible care for a resident. She stated the care plan helps ensure all the resident's needs are being met. When asked how she makes sure a resident's comprehensive care plan is being implemented, LPN #1 stated she does her best to follow all of the physician's orders. On 10/25/21 at 3:23 p.m., RN (registered nurse) #5 was interviewed. She stated the resident had recently reported to her that he had not been showering because there was not enough staff. She stated, as far as she knew, this was true. RN #5 stated Resident #53's unit has an assigned shower aide, but the aide is most often pulled to work a regular assignment, due to lack of staff. RN #5 stated when this happens, residents do not receive a bath or shower. She stated she had spoken multiple times to the CNAs (certified nursing assistants) about bathing Resident #53, but they only have so much time in their day. RN #5 stated that on 10/7/21, Resident #53's mother had called to complain about Resident #53's not having received a bath/shower recently. She stated she had already spoken to the aides about this. She stated she assumes when the resident does not get a shower or bath, they receive a wipe down or bed bath. RN #5 stated she could not recall a CNA specifically reporting to her that Resident #53's bath or shower had not been completed. When shown Resident #53's bath records, RN #5 stated the records looked about right, and she could not verify that the resident had received a bath during the long gaps of blanks on the shower records. When asked the purpose of a care plan, RN #5 stated the care plan tells the staff what the resident needs for his or her care. When asked who is responsible for implementing a resident's care plan, RN #5 stated, All of us. The whole team. On 10/25/21 at 3:42 p.m., CNA (certified nursing assistant) #12 was interviewed. She stated she has worked with Resident #53 since he was admitted to the facility. CNA #12 stated the resident has for sure gone for long stretches of time without a shower or bath. She stated she did not usually have the time to give him a bed bath. She stated if she did so, she would document it on the bath record. CNA #12 stated there was frequently not enough staff working the unit to give Resident #53 a bath or shower. When asked the purpose of a resident's care plan, she stated the care plan tells everyone how to take care of the resident. When asked the importance of following a resident's care plan, CNA #12 stated the care plan must be followed so the resident can be their best. On 10/26/21 at 3:50 p.m., ASM #1 and ASM #2 were informed of these concerns. Additional evidence verifying Resident #53 had received showers or baths during the gaps identified above, and the care plan as documented above was implemented, was requested. A review of the facility policy, Plans of Care, revealed, in part: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .develop and implement an individual person-centered comprehensive plan of care by the Interdisciplinary Team that includes, but is not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident .as determined by the resident's needs. No further information was provided prior to exit. 1. b. The facility staff failed to implement Resident #53's comprehensive care plan to administer Diazepam (1), a medication to treat anxiety, per a physician's order. On 10/24/21 at 4:26 p.m., Resident #53 and his parents requested to meet with the survey team. Resident #53's mother reported concerns regarding Resident #53 not receiving his medications as ordered. She stated Resident #53 had not received Diazepam since Wednesday, 10/20/21. Resident #53 confirmed his mother's statement. Resident #53 stated he had been miserable since that time. A review of Resident #53's comprehensive care plan dated 3/11/21 revealed, in part: [Resident #53] uses anti-anxiety medications .Administer anti-anxiety medications as ordered by physician. A review of Resident #53's physician's orders revealed, in part, the following: Diazepam Tablet 5 mg (milligrams. Give 2 tablets by mouth at bedtime .related to anxiety disorder. A review of Resident #53's October 2021 MAR (medication administration record) revealed the number 9 in the square for the Diazepam administration on 10/21/21, 10/22/21, and 10/23/21. The legend for the October 2021 MAR documented: 9 =Other/See Nurse Note. A review of Resident #53's progress notes revealed, in part: 10/21/2021 11:23 p.m .Medication Administration Note Text: medication not available. 10/22/2021 10:47 p.m .Medication Administration Note Text: medication not available. 10/23/21 10:11 p.m .Medication Administration Note Text: medication not available. Further review of Resident #53's progress notes revealed, in part, the following: 10/23/2021 18:00 (6:00 p.m.) Nursing Progress Note: Attempted calls to [ASM (administrative staff member) #8 (medical director and Resident #53's attending physician)] on numerous occasions to get Valium (Diazepam) .to be called to pharmacy for this resident. 1430 (2:30 p.m.), 1450 (2:50 p.m.), 1530 (3:30 p.m.), 1635 (4:35 p.m.) no answer, goes to voicemail that says that mailbox is full. The nurse who wrote this note was unavailable for interview at the time of the survey. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked the purpose of a care plan, she stated a care plan enables the staff to offer the best possible care for a resident. She stated the care plan helps ensure all the resident's needs are being met. When asked how she makes sure a resident's care plan is being implemented, she stated she does her best to follow all of the physician's orders. On 10/25/21 at 3:23 p.m., RN (registered nurse) #5 was interviewed. She stated she was taking care of Resident #53 that morning and that he is upset because he has not received his Diazepam the past few nights. She stated she had personally faxed the refill request to the NP (nurse practitioner), ASM (administrative staff member) #6, on Thursday, 10/21/21. RN #5 stated she had called ASM #6 and told her Resident #53 would soon be completely out of the Diazepam, and needed a refill. She stated because Diazepam is a controlled substance, a refill required the NP or physician to directly contact the pharmacy to authorize it. RN #5 stated she did not work between Thursday, 10/21/21 and that morning (10/25/21), she had not had the opportunity follow up on this refill. She stated when she arrived at work at 7:00 a.m. on 10/25/21, she discovered the medication had finally been re-ordered on 10/24/21, but still had not been delivered to the facility. RN #5 stated she had looked for, but had not been able to locate the refill requests she had faxed to ASM #6 on 10/21/21. When asked whether Resident #53's care plan was being implemented if he was not receiving Diazepam as ordered, RN #5 stated, No. I don't believe it is. On 10/26/21 at 9:34 a.m., ASM #8, the medical director and Resident #53's attending physician, was interviewed. When asked about the process followed for authorizing refills for controlled medications, ASM #8 stated the facility nurses should communicate the refill needs a week before the medication runs out. He stated if he receives a request for a refill, he can send an electronic order directly to the pharmacy, or he can call the pharmacy to refill the medication. When asked what happens if the refill is urgently needed on a weekend, ASM #8 stated the nurses at the facility have his phone number, as well as the phone numbers for both nurse practitioners, and they should call one of the providers. When asked if he was aware that facility staff had attempted to call him over the weekend, he stated he was not. ASM #8 stated his voicemail had not been full over the weekend. On 10/26/21 at 12:19 p.m., ASM #6, the nurse practitioner, was interviewed. She stated if a resident needs a refill for a controlled medication, the staff prints out the paper prescription for the provider to sign on their next visit to the facility. She stated if the refill is needed urgently, the staff may call her, and she can directly transmit an electronic refill request to the pharmacy. ASM #6 stated she had not received any phone calls or faxes from facility nurses regarding Resident #53's Diazepam prescription. On 10/26/21 at 3:42 p.m., ASM #2, the director of clinical services, was interviewed. She stated if a resident needs an urgent refill for a controlled substance, the nursing staff may all a provider and request the provider to transmit the refill request directly to the pharmacy. She stated she was not aware of any concerns regarding Resident #53's Diazepam. ASM #2 was informed that timely Diazepam administration was included on Resident #53's care plan. On 10/26/21 at 3:50 p.m., ASM #1, the executive director, and ASM #2 were informed of these concerns. Additional evidence that Resident #53 had received the Diazepam as ordered was requested. No further information was provided prior to exit. REFERENCES (1) Diazepam is used to relieve anxiety and to control agitation caused by alcohol withdrawal. It is also used along with other medications to control muscle spasms and spasticity caused by certain neurological disorders such as cerebral palsy (condition that causes difficulty with movement and balance), paraplegia (inability to move parts of the body), athetosis (abnormal muscle contractions), and stiff-man syndrome (a rare disorder with muscle rigidity and stiffness). This information is taken from the website https://medlineplus.gov/druginfo/meds/a682047.html. 2. a. The facility staff failed implement Resident #26's comprehensive care plan to provide preventative pressure ulcer treatments, and to provide treatments for Resident #26's pressure ulcer on multiple dates in August, September, and October 2021. Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). The resident was coded as requiring the assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. He was coded as having received dialysis services during the look back period. Resident #26 was coded as having two pressure ulcers (1), both at stage 3 (2). Resident #26 refused surveyor observation of his pressure ulcers during the survey. A review of Resident #26's comprehensive care plan dated 7/27/20, and most recently updated 9/24/21, revealed, in part: [Resident #26] has pressure injury .related to immobility and refusal to lay (sic) side to side .Administer treatments as ordered and monitor for effectiveness .[Resident #26] has potential impairment to skin .treatments per order. A review of Resident #26's clinical record revealed the following physician's orders and medication administration records, as documented on the TARs (treatment administration records): Clean wound to right and left buttock with Normal saline, pat dry, apply maxorb (an absorbent material) and cover with foam dressing. This order was written 7/23/21 and discontinued 9/6/21. Resident #26's TARs revealed blanks for administration of this order on 8/9/21 and 8/12/21. Preventative skin care: apply skin barrier after each incontinent episode every shift and as needed to prevent skin breakdown. This order was written 12/9/20. Resident #26's TARs revealed blanks for administration of this order on 8/3/21, 8/4/21, 8/5/21, 8/10/21, 8/11/21, 9/14/21, 9/25/21, 9/27/21, 9/29/21, 9/30/21, 0/8/21, 10/9/21, 10/14/21, 10/15/21, 10/18/21, and 10/19/21. Clean stage 3 to coccyx with NS (normal saline), pat dry .Apply Silvadene (dressing) and cover with foam dressing. Change Q (every) day and prn (as needed). This order was written 9/18/21 and discontinued 10/7/21. Resident #26's TARs revealed blanks for administration of this order on 9/22/21, 9/27/21, 9/28/21, 10/1/21, 10/3/21, and 10/7/21. Left lower buttock: cleanse area with NS, pat dry, apply medihoney (medication to treat wounds) and cover with dry dressing. Change dressing if soiled or loosened prn every day shift. This order was written on 9/18/21 and discontinued on 10/7/21. Resident #26's TARs revealed blanks for administration of this order on 9/22/21, 9/27/21, 9/28/21, 10/1/21, 10/3/21, and 107/21. Right upper buttock: Cleanse area with NS, pat dry, apply silvadene, and cover with dry dressing. Change dressing if soiled or loosened prn every day shift. This order was written on 9/18/21 and discontinued on 9/28/21. Resident #26's TARs revealed blanks for administration of this order on 9/22/21, 9/27/21. 9/28/21, 9/30/21, 10/1/21, 10/3/21, and 10/7/21. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked how she documents a pressure ulcer treatment once she has completed it, LPN #1 stated she signs it on the electronic medical record. She stated her signature shows up as her initials and a check mark in the box for the specific date and time a treatment is due. When asked how a blank on a TAR should be interpreted, LPN #1 stated: There's no way of knowing. If it's not documented, it did not happen. When shown Resident #26's TARs for August, September, and October 2021, and asked to interpret the blanks for the resident's pressure ulcer treatments, LPN #1 stated, If it's not documented, it was not done. When asked the purpose of a comprehensive care plan, she stated a care plan enables the staff to offer the best possible care for a resident. She stated the care plan helps ensure all the resident's needs are being met. When asked how she makes sure a resident's care plan is being implemented, she stated she does her best to follow all of the physician's orders. When asked if Resident #26's care plan to prevent and treat pressure ulcers was being followed, LPN #1 stated it was not. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. A review of the facility policy, Clinical Guidelines Skin & Wound, revealed in part: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated .Develop individualized goals and interventions. No further information was provided prior to exit. REFERENCES (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. 2. b. The facility staff failed to implement Resident #26's comprehensive care plan for dialysis services. A review of Resident #26's comprehensive care plan dated 7/27/20 and updated 8/11/20, revealed, in part: [Resident #26] needs dialysis r/t (related to) renal (kidney) failure .monitor vital signs .1200 ml/day fluid restriction. He is noncompliant at times. A review of Resident #26's physician's orders, dialysis communication sheets, and MARs (medication administration records) for August, September, and October 2021 revealed, in part: PreDialysis assessment prior to appointment every day shift Monday, Wednesday and Friday. This order was written 7/7/21. Resident #26's clinical record contained no evidence of a pre-dialysis assessment, including vital signs and dialysis access site, or communication to the dialysis center on 8/30/21, 10/1/21, 10/8/21, and 10/11/21. PostDialysis assessment every day shift Monday, Wednesday and Friday. This order was written 7/7/21. Resident #26's clinical record contained no evidence of a post-dialysis assessment, including vital signs and dialysis access site, on 8/9/21, 8/30/21, 10/1/21, and 10/8/21. Further review of Resident #26's physician's order revealed the following order, dated 12/9/20: Fluid restriction: 1200 ml/day (milliliters per day). Dietary: Breakfast 240 ml, lunch 240 ml, dinner 240 ml = 720 with meals. Nursing 7a - 7p = 240. 7p - 7a = 240 = 480 ml with meds (medications) every shift for fluid restriction. A review of Resident #26's MARs and Point of Care records for October 2021 revealed no evidence of the exact amount of fluids Resident #26 received on any shift, or for any 24 hour period in total. A review of a dietary instruction slip for dinner on 10/21/21 revealed, in part: 6 oz (ounce) tea of choice .1200 ml fluid restriction. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked how she calculates if a resident is compliant with a physician ordered fluid restriction, LPN #1 stated she only documents how much fluid she is giving with medications, or if she is offering the resident something to drink. When asked who documents how much fluid a resident receives on a meal tray, she stated the CNAs document this information on the point of care records. When asked who is responsible for calculating a total amount of fluids consumed by a resident for a 24 hour period, LPN #1 stated, That's an excellent question. LPN #1 stated, Someone should be, but she doesn't know who is actually doing it. When asked why it would be important to know exactly how much fluid a resident is drinking, she stated if the resident is on dialysis, too much fluid could harm their kidneys even more. When asked what assessments she performs on a resident before the resident goes to dialysis, LPN #1 stated she checks vital signs, and checks the dialysis access site. LPN #1 stated, She communicates this information, as well as any lab [laboratory] results, weights, and medication changes, to the dialysis center by way of a dialysis communication book. LPN #1 stated, It's a form we all fill out. The dialysis center fills in their part and the book comes back to us. When shown the gaps in documentation for Resident #26's dialysis assessments and communication book, LPN #1 stated, It does not look like things were done on those days. When asked the purpose of a care plan, she stated a care plan enables the staff to offer the best possible care for a resident. She stated the care plan helps ensure all the resident's needs are being met. When asked how she makes sure a resident's care plan is being implemented, LPN #1 stated she does her best to follow all of the physician's orders. On 10/20/21 at 2:26 p.m., LPN (licensed practical nurse) #7 was interviewed. When asked about the blanks in dialysis assessments and dialysis communication book for Resident #26, she stated if there are blanks, then she would have to say the assessments were not done. On 10/20/21 at 3:12 p.m., CNA (certified nursing assistant) #2 was interviewed. When asked what she documents for residents who are on a fluid restriction, CNA #2 stated she can only document the percentage of a meal the resident has eaten. She stated there is no place on the point of care system to document an exact amount of fluid a resident receives with meals. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. No further information was provided prior to exit. 2. c. The facility staff failed implement Resident #26's comprehensive care plan to obtain laboratory [lab] testing on 9/30/21. A review of Resident #26's comprehensive care plan dated 7/27/20 revealed, in part: Obtain and monitor lab/diagnostic work as ordered. A review of Resident #26's physician's orders revealed the following: CBC (complete blood count) with diff (differentiation), BMP (basic metabolic panel), CRP (C-reactive protein), Ferritin (Iron level), D-dimer (clotting level), Fibrinogen (helps clotting) one time a day every Thursday for 14 days. Start date 9/23/21. Further review of Resident #26's September 2021 TARs (treatment administration records) and laboratory results revealed no results for the laboratory tests ordered for 9/30/21. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the information for lab (laboratory) tests that need to be done is kept in a book at the nurses' desk. She stated the nurse who receives an order for a lab test fills out a request slip, and puts in the book. When the outside lab company staff arrive at the facility, they check the book and obtain blood specimens as ordered. She stated she is not sure why Resident #26's lab tests were not performed for 9/30/21, but she could not find any evidence that the tests were done. LPN #1 stated Resident #26's care plan was not being followed regarding laboratory testing. On 10/21/21 at 8:36 a.m., ASM #2 confirmed the lab tests had not been done for Resident #26 on 9/30/21. She stated the night shift nurse is responsible for double checking that all lab requests for a particular day are accurate and in the book for the outside lab company. She stated she could not locate a lab test request sheet for Resident #26 for 9/30/21. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. No further information was provided prior to exit. 3. The facility staff failed to implement Resident #33's comprehensive care plan to provide to provide treatments for Resident #26's pressure ulcer on multiple dates in August, September, and October 2021. Resident #33 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses of diabetes, history of a stroke, and dementia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, Resident #33 was coded as being severely cognitively impaired for making daily decisions; the resident was not able to be interviewed for the BIMS (brief interview for mental status). Resident #33 was coded as being dependent on staff assistance for all activiti[TRUNCATED]

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide care and services for the treatment of a pressure ulcer for two of 41 residents in the survey sample, Residents #26 and #33. The facility staff failed to provide preventative pressure ulcer treatments, and failed to provide treatments for Resident #26's pressure ulcer and Resident #33's pressure ulcer on multiple dates in August, September, and October 2021. The findings include: 1. Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). Resident #26 was coded as requiring the assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. He was coded as having received dialysis services during the look back period. He was coded as having two pressure ulcers (1), both at stage 3 (2). Resident #26 refused surveyor observation of his pressure ulcers during the survey. A review of Resident #26's clinical record revealed the following physician's orders and medication administration records, as documented on the TARs (treatment administration records): Clean wound to right and left buttock with Normal saline, pat dry, apply maxorb (an absorbent material) and cover with foam dressing. This order was written 7/23/21 and discontinued 9/6/21. Resident #26's TARs revealed blanks for administration of this treatment order on 8/9/21 and 8/12/21. Preventative skin care: apply skin barrier after each incontinent episode every shift and as needed to prevent skin breakdown. This order was written 12/9/20. Resident #26's TARs revealed blanks for administration of this order on 8/3/21, 8/4/21, 8/5/21, 8/10/21, 8/11/21, 9/14/21, 9/25/21, 9/27/21, 9/29/21, 9/30/21, 0/8/21, 10/9/21, 10/14/21, 10/15/21, 10/18/21, and 10/19/21. Clean stage 3 to coccyx with NS (normal saline), pat dry .Apply Silvadene (dressing) and cover with foam dressing. Change Q (every) day and prn (as needed). This order was written 9/18/21 and discontinued 10/7/21. Resident #26's TARs revealed blanks for administration of this order on 9/22/21, 9/27/21, 9/28/21, 10/1/21, 10/3/21, and 10/7/21. Left lower buttock: cleanse area with NS, pat dry, apply medihoney (medication to treat wounds) and cover with dry dressing. Change dressing if soiled or loosened prn every day shift. This order was written on 9/18/21 and discontinued on 10/7/21. Resident #26's TARs revealed blanks for administration of this order on 9/22/21, 9/27/21, 9/28/21, 10/1/21, 10/3/21, and 107/21. Right upper buttock: Cleanse area with NS, pat dry, apply silvadene, and cover with dry dressing. Change dressing if soiled or loosened prn every day shift. This order was written on 9/18/21 and discontinued on 9/28/21. Resident #26's TARs revealed blanks for administration of this order on 9/22/21, 9/27/21. 9/28/21, 9/30/21, 10/1/21, 10/3/21, and 10/7/21. A review of Resident #26's wound tracking revealed no gaps in measurements and staging of the wound. The wound had not worsened during the period of August 2021 through survey entrance. No other wounds had developed during this time frame. A review of Resident #26's comprehensive care plan dated 7/27/20, and most recently updated 9/24/21, revealed, in part: [Resident #26] has pressure injury .related to immobility and refusal to lay (sic) side to side .Administer treatments as ordered and monitor for effectiveness .[Resident #26] has potential impairment to skin .treatments per order. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked how she documents a pressure ulcer treatment once she has completed it, LPN #1 stated she signs it on the electronic medical record. She stated her signature shows up as her initials and a check mark in the box for the specific date and time a treatment is due. When asked how a blank on a TAR should be interpreted, LPN #1 stated, There's no way of knowing. If it's not documented, it did not happen. When shown Resident #26's TARs for August, September, and October 2021, and asked to interpret the blanks for the resident's pressure ulcer treatments, LPN #6 stated, If it's not documented, it was not done. On 10/20/21 at 2:26 p.m., LPN (licensed practical nurse) #7 was interviewed. When asked about the blanks on the TARs for Resident #26, LPN #7 stated if there are blanks, then she would have to say the treatments were not done. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. The facility staff were asked to provide evidence that Resident #26's treatments for pressure ulcers had been administered as ordered by the physician on the dates identified above. A review of the facility policy, Clinical Guidelines Skin & Wound, revealed in part: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated .Develop individualized goals and interventions. No further information was provided prior to exit. REFERENCES (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. 2. Resident #33 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses of diabetes, history of a stroke, and dementia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, Resident #33 was coded as being severely cognitively impaired for making daily decisions; the resident was not able to be interviewed for the BIMS (brief interview for mental status). The resident was coded as being dependent on staff assistance for all activities of daily living. Resident #33 was coded as having a Stage 3 (1) pressure ulcer (2). On 10/21/21 at 10:51 a.m., observation was made of RN (registered nurse) #5 providing wound care to Resident #33. RN #5 removed the old dressing from Resident #33's sacrum. She changed gloves, sanitized her hands, and donned new gloves. She cleansed the wound with acetic acid, applied [NAME] Alginate to the wound, and covered the wound with an adhesive foam dressing. She removed her gloves and sanitized her hands. RN #5 measured the sacral wound at 1.4 cms (centimeters) X (by) 0.8 cms X 0.3 cms. The wound bed was 100% beefy red granulation (healing) tissue. No concerns were identified with technique or treatment during the observation. A review of Resident #33's clinical record revealed the following physician's orders and medication administration records, as documented on the TARs (treatment administration records) for August, September, and October 2021: Acetic Acid Solution 2% 10 ml (milliliters) miscellaneous every day shift for Stage 3 PI (pressure injury) to sacrum. Cleanse Stage 3 PI to sacrum with 2% acetic acid, pat dry, apply collagen/maxorb (dressing), cover with foam dressing daily and prn (as needed). This order was written 3/20/21. Resident #33's TARs revealed blanks for administration of this order on 8/7/21, 9/25/21, 9/26/21, 9/30/21, 10/1/21, 10/8/21, 10/9/21, 10/10/21, 10/15/21, and 10/18/21. Cleanse sacral wound with normal saline, pat dry, and apply collagen/maxorb covered by a foam dressing every day shift. This order was written on 6/9/21. Resident #33's TARs revealed blanks for administration of this order on 8/7/21, 9/25/21, 9/26/21, 9/30/21, 10/1/21, 10/9/21, 10/10/21, 10/15/21, and 10/18/21. A review of Resident #33's wound tracking revealed no gaps in measurements and staging of the wound. The wound had not worsened during the period of August 2021 through survey entrance. No other wounds had developed during this time frame. A review of Resident #33's comprehensive care plan dated 6/9/20, and updated 7/7/20, revealed, in part: [Resident #33] has pressure injury to her coccyx .Administer treatments as ordered and monitor for effectiveness. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked how she documents a pressure ulcer treatment once she has completed it, LPN #1 stated she signs it on the electronic medical record. She stated her signature shows up as her initials and a check mark in the box for the specific date and time a treatment is due. When asked how a blank on a TAR should be interpreted, LPN #1 stated, There's no way of knowing. If it's not documented, it did not happen. When shown Resident #33's TARs for August, September, and October 2021, and asked to interpret the blanks for the resident's pressure ulcer treatments, LPN #1 stated, If it's not documented, it was not done. On 10/20/21 at 2:26 p.m., LPN (licensed practical nurse) #7 was interviewed. When asked about the blanks in TARs for Resident #33, LPN #7 stated if there are blanks, then she would have to say the treatments were not done. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. The facility staff were asked to provide evidence that Resident #33's treatments for pressure ulcers had been administered as ordered by the physician on the dates identified above. A review of the facility policy, Clinical Guidelines Skin & Wound, revealed in part: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated .Develop individualized goals and interventions. No further information was provided prior to exit. REFERENCES (1) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services related to dialysis consistent with the plan of care for one of 41 residents in the survey sample, Resident #26. The facility staff failed to ensure assessments of Resident #26 prior to, and post dialysis appointments as ordered, and failed to communicate with the dialysis center on multiple occasions during August, September, and October 2021. The findings include: Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). Resident #26 was coded as having received dialysis services during the look back period. A review of Resident #26's physician's orders, dialysis communication sheets, and MARs (medication administration records) for August, September, and October 2021 revealed, in part: A physician order for: PreDialysis assessment prior to appointment every day shift Monday, Wednesday and Friday. This order was written 7/7/21. Resident #26's clinical record contained no evidence of a pre-dialysis assessment, including vital signs and dialysis access site, or communication to the dialysis center on 8/30/21, 10/1/21, 10/8/21, and 10/11/21. A physician order for: PostDialysis assessment every day shift Monday, Wednesday and Friday. This order was written 7/7/21. Resident #26's clinical record contained no evidence of a post-dialysis assessment, including vital signs and dialysis access site, on 8/9/21, 8/30/21, 10/1/21, and 10/8/21. A review of Resident #26's comprehensive care plan dated 7/27/20 and updated 8/11/20, revealed, in part: [Resident #26] needs dialysis r/t (related to) renal (kidney) failure .monitor vital signs .1200 ml/day fluid restriction. He is noncompliant at times. On 10/20/21 at 1:44 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked what assessments she performs on a resident before the resident goes to dialysis, LPN #1 stated she checks vital signs, and checks the dialysis access site. She stated she communicates this information, as well as any lab [laboratory test] results, weights, and medication changes, to the dialysis center by way of a dialysis communication book. LPN #1 stated, It's a form we all fill out. The dialysis center fills in their part and the book comes back to us. When shown the gaps in documentation for Resident #26's dialysis assessments and communication book, LPN #1 stated, It does not look like things were done on those days. On 10/20/21 at 2:26 p.m., LPN (licensed practical nurse) #7 was interviewed. When asked about the blanks in dialysis assessments and dialysis communication book for Resident #26, LPN #7 stated if there are blanks, then she would have to say the assessments were not done. On 10/20/21 at 4:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the regional vice president of operations, and ASM #4, the regional clinical nurse, were informed of these concerns. The facility staff were asked to provide evidence that Resident #26's dialysis assessments were performed for the gaps identified above. A review of the facility policy, Coordination of Hemodialysis Services, revealed, in part: The dialysis Communication form will be initiated by the facility for any resident going to an ESRD (end stage renal dialysis) facility for hemodialysis .Nursing will collect and complete the information regarding the resident to send to the ESRD center .Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center .Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's clinical record. No further information was provided prior to exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0886 (Tag F0886)

Could have caused harm · This affected multiple residents

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Based on staff interview and facility document review, it was determined that the facility staff failed to evidence documentation that COVID-19 testing was completed for fourteen of 45 employee reviews. The facility staff failed to evidence documentation that COVID-19 testing was completed and the results of each staff test for multiple employees in September 2021 and October 2021. The findings include: Review of facility documentation revealed the facility began COVID-19 outbreak status on 8/26/21. Further review of facility documentation failed to reveal evidence that the facility staff tracked employee COVID-19 testing from 8/26/21 to the beginning of survey (10/19/21). Review of individual employee tests revealed the following: -For OSM #13 (temporary nurse aide) hired on 9/15/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 10/9/21 and 10/16/21. -For CNA #14 hired on 9/17/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 9/25/21, 10/2/21 and 10/16/21. -For RN #2 hired on 9/21/21, the facility staff failed to evidence documentation of completed testing for the week ending 10/2/21. -For CNA #15 hired on 4/19/21, the facility staff failed to evidence documentation of completed testing for the week ending 9/18/21. -For ASM #7 (nurse practitioner) hired on 8/31/20, the facility staff failed evidence documentation of completed testing for the weeks ending 9/18/21, 9/25/21, 10/2/21, 10/9/21 and 10/16/21. -For CNA #1 hired on 8/25/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 9/11/21 and 9/25/21. -For OSM #21 (dietary supervisor) hired on 4/6/20, the facility staff failed to evidence documentation of completed testing for the weeks ending 9/11/21, 9/18/21, 9/25/21, 10/2/21 and 10/16/21. -For OSM #9 (transportation/central supply) hired on 5/12/20, the facility staff failed to evidence documentation of completed testing for the weeks ending 10/2/21 and 10/16/21. -For RN #4 hired on 9/14/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 9/25/21, 10/9/21 and 10/16/21. -For LPN #4 hired on 3/2/21, the facility staff failed to evidence documentation of completed testing for the week ending 10/9/21. -For CNA #22 hired on 7/1/21, the facility staff failed to evidence completed documentation of testing for the weeks ending 9/11/21, 9/18/21, 9/25/21, 10/2/21, 10/9/21 and 10/16/21. -For CNA #9 hired on 8/2/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 9/11/21, 9/18/21, 9/25/21, 10/2/21, 10/9/21 and 10/16/21. -For CNA #23 hired on 8/11/21, the facility staff failed to evidence documentatiomn of completed testing for the weeks ending 9/11/21 and 9/18/21. -For CNA #24, hired on 1/8/21, the facility staff failed to evidence documentation of completed testing for the week ending 9/18/21. On 10/26/21 at 8:36 a.m., an interview was conducted with OSM #21. OSM #21 stated she is tested for COVID-19 every Tuesday and Thursday by different nurses. On 10/26/21 at 8:49 a.m., an interview was conducted with CNA #9. CNA #9 stated she had been tested twice a week for COVID-19 by a nurses or someone who was trained. On 10/26/21 at 8:51 a.m., an interview was conducted with #9. OSM #9 stated that prior to the survey, staff were completing their own testing. OSM #9 stated he only looked to see if the tests were positive, checked off the testing forms and gave the forms to ASM (administrative staff member) #1 (the executive director). When asked who was tracking employee testing to ensure required testing was being completed, OSM #9 stated he was not sure but now he is responsible and he has a tracking roster. On 10/26/21 at 8:57 a.m., an interview was conducted with ASM #2 (the director of clinical services and infection preventionist). ASM #2 stated in August 2021 when the first resident tested positive, she told ASM #1 all staff had to be tested and would need to be tested twice weekly. ASM #1 stated the facility was conducting broad based testing. ASM #1 stated all testing records were kept in a book in ASM #1's office. On 10/26/21 at 9:04 a.m., an interview was conducted with ASM #1. ASM #1 stated the testing records were kept in his office and he would go through the test results based on an employee roster. ASM #1 stated he had now learned the employee roster was not complete. On 10/26/21 at 4:15 p.m., ASM #2 was asked why there was no tracking for COVID-19 employee testing. ASM #2 shook her head. The facility COVID-19 pandemic plan documented, Testing: 1. Centers will follow Federal and State regulations for testing of staff and residents .Documentation: Outbreak Investigation includes: -Date case was identified -Date all other residents and staff were tested -Date all residents and staff were retested -Results of all test -Outbreak Testing strategy used and rational (contact tracing or broad-based testing) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an operational call bell system for two of 41 residents in the survey sample, Residents #8 and #130. The findings include: 1. The facility staff failed to ensure Resident #8's call bell was operational since July 2021. Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to major depressive disorder, diabetes and muscle weakness. Resident #8's annual minimum data set assessment with an assessment reference date of 8/2/21, coded the resident as being cognitively intact. Section G coded Resident #8 as requiring extensive assistance of two or more staff with bed mobility. On 10/19/21 at 10:09 a.m., Resident #8 was observed lying in bed. The resident's call bell was not operational. There was no light or sound signal when the call bell was pressed. An interview was conducted with Resident #8 at this time. Resident #8 stated that he sometimes uses his call bell but it hasn't worked. On 10/19/21 at 11:39 a.m., an interview was conducted with OSM (other staff member) #1 (the maintenance director). OSM #1 stated Resident #8's call bell has not been operational since July 2021 but the resident did have a hand held ring bell. OSM #1 stated he can fix some call bell issues such as installing a new switch or new cord but some issues such as wiring have to be fixed by an outside company. OSM #1 stated he had notified the outside company regarding Resident #8's call bell but they had not recently been in the facility. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Call Bell System- Inoperable documented, Resident must have, at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regularly scheduled basis by Maintenance. If the Call Bell System is inoperable, in one room, one hall, or the entire unit, the following procedure must be followed: Procedure: -Maintenance, the Executive Director, and the Director of Clinical Services must be notified immediately if any call bell or the system is inoperable. -Hand bells or tap type bells will be placed within reach of any resident affected by an inoperable call bell. Residents and staff will be educated on their usage. -The Director of Maintenance and the Executive Director will focus on the repair of the inoperable call bell(s) which will be their priority until they are operable . Note: The outside company came onsite to repair Resident #8's call bell during the survey. No further information was presented prior to exit. 2. The facility staff failed to ensure Resident #130's call bell was operational on 10/19/21. Resident #130 was admitted to the facility on [DATE]. Resident #130's diagnoses included but were not limited to chronic kidney disease, diabetes and muscle weakness. Resident #130's admission minimum data set assessment with an assessment reference date of 10/21/21, coded the resident as being cognitively intact. On 10/19/21 at approximately 11:15 a.m., Resident #130 was observed in their room. The resident's call bell was tested and was not operational. There was no light or sound signal when the call bell was pressed. On 10/19/21 at 2:15 p.m., an interview was conducted with OSM (other staff member) #1 (the maintenance director). OSM #1 stated all call bells were checked by the maintenance department during the previous week and Resident #130's call bell was functioning. OSM #1 stated the switch attached to the bathroom call bell has to be pushed all the way up when turned off or the bedroom call bell will not signal. OSM #1 stated this can especially occur when the bathroom switch is worn and loose. On 10/19/21 at approximately 3:00 p.m., the above interview was verified and Resident #130's call bell was functional at this time. On 10/19/21 at 4:07 p.m., OSM #1 stated he replaced the call bell switch in Resident #130's bathroom. On 10/10/21 at 12:32 p.m., an interview was conducted with Resident #130. When asked if she uses the call bell, Resident #130 stated, I sure do. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. No further information was presented prior to exit.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on observation and staff interview, it was determined that the facility staff failed to post current nurse staffing information. Nurse staffing information for 10/19/21 was not posted on 10/19/21. Instead, nurse staffing information for 10/8/21 was posted. The findings include: On 10/19/21 at 9:26 a.m , observation of the nurse staff posting was conducted in the hall outside of the lobby. The nurse staff posting was dated 10/8/21 and contained staffing information for that date. On 10/19/21 at 3:57 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of clinical services). ASM #2 stated the scheduler is supposed to document and post the nurse staff information but the facility did not currently employ a scheduler. ASM #2 stated the human resources employee had recently been posting the nurse staffing information and she (ASM #2) tries to help the human resources employee with this task. ASM stated the nurse staffing information that was posted this morning was dated 10/8/21 and current nurse staffing information had not been posted because the facility did not currently have a scheduler. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 were made aware of the above concern. On 10/20/21 at 5:30 p.m., ASM #1 was asked to provide a policy regarding the nurse staff posting. On 10/26/21 at 2:11 p.m., ASM #1 stated the facility did not have the requested policy. No further information was presented prior to exit.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $99,827 in fines, Payment denial on record. Review inspection reports carefully.
• 114 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $99,827 in fines. Extremely high, among the most fined facilities in Virginia. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Woodstock Valley Health And Rehabilitation's CMS Rating?

CMS assigns Woodstock Valley Health and Rehabilitation an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Woodstock Valley Health And Rehabilitation Staffed?

CMS rates Woodstock Valley Health and Rehabilitation's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 65%, which is 19 percentage points above the Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 82%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Woodstock Valley Health And Rehabilitation?

State health inspectors documented 114 deficiencies at Woodstock Valley Health and Rehabilitation during 2021 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 107 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Woodstock Valley Health And Rehabilitation?

Woodstock Valley Health and Rehabilitation is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE, a chain that manages multiple nursing homes. With 88 certified beds and approximately 75 residents (about 85% occupancy), it is a smaller facility located in WOODSTOCK, Virginia.

How Does Woodstock Valley Health And Rehabilitation Compare to Other Virginia Nursing Homes?

Compared to the 100 nursing homes in Virginia, Woodstock Valley Health and Rehabilitation's overall rating (1 stars) is below the state average of 3.0, staff turnover (65%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Woodstock Valley Health And Rehabilitation?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.

Is Woodstock Valley Health And Rehabilitation Safe?

Based on CMS inspection data, Woodstock Valley Health and Rehabilitation has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Woodstock Valley Health And Rehabilitation Stick Around?

Staff turnover at Woodstock Valley Health and Rehabilitation is high. At 65%, the facility is 19 percentage points above the Virginia average of 46%. Registered Nurse turnover is particularly concerning at 82%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Woodstock Valley Health And Rehabilitation Ever Fined?

Woodstock Valley Health and Rehabilitation has been fined $99,827 across 2 penalty actions. This is above the Virginia average of $34,077. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Woodstock Valley Health And Rehabilitation on Any Federal Watch List?

Woodstock Valley Health and Rehabilitation is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 88
Avg. Residents: 75
Occupancy: 86.1%
Ownership: For profit - Corporation
Chain: CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
3 Immediate Jeopardy citations: -36
2 Actual Harm citations: -10
114 Deficiencies: -10
Fines ($99,827): -10
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 495315