Every finding on record at Advanced Center for Nursing & Rehabilitation

Based on observations, facility documentation, facility policy and interviews, the facility failed follow the Center for Disease Control (CDC) guidance for scheduled testing of the water, obtain the appropriate amount of water samples to be tested, and replace the sink filters every ninety (90) days according to the manufacturer's guidance after a resident had tested positive for legionella at the hospital. The findings include:On [DATE], the facility was notified that a resident (Resident #3) had tested positive for legionella while admitted to the hospital. On [DATE] at 2:23 PM the Director of Nursing (DON) communicated with the Connecticut Department of Public Health's epidemiologist (Person #1) and was given guidance regarding the schedule of environmental water sample testing: the CDC guidance of collecting samples for culture was at two (2) week intervals for three (3) months and if legionella was not detected during that time, then cultures would be collected monthly for another three (3) months. Review of the CDC's Sampling Procedure and Potential Sampling Sites guidance, the volume of the sample at each testing site (sink, shower, water tanks, etc.) should be one (1) liter, 1000 milliliters or ml. Review of the facility's water sampling test results identified the facility tested the water samples on [DATE] with a volume of 100 ml per sample site (900 ml short of the recommended volume). The next test of the water samples was on [DATE] with a volume of 100 ml per sample site (900 ml short of the recommended volume). The facility then tested water samples on [DATE] (eighteen (18) days after the previous testing) with a volume of 100 ml per sample site (900 ml short of the recommended volume). The next test was on [DATE] with the volume of 1000 ml. The facility tested the water samples on [DATE] (twenty-eight (28) days after the previous testing) with a volume of 1000 ml and then on [DATE] (twenty-six (26) days after the previous testing). On [DATE] at 11:35 AM the administrator had communication with the Connecticut Department of Public Health's assistant director of infectious disease (Person #2) regarding the volume and frequency of the facility's testing was inadequate on [DATE], [DATE] and [DATE], therefore, those samples would not be included as part of the monitoring sequence. The communication identified the collection samples on [DATE] and [DATE] were adequate in volume, but were performed almost a month apart and not within the two (2) week sequence per the CDC guidance and the monitoring sequence needed to be bi-weekly for three (3) months and then if all tests were negative the facility may adapt a monthly testing schedule for three (3) months. The communication identified employed control measures, including point of use filters, should remain in place until the testing was concluded per the CDC guidelines. Observations on [DATE] at 12:52 PM identified the Nephros S100 sink filters (point of use sink filters) were applied on [DATE] with the date of installation written on the filters. Review of the manufacturer instructions for use of the Nephros S100 sink filters identified the filter should operate for up to three (3) months of normal use with minimal degradation in flow. Interview with the Director of Maintenance on [DATE] at 11:08 AM identified the facility tests water from multiple different sources for each test sample and the sources are rotated after each test. The Director of Maintenance indicated initially the facility was testing with 100 ml of volume from each source, but since being notified, they have been testing with 1000 ml of volume. The Director of Maintenance identified the facility continues to test the water supply. The Director of Maintenance explained the facility was made aware that they would have to re-start testing every two (2) weeks due to the volume being insufficient for the first few test rounds and the frequency was not met for the last three (3) rounds. The Director of Maintenance identified the current point of use filters were installed on [DATE] when the facility was first notified of the positive legionella case. The Director of Maintenance indicated the facility had not changed the filters but was going to replace them since they were expiring, per the manufacturer's instructions the filters were operable for ninety (90) days indicating the filters had expired on [DATE]. Interview with the administrator and the Director of Nursing (DON) on [DATE] at 1:11 PM identified when the facility was notified of the positive legionella case, they began immediate mitigation strategies including testing of the facility water, bringing in bottled potable water (water intended for human contact or consumption), and installing point of use sink filters on all sinks and showers. The DON explained the facility's guideline for testing volume was 250 ml, but it was later discovered the facility needed to be using a testing volume of 1000 ml for each sample. The DON identified when the facility began testing, they were using the minimal amount of water volume and once they became aware of the need for the increased volume of water, they began testing with 1000 ml volume. The DON and administrator identified the facility had tested every two (2) weeks for December and January, but they were testing the wrong volume for each sample. The DON indicated from January through March they had been testing monthly and not every two (2) weeks as the guidelines state. The DON identified she had been in contact with Person #1 and did not think they had to continue testing every two (2) weeks because their first test was negative, however they should have been testing every two (2) weeks from the point of the correction of the volume sample size for three (3) months from the start of testing. The DON explained the facility installed the point of use filters on [DATE], they were going by the expiration date on the box of the filters, use by date which was noted to be 2028, therefore the filters were not replaced in ninety (90) from initial installation. The DON identified she would contact the manufacturer for more guidance on the expiration date of the filters, and the facility would replace them moving forward. Review of the facility Water Management Policy, undated, failed to identify the volume and frequency of surveillance testing after a confirmed positive case of Legionella. Review of the facility Infection Prevention and Control Program, last revised 9/2025, directed, in part, the facility will implement an ongoing, data-driven infection prevention and control program (IPCP) that integrates infection prevention practices into all resident care and environmental operations with the purpose to establish and maintain a facility-wide, evidence based IPCP designed to prevent, identify, investigate, and control infections among residents, staff, volunteers, visitor in accordance with federal, state and local regulations. The policy further directed, in part, to maintain ongoing infection surveillance using standardized definitions and to define outbreak thresholds per disease type, initiate immediate control measures, notify Connecticut DPH, the medical director and administrator immediately upon suspicion, maintain a line list, exposure log, and documentation of interventions and outcomes and conduct post-outbreak review and revise prevention plan accordingly. y.

Based on review of the clinical record, facility documentation/policy, and interviews for two (2) of three (3) residents (Resident #2 and Resident #14) reviewed for neglect, the facility failed to ensure nail care was performed for a dependent resident (Resident #2) with a contracted hand, failed to implement effective interventions when the resident resisted care, and failed to report ongoing care concerns to the provider for further evaluation, resulting in overgrown, unkempt fingernails and a left fourth finger infection requiring surgical intervention (incision and drainage); and failed to ensure bathing care was provided for a cognitively impaired resident (Resident #14) and failed to identify, report, and address ongoing gaps in care delivery, resulting in poor hygiene requiring hand soaks to remove fecal matter from underneath the fingernails. The findings included:1.Resident #2 was admitted to the facility in February of 2022 with diagnoses which included Type 2 diabetes mellitus with diabetic autonomic neuropathy, contracture of the left hand, and schizoaffective disorder, bipolar type. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 moderately cognitively impaired (Brief Mental Interview for Mental Status (BIMS) of 9) and dependent with toileting, bathing, and lower body dressing. The Resident Care Plan (RCP) dated 12/18/25 identified the resident exhibited behaviors as evidenced by refusals of care with staff at times. Interventions directed to re-approach the resident at another time, monitor changes in mood/behavior, and report to the medical doctor. The hospital Discharge summary dated [DATE] identified Resident #2 had a principal diagnoses of septic shock due to Methicillin Sensitive Staphylococcus Aureus (MSSA), pneumonia, urinary tract infection, and hypoxic and hypercapnic respiratory failure. Resident #2 had a left fourth finger paronychial infection and chronic contracture which required nail removal, incision and drainage, with wound cultures growing MSSA and Staphlococcus Lugdunensis. Photographs of Resident #2's left contracted hand identified fingernails that were overgrown and unkempt with notation Resident #2 was unable to passively extend any of the left upper extremity digits at the distal interphalangeal, proximal interphalangeal, and metacarpal phalangeal joints but was able to flex and extend his/her left thumb. Resident #2 was continued on Cefazolin (antibiotic) with local wound care soaks and cleared for discharge.Interview with LPN #1, on 3/10/26 at 11:45 AM identified nail care was performed on shower days or as needed and was typically performed by the NAs. LPN #1 further indicated he/she was not informed Resident #2 had nail care issues during January of 2026. Interview with NA #1 on 3/10/26 at 12:02 PM identified Resident #2 would have his/her nail care done on bath days, which occurred during the 3:00 PM to 11:00 PM shift. NA #1 indicated Resident #2 had nail care issues and staff had difficulty trying to open his/her left hand to perform care. NA #1 identified Resident #2 demonstrated resistance to left hand care, responding in pain when contact was made and pulling away when attempts to open the hand occurred. NA #1 indicated he/she was limited in what areas of the hand he/she could clean.Interview with APRN #1 on 3/10/26 at 1:26 PM identified he/she was not informed of Resident #2's nail care issues until after the 1/24/26 to 2/6/26 hospitalization, however, APRN #1 was aware of Resident #2's resistance to staff touching/opening the left hand. APRN #1 indicated he/she should have been informed of Resident #2's resistance to nail care, and had Resident #2 received regular nail care, the nail infection identified during the January of 2026 hospitalization could have been prevented. Interview with LPN #2 on 3/10/26 at 3:13 PM identified nail care was an on-going issue for Resident #2 and she first observed Resident #2's untrimmed nails prior to January of 2026 when Resident #2 was transferred to the nursing unit she was assigned. LPN #2 identified having difficulty visualizing the nails on his/her left hand due to the contracture. LPN #2 further indicated Resident #2 would resist having his/her left hand cleaned or opened, so LPN #2 was unable to assess the condition of his/her nails and did not inform the nursing supervisor or provider that Resident #2's nail care was not being performed because she believed the issue was common knowledge.Interview with NA #2 on 3/10/26 at 3:31 PM identified Resident #2 would refuse nail care to the left hand, would pull his/her hand away, and only allowed NA #2 to trim the left thumb and left fifth digit fingernails at times. NA #2 further indicated Resident #2, even when reapproached, would infrequently allow him/her to clean the upper surface of his/her left hand. However, he/she was sometimes able to slide a thin washcloth through the underside of his/her contracted fingers, which NA #2 indicated had a strong foul odor following the cleaning. NA #2 identified he/she informed LPN #2 of the issue with performing Resident #2's nail care.Interview with the Director of Nursing Services (DNS) on 3/11/26 at 1:26 PM identified he/she was unaware of difficulties performing Resident #2's nail care, hence no alternative nail care treatments were offered. The DNS identified facility practice was to perform nail care on shower days and as needed, and if unable to perform initially, NAs were to reattempt and/or revisit the task. If unsuccessful, the nurse was to be informed and attempt to complete the task. If still unable to complete the task, the nurse supervisor/DNS/provider were to be informed of the issue. The DNS further indicated a referral to physiatry and/or physical therapy/occupational therapy could have provided additional insight/intervention on how to address the concern.2. Resident #14's diagnoses included vascular dementia without behavioral disturbances and adult failure to thrive.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance for eating, partial assistance for bed mobility and transfers and supervision assistance for ambulation.The Resident Care Plan (RCP) dated 10/01/25 identified Resident #14 required assistance with functional Activities of Daily Living (ADLs). Interventions included assistance with showering every Monday on the 3:00 PM to 11:00 PM shift.Review of the Point of Care History for December 2025 identified Resident #14 received a shower on 12/5/25 at 3:44 PM and a complete bed bath on 12/7/25 at 11:31 AM but failed to identify Resident #14 received a shower or bed bath at least weekly between 12/8/25 and 12/20/25 or between 12/24/25 and 12/31/25.A Grievance/Concern Form dated 1/6/26 identified on 1/6/26 Resident #14 was noted with feces under his/her nails that required Resident #14's hands to be soaked to a bowl of soapy warm water to remove. It identified staff was educated regarding daily nail/foot care.Review of the Point of Care History for January 2026 identified Resident #14 received a partial bed bath on 1/10/26 at 5:17 AM but failed to identify Resident #14 received a shower or bed bath at least weekly between 1/1/26 and 1/9/26 or between 1/21/26 through 1/27/26.Review of the Point of Care History for March 2026 identified Resident #14 received a partial bed bath on 3/5/26 at 2:07 PM but failed to identify Resident #14 received a shower or bed bath at least weekly between 3/6/26 and 3/13/26.Review of the clinical record from 12/1/25 through 3/15/26 failed to identify Resident #14 refused a shower or bed bath.Interview with the DNS on 3/19/26 at 12:45 PM identified each resident should be provided with either a shower or a complete bed bath at least weekly. She identified the clinical record did not reflect Resident #14 received a shower or bed bath the week leading up to the grievance.Review of the Bathing and Grooming Care policy dated 1/19/18 directed, in part, rooms are assigned to either a day or evening shift to enable those residents to be provided with at least a weekly shower. Nail care, facial hair care and skin care is provided as a standard of care with bathing and grooming.The Resident Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property, and Retaliation policy directed it was the policy of the facility to ensure residents were free from abuse, mistreatment, neglect, exploitation, misappropriation of property, and retaliation and defined neglect as the failure of the facility, its employees or service providers to provide goods or services to a resident that were necessary to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Based on review of the clinical record, facility documentation/policy, and interviews for three (3) of three (3) residents (Residents #2, #14, and #18) reviewed for significant weight loss, the facility failed to ensure adequate nutritional monitoring and intervention to prevent significant weight loss by failing to obtain weights per policy and physician orders, failing to obtain timely re-weights following significant changes, and failing to consistently document and evaluate meal intake to guide care resulting in an inability to identify and respond to nutritional decline and contributed to continued weight loss, and for Resident #14, malnutrition. The findings include:1. Resident #14's diagnoses included vascular dementia without behavioral disturbances and adult failure to thrive.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required setup assistance for eating and was independent for bed mobility, transfers and ambulation.The Resident Care Plan (RCP) dated 6/10/25 identified Resident #14 was at risk for malnutrition related to a history of adult failure to thrive, altered nutrition related bloodwork, body mass index less than 23 and significant weight changes. Interventions included assessing intakes, bloodwork and weights, monitoring weight for significant changes and encouraging and monitoring meal, snack and medication pass intakes.A weight dated 6/9/25 identified a weight of 119.3 pounds (lbs).Review of physician orders dated 7/1/25 through 3/19/26 failed to identify an order to obtain weights.Review of the clinical record failed to identify weights were obtained from 6/10/25 through 7/10/25.The facility census identified Resident #14 was admitted to the hospital from [DATE] through 8/22/25.A readmission Nutrition assessment dated [DATE] at 9:53 AM identified Resident #14 had poor to fair intake and was consuming fifty (50) % of meals or less upon return from the hospital on 8/22/25. The assessment identified that a weight had not been obtained and an updated weight was requested to further assess current weight trends.A weight dated 9/10/25 (19 days after readmission to the facility) identified a weight of 117.3 lbs.Review of the clinical record identified no additional weights were obtained from 9/11/25 through 9/19/25.The facility census identified Resident #14 was admitted to the hospital from [DATE] through 9/30/25A weight dated 10/9/25 (9- days after readmission to the facility) identified a weight of 114.1 lbs. A weight dated 11/12/25 identified a weight of 108.6 lbs. A Weight Change Nutrition assessment dated [DATE] at 3:46 PM identified Resident #14 had a weight of 108.6 lbs on 11/16/25 and had a significant undesirable/unplanned weight loss of ten (10) % for the prior six (6) months related to decreased by mouth intake and a dementia related decline.The facility census identified Resident #14 was admitted to the hospital from [DATE] through 12/14/25.A weight dated 12/16/25 (2 days after readmission to the facility) identified a weight of 95.9 lbs (weight loss of 12.7 lbs (11.694% ) in one month). A Readmission/Weight Change Nutrition assessment dated [DATE] at 4:25 PM identified Resident #14 had a significant undesirable/unplanned weight loss consuming less than twenty-five (25) % to fifty (50) % and met the criteria for severe malnutrition related to inadequate by mouth intake. Recommendations included continuing the current plan of care.A re-weight of 106.6 lbs was obtained on 1/15/26 (30-days after the 12/16/25 weight of 95.9 lbs was obtained) which was an increase of 10.7 lbs (11.157%) in one month.A Monthly Weight Change Nutrition assessment dated [DATE] at 12:42 PM identified Resident #14's 1/15/26 weight was a significant beneficial/desired weight gain over the prior month, suspected a potential outlier for the 12/16/25 weight and gradual improvement in by mouth intake was reported by the staff.A re-weight of 104.4 lbs was obtained on 2/4/26 (20-days after the 1/15/26 weight of 106.6 lbs was obtained).Review of the clinical record from 8/22/25 through 2/3/26 failed to identify that additional weights were obtained or that Resident #14 refused the readmission weights on 8/22/25, 9/30/25 or 12/14/25 or re-weights following the significant loss/gain on 12/16/25 and 1/15/26.Meal percentage documentation from 9/1/25 through 1/31/26 identified that only seventy-four (74) out of four hundred fifty-nine (459) meal percentages were recorded (16%).2. Resident #2's diagnoses included severe protein calorie malnutrition, adult failure to thrive, type II diabetes mellitus and stage 3 pressure ulcer (full thickness skin loss that extends through the skin into deeper tissue and fat but doesn't reach muscle, tendon or bone).The significant change in status MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9), required partial assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The MDS identified Resident #2 had a weight loss of 5% or more over the last month or a loss of 10% or more over the last six (6) months and was not on a physician-prescribed weight-loss regimen.The Resident Care Plan (RCP) dated 10/01/25 identified Resident #2 was at increased risk for alterations in nutritional status secondary to the potential for weight loss/gain and a history of significant weight loss. Interventions included monitoring weight for significant changes and encouraging and monitoring by mouth intake at meals, snacks and medication pass.Review of physician's orders dated 10/1/25 through 3/19/26 failed to identify an order to obtain weights.Review of the clinical record identified the following weights were obtained: 112.8 pounds (lbs) on 11/10/25, 108.6 lbs on 1/7/26 and 107.1 lbs on 2/6/26 and failed to identify a weight was obtained in December 2025.Review of the clinical record from 11/11/25 through 1/6/26 failed to identify any additional weights were obtained or that Resident #2 refused the December 2025 weight.Meal percentage documentation from 9/1/25 through 1/31/26 identified that only forty-two (42) out of two hundred seventy (270) meal percentages were recorded (15%).3. Resident #18 's diagnoses included malignant neoplasm of the gallbladder (rare, aggressive cancer of the gallbladder), acute on chronic right heart failure (when the heart's right ventricle is too weak to pump blood to the lungs leading to fluid overload and significant fatigue) and Acute Immunodeficiency Virus (a virus that attacks the body's immune system making it hard to fight other infections and diseases).A physician's order dated 4/4/25 directed to obtain a weekly weight on Mondays at 6:00 AM.The annual MDS assessment dated [DATE] identified Resident #18 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required setup assistance for eating and was independent with bed mobility, transfers and ambulation. The MDS identified Resident #18 had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six (6) months and was not on a physician-prescribed weight-loss regimen.The Resident Care Plan (RCP) dated 10/15/25 identified Resident #18 was at increased risk for alterations in nutritional status secondary to the potential for weight loss/gain. Interventions included monitoring weight for significant changes and encouraging and monitoring by mouth intake at meals, snacks and medication pass.Review of the clinical record identified the following weights were obtained: 219.6 lbs on 10/3/25, 222.8 lbs on 10/7/25, 223.0 lbs on 11/3/25, 231.0 lbs on 12/8/25, 233.1 lbs on 12/29/25, 228.1 lbs on 1/5/26 and 228.1 lbs on 1/6/26.Review of the clinical record failed to identify that weights were obtained or that Resident #18 refused weights from 10/8/25 through 11/2/25, 11/4/25 through 12/7/25, 10/13/25 through 10/27/25, 11/10/25 through 12/1/25, and 12/15/25 through 12/22/25.The facility census identified Resident #18 was admitted to the hospital from [DATE] through 1/10/26.Review of the clinical record from 1/10/26 through 2/3/26 failed to identify that weekly weights were obtained from 1/12/26 through 2/2/26 per physician's order or that Resident #18 refused the weights.A weight of 219.1 was obtained on 2/4/26, 25 days after Resident #18's readmission to the facility.Meal percentage documentation from 10/1/25 through 2/28/26 identified only two hundred sixty-nine (269) out of four hundred fifty-three (453) meals were recorded for Resident #18 (59.38%).Interview with the Registered Dietician (RD) on 3/17/26 at 2:14 PM identified all residents (except those on hospice) should have an order for weights and be weighed at least monthly. She reported that a weight should be obtained within 24 to 48 hours of readmission to the facility and any resident with a weight change of five (5) % or more should be reweighed within (2) days and she should be notified. She identified all weights should be documented in the clinical record. The RD identified that she reviewed readmissions, ordered weights (weekly, monthly, etc.) and re-weights for residents who triggered for significant weight loss. She identified that if weights were not obtained or reweights were required, she would follow up with staff to ensure they were done and further indicated she was inconsistent with the follow up. She identified that when a resident had a significant weight loss, she was unable to review meal documentation over a period of time because it was incomplete, therefore, she was unable to obtain a clear picture of the resident's intake. She identified that despite the incomplete documentation affecting a resident's assessment and plan of care, she had not reported the issue to the DNS or provider. The RD identified that it was best practice to obtain weights more frequently for residents who had a significant weight loss, and she was responsible for making recommendations to the provider but did not recommend more frequent weight monitoring for Resident #14.Interview with the DON on 3/19/26 at 12:45 PM identified Residents #2 and #14 should have had physician's orders to direct the frequency and schedule for obtaining weights, especially for residents with weight loss/gain, and reported she was unaware residents were missing weight orders. She identified nursing staff was responsible for entering weight orders on admission/readmission and if directed by a provider. She identified the RD should closely monitor weights for residents with significant weight loss, ensure orders were in place, ensure weights were obtained and notify nursing of any issues. She identified the RD should make recommendations on how often weights are obtained and collaborate with the provider on preventing weight loss. The DNS reported Residents #2, #14 and #18 should have had weights obtained at least monthly or per physician's orders, as well as on readmission and with any significant change in weight from the previous recorded weight so that interventions could be implemented timely to prevent further weight loss. She identified admission weights, readmission weights and re-weights should be obtained within 24 hours and documented before the end of the shift. Further, she identified meal percentages should be recorded for every resident and if a resident refused a meal, the refusal should be documented and nursing should be notified. The DNS reported she was unaware meal percentages were not being documented consistently and identified the importance of the accuracy, especially for residents at risk of or with actual weight loss/gain.Review of the Weight policy (undated) directed, in part, it is the policy of the facility to weigh each resident on admission, then weekly for four (4) weeks, then monthly thereafter, unless otherwise ordered by the physician or interdisciplinary team. The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss in the residents. Each resident will be weighed monthly by the tenth (10th) day of the month. New and re-admission residents' weight will be obtained within 24 hours of admission and the assigned NA, under the supervision of the licensed nurse or the Registered Dietician will obtain all resident weights. Any resident displaying a significant change in weight of greater than or equal to 5 percent (%) gain/loss in one month will be reported to the Registered Dietician and reweighed. The Registered Dietician will review the medical record or residents with significant weight changes (5% loss/gain in one month, 7.5% loss/gain in 3 months, 10% loss/gain in 6 months). Dietary interventions will be recommended as needed. All significant weight losses will be reported to the physician. Interventions that are initiated in response to a weight change will be reflected in the care plan. Residents with weight loss/gain will be further reviewed in the interdisciplinary meeting/risk meeting.Although requested, facility policies for significant weight loss and obtaining re-weights were not provided.

Based on review of clinical records, interviews, and facility documentation/policy for one (1) of three (3) residents (Resident #1) reviewed for a leave of absence (LOA), the facility failed to update the Resident Care Plan (RCP) to include directives for the management of the residents independent LOA in accordance with facility policy and for one (1) of three (3) residents (Resident #2) reviewed for activities of daily living, the facility failed to implement interventions related to physician notification for refusal of contracture care. The findings included:Resident #1 was admitted to the facility in October of 2025 and had diagnoses which included Type 2 diabetes mellitus, chronic osteomyelitis of the right foot and ankle, and cellulitis of the right lower limb.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and utilized a walker and wheelchair for mobility.The RCP dated 10/10/25 identified Resident #1 had a history or active diagnosis of substance abuse. Interventions directed to seek support from family and friends to support treatment once the resident returned to the community.A physician's order dated 12/8/25 identified an independent LOA.Review of the RCP failed to include goals of care related to Resident #1's independent LOA. Interview with the Director of Nursing Services on 3/10/26 at 10:15 PM identified goals and interventions for residents with active LOA orders should be implemented into the RCP once the LOA order was approved. Review of the LOA policy dated 11/1/25 identified the facility supports the residents' rights to participate in community activities and family events by allowing temporary LOAs in accordance with the resident's care plan, physician orders, and applicable state and federal regulations.Review of the Comprehensive Care Planning policy identified that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. 2. Resident #2 was admitted to the facility in February 2022 with diagnoses which included Type 2 diabetes mellitus with diabetic autonomic neuropathy, contracture of the left hand, and schizoaffective disorder, bipolar type. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 moderately cognitively impaired (Brief Mental Interview for Mental Status (BIMS) of 9) and dependent with toileting, bathing, and lower body dressing. The Resident Care Plan (RCP) dated 12/18/25 identified the resident exhibited behaviors as evidenced by refusals of care with staff at times. Interventions directed to re-approach the resident at another time, monitor changes in mood/behavior, and report to the medical doctor. Interview with NA #1 on 3/10/26 at 12:02 PM identified Resident #2 would have his/her nail care done on bath days, which occurred during the 3:00 PM to 11:00 PM shift. Interview with LPN #2 on 3/10/26 at 3:13 PM identified nail care was an on-going issue for Resident #2 and she first observed Resident #2's untrimmed nails prior to January of 2026 when Resident #2 was transferred to the nursing unit she was assigned. LPN #2 identified having difficulty visualizing the nails on his/her left hand due to the contracture. LPN #2 further indicated Resident #2 would resist having his/her left hand cleaned or opened, so LPN #2 was unable to assess the condition of his/her nails and did not inform the nursing supervisor or provider that Resident #2's nail care was not being performed because she believed the issue was common knowledge.Interview with the Director of Nursing Services (DNS) on 3/11/26 at 1:26 PM identified he/she was unaware of difficulties performing Resident #2's nail care, hence no alternative nail care treatments were offered. The DNS identified facility practice was to perform nail care on shower days and as needed, and if unable to perform initially, NAs were to reattempt and/or revisit the task. If unsuccessful, the nurse was to be informed and attempt to complete the task. If still unable to complete the task, the nurse supervisor/DNS/provider were to be informed of the issue.Review of the Comprehensive Care Planning policy identified that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The policy further identified care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes, and relevant clinical decision making.

Based on review of the clinical record, facility documentation/policy, and interviews for two (2) of three (3) residents (Resident #2 and Resident #14) reviewed for activities of daily living, the facility failed to provide necessary assistance with personal hygiene, including hand and nail care for a dependent resident with a contracted hand (Resident #2), and bathing care for a cognitively impaired resident (Resident #14), and failed to implement effective interventions when care was resisted, resulting in poor hygiene, including overgrown, unkempt fingernails with compromised skin integrity and the need for hand soaks to remove fecal matter from underneath the fingernails. The findings included:1.Resident #2 was admitted to the facility in February of 2022 with diagnoses which included Type 2 diabetes mellitus with diabetic autonomic neuropathy, contracture of the left hand, and schizoaffective disorder, bipolar type. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 moderately cognitively impaired (Brief Mental Interview for Mental Status (BIMS) of 9) and dependent with toileting, bathing, and lower body dressing. The Resident Care Plan (RCP) dated 12/18/25 identified the resident exhibited behaviors as evidenced by refusals of care with staff at times. Interventions directed to re-approach the resident at another time, monitor changes in mood/behavior, and report to the medical doctor. The hospital Discharge summary dated [DATE] identified Resident #2 had a principal diagnoses of septic shock due to Methicillin Sensitive Staphylococcus Aureus (MSSA), pneumonia, urinary tract infection, and hypoxic and hypercapnic respiratory failure. Resident #2 had a left fourth finger paronychial infection and chronic contracture which required nail removal, incision and drainage, with wound cultures growing MSSA and Staphlococcus Lugdunensis. Photographs of Resident #2's left contracted hand identified fingernails that were overgrown and unkempt with notation Resident #2 was unable to passively extend any of the left upper extremity digits at the distal interphalangeal, proximal interphalangeal, and metacarpal phalangeal joints but was able to flex and extend his/her left thumb. Resident #2 was continued on Cefazolin (antibiotic) with local wound care soaks and cleared for discharge.Interview with LPN #1, on 3/10/26 at 11:45 AM identified nail care was performed on shower days or as needed and was typically performed by the NAs. LPN #1 further indicated he/she was not informed Resident #2 had nail care issues during January of 2026. Interview with NA #1 on 3/10/26 at 12:02 PM identified Resident #2 would have his/her nail care done on bath days, which occurred during the 3:00 PM to 11:00 PM shift. NA #1 indicated Resident #2 had nail care issues and staff had difficulty trying to open his/her left hand to perform care. NA #1 identified Resident #2 demonstrated resistance to left hand care, responding in pain when contact was made and pulling away when attempts to open the hand occurred. NA #1 indicated he/she was limited in what areas of the hand he/she could clean.Interview with APRN #1 on 3/10/26 at 1:26 PM identified he/she was not informed of Resident #2's nail care issues until after the 1/24/26 to 2/6/26 hospitalization, however, APRN #1 was aware of Resident #2's resistance to staff touching/opening the left hand. APRN #1 indicated he/she should have been informed of Resident #2's resistance to nail care, and had Resident #2 received regular nail care, the nail infection identified during the January of 2026 hospitalization could have been prevented. Interview with LPN #2 on 3/10/26 at 3:13 PM identified nail care was an on-going issue for Resident #2 and she first observed Resident #2's untrimmed nails prior to January of 2026 when Resident #2 was transferred to the nursing unit she was assigned. LPN #2 identified having difficulty visualizing the nails on his/her left hand due to the contracture. LPN #2 further indicated Resident #2 would resist having his/her left hand cleaned or opened, so LPN #2 was unable to assess the condition of his/her nails and did not inform the nursing supervisor or provider that Resident #2's nail care was not being performed because she believed the issue was common knowledge.Interview with NA #2 on 3/10/26 at 3:31 PM identified Resident #2 would refuse nail care to the left hand, would pull his/her hand away, and only allowed NA #2 to trim the left thumb and left fifth digit fingernails at times. NA #2 further indicated Resident #2, even when reapproached, would infrequently allow him/her to clean the upper surface of his/her left hand. However, he/she was sometimes able to slide a thin washcloth through the underside of his/her contracted fingers, which NA #2 indicated had a strong foul odor following the cleaning. NA #2 identified he/she informed LPN #2 of the issue with performing Resident #2's nail care.Interview with the Director of Nursing Services (DNS) on 3/11/26 at 1:26 PM identified he/she was unaware of difficulties performing Resident #2's nail care, hence no alternative nail care treatments were offered. The DNS identified facility practice was to perform nail care on shower days and as needed, and if unable to perform initially, NAs were to reattempt and/or revisit the task. If unsuccessful, the nurse was to be informed and attempt to complete the task. If still unable to complete the task, the nurse supervisor/DNS/provider were to be informed of the issue. The DNS further indicated a referral to physiatry and/or physical therapy/occupational therapy could have provided additional insight/intervention on how to address the concern.2. Resident #14's diagnoses included vascular dementia without behavioral disturbances and adult failure to thrive.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance for eating, partial assistance for bed mobility and transfers and supervision assistance for ambulation.The Resident Care Plan (RCP) dated 10/01/25 identified Resident #14 required assistance with functional Activities of Daily Living (ADLs). Interventions included assistance with showering every Monday on the 3:00 PM to 11:00 PM shift.Review of the Point of Care History for December 2025 identified Resident #14 received a shower on 12/5/25 at 3:44 PM and a complete bed bath on 12/7/25 at 11:31 AM but failed to identify Resident #14 received a shower or bed bath at least weekly between 12/8/25 and 12/20/25 or between 12/24/25 and 12/31/25.A Grievance/Concern Form dated 1/6/26 identified on 1/6/26 Resident #14 was noted with feces under his/her nails that required Resident #14's hands to be soaked to a bowl of soapy warm water to remove. It identified staff was educated regarding daily nail/foot care.Review of the Point of Care History for January 2026 identified Resident #14 received a partial bed bath on 1/10/26 at 5:17 AM but failed to identify Resident #14 received a shower or bed bath at least weekly between 1/1/26 and 1/9/26 or between 1/21/26 through 1/27/26.Review of the Point of Care History for March 2026 identified Resident #14 received a partial bed bath on 3/5/26 at 2:07 PM but failed to identify Resident #14 received a shower or bed bath at least weekly between 3/6/26 and 3/13/26.Review of the clinical record from 12/1/25 through 3/15/26 failed to identify Resident #14 refused a shower or bed bath.Interview with the DNS on 3/19/26 at 12:45 PM identified each resident should be provided with either a shower or a complete bed bath at least weekly. She identified the clinical record did not reflect Resident #14 received a shower or bed bath the week leading up to the grievance.The Activities of Daily Living policy identified residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy further directed, if residents with cognitive impairment or dementia resisted care, staff would attempt to identify the underlying cause of the problem, not assume the resident was refusing or declining care, and that approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents (Residents #2 and #14) reviewed for bathing and grooming, the facility failed to ensure the clinical record was complete and accurate to reflect the provision of required hygiene care, including weekly showers and/or bed baths, resulting in an inability to verify care delivery. The findings include:1. Resident #2's diagnoses included severe protein calorie malnutrition, adult failure to thrive, type II diabetes mellitus and stage 3 pressure ulcer (full thickness skin loss that extends through the skin into deeper tissue and fat but does not reach muscle, tendon or bone). The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9), required partial assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 10/01/25 identified Resident #2 required assistance with functional Activities of Daily Living (ADLs). Interventions included total care for showering and grooming. Review of the Point of Care History for December 2025 identified Resident #2 received a shower on 12/8/25 at 3:51 PM and a partial bed bath on 12/17/25 at 7:30 PM, but failed to identify Resident #2 received a shower or bed bath at least weekly between 12/1/25 and 12/7/25 or between 12/18/25 and 12/31/25. Review of the Point of Care History for January 2026 identified Resident #2 received a partial bed bath on 1/1/26 at 10:51 PM but failed to identify Resident #2 received a shower or bed bath at least weekly between 1/2/26 and 1/11/26 or between 1/25/26 and 1/31/26. Review of the clinical record from 12/1/25 through 1/31/26 failed to identify Resident #2 refused a shower or bed bath. 2. Resident #14's diagnoses included vascular dementia without behavioral disturbances and adult failure to thrive. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance for eating, partial assistance for bed mobility and transfers and supervision assistance for ambulation. The Resident Care Plan (RCP) dated 10/01/25 identified Resident #14 required assistance with functional Activities of Daily Living (ADLs). Interventions included assistance with showering every Monday on the 3:00 PM to 11:00 PM shift. Review of the Point of Care History for December 2025 identified Resident #14 received a shower on 12/5/25 at 3:44 PM and a complete bed bath on 12/7/25 at 11:31 AM but failed to identify Resident #14 received a shower or bed bath at least weekly between 12/8/25 and 12/20/25 or between 12/24/25 and 12/31/25. A Grievance/Concern Form dated 1/6/26 identified on 1/6/26 Resident #14 was noted with feces under his/her nails that required Resident #14's hands to be soaked to a bowl of soapy warm water to remove. It identified staff was educated regarding daily nail/foot care. Review of the Point of Care History for January 2026 identified Resident #14 received a partial bed bath on 1/10/26 at 5:17 AM but failed to identify Resident #14 received a shower or bed bath at least weekly between 1/1/26 and 1/9/26 or between 1/21/26 through 1/27/26. Review of the Point of Care History for March 2026 identified Resident #14 received a partial bed bath on 3/5/26 at 2:07 PM but failed to identify Resident #14 received a shower or bed bath at least weekly between 3/6/26 and 3/13/26. Review of the clinical record from 12/1/25 through 3/15/26 failed to identify Resident #14 refused a shower or bed bath. Interview with the DON on 3/19/26 at 12:45 PM identified each resident should be provided with either a shower or a complete bed bath at least weekly. She identified care should be documented in the clinical record before the end of the shift. She identified the clinical record did not reflect Resident #14 received a shower or bed bath the week leading up to the grievance. Review of the Bathing and Grooming Care policy dated 1/19/18 directed, in part, rooms are assigned to either a day or evening shift to enable those residents to be provided with at least a weekly shower. Nail care, facial hair care and skin care is provided as a standard of care with bathing and grooming. Although requested, facility policies for Nurse Aide documentation or Kardex/Care Card were not available.

Based on review of clinical records, interviews, and review of facility documentation and policy for seven (7) of nine (9) residents (Resident #1, #3, #4, #7, #8, #9, and #13) reviewed for discharge, the facility failed to provide timely notification to the ombudsman when residents were discharged and/or planned for discharge from the facility. The findings included:1.Resident #1 was admitted to the facility in October of 2025 and had diagnoses which included Type 2 diabetes mellitus with foot ulcer, chronic osteomyelitis of the right foot and ankle, and cellulitis of the right lower limb.A physician's order dated [DATE] identified an independent leave of absence (LOA) was granted.The LOA Notification Form dated [DATE] at 9:36 AM identified Resident #1 left the faciity on an LOA and planned to return at 11:00 AM on [DATE].A nurse's note by RN #1 on [DATE] at 1:53 PM identified he/she called Resident #1 and Resident #1 indicated he/she would return the following morning ([DATE]). RN #1 further indicated the physician was updated Resident #1 would miss medications due to the overnight LOA. Interview with the Director of Nursing Services (DNS) on [DATE] at 10:23 AM identified Resident #1 was found sleeping on a park bench, intoxicated, and hypothermic upon arrival to the emergency department (ED). The DNS further indicated despite lifesaving measures, Resident #1 expired while in the ED the afternoon of [DATE].Although the facility provided an Admit/Discharge Report dated [DATE] to [DATE] which indicated Resident #1 was on hospital leave [DATE], the facility was unable to provide evidence that a discharge notice was uploaded to the Aging and Disability Services application portal. 2.Resident #3 was admitted to the facility in January of 2026 and had diagnoses which included acute osteomyelitis of the right ankle and foot, peripheral vascular disease, and gas gangrene.A social service's note by Social Worker (SW) #2 dated [DATE] at 4:41 PM identified Resident #3 planned on staying at the facility short term, planned to return to his/her residence in the community, and a seventy-two (72) hour meeting was conducted on [DATE] with Resident #3's daughter, son-in-law, therapy, and Director of Nursing Services (DNS) in attendance.The Notice of Intent to discharge date d [DATE] identified a thirty (30) day notice was provided to Resident #3 as he/she no longer needed the services of the facility due to improved health and the facility was planning to discharge him/her to the previous home address.A social service's note by SW #2 on [DATE] at 3:00 PM identified Resident #3 was discharged on [DATE].The New Discharge Notification File Confirmation email identified Resident #3's discharge notice was uploaded to the Aging and Disability Services application portal on [DATE] at 10:30 AM (twelve (12) days after the Notice of Intent to discharge was given to Resident #3).3.Resident #4 was admitted to the facility in October of 2023 and had diagnoses which included Type 2 Diabetes Mellitus with diabetic peripheral angiopathy with gangrene, coronary artery disease, and renal insufficiency. A social service's note by SW #3 on [DATE] at 3:49 PM identified Resident #4 was provided diabetic education regarding preferred meal regimen along with lifestyle changes to maintain normal ranges once discharged home.The Notice of Intent to discharge date d [DATE] identified a thirty (30) day notice was provided to Resident #4 as his/her application for Money Follows the Person was accepted, and the team found him/her housing.A social service's note by SW #2 dated [DATE] at 4:34 PM identified Resident #4 was successfully discharged from the facility at approximately 12:15 PM. The New Discharge Notification File Confirmation email identified Resident #4's discharge was uploaded to Aging and Disability Services application portal on [DATE] at 2:28 PM (twenty-three (23) days after the Notice of Intent to Discharge was given to Resident #4).4.Resident #7 was admitted to the facility in October of 2025 and had diagnoses which included Type 2 diabetes mellitus, anxiety disorder, and chronic obstructive pulmonary disease. A social service's note by SW #1 on [DATE] at 10:03 AM identified he/she spoke with Resident #7 and Resident #7's family as they were working on cleaning the resident's apartment in the community as Resident #7 was adamant about returning home by the end of the month and made Resident #7 aware he/she would receive limited services with his/her insurance. The Notice of Intent to discharge date d [DATE] identified a thirty (30) day notice was provided to Resident #7 as he/she no longer needed the services of the facility due to improved health and the resident/writer/family helped facilitate a safe discharge back to his/her apartment set for Friday, [DATE]. A social service's note by SW #1 dated [DATE] at 4:37 PM identified Resident #7 was discharged back to his/her apartment.The New Discharge Notification File Confirmation email identified Resident #7's discharge was uploaded to Aging and Disability Services application portal on [DATE] at 9:47 AM (one (1) day after the Notice of Intent to Discharge was given to Resident #7 but four (4) days after Resident #7 informed the facility of his desire to be discharged from the facility and the facility uploading the notification.5.Resident #8 was admitted to the facility in January of 2025 and had diagnoses which included Type 2 diabetes mellitus, depression, and Multiple Sclerosis.The Notice of Intent to discharge date d [DATE] identified a thirty (30) day notice was provided to Resident #8 as he/she no longer needed the services of the facility due to improved health.The New Discharge Notification File Confirmation email identified Resident #8's discharge was uploaded to Aging and Disability Services application portal on [DATE] at 12:13 PM, twelve (12) days after Resident #7 was given the Notice of Intent to Discharge.A social service's noted by SW #2 on [DATE] at 2:18 PM identified Resident #8 was successfully discharged from the facility on [DATE].6.Resident #9 was admitted to the facility in September of 2025 and had diagnoses which included heart failure, chronic obstructive pulmonary disease, and respiratory failure. A social service's note by SW #1 on [DATE] at 3:18 PM identified a meeting was held with Resident #9, therapy, and family per request and that a discharge date of [DATE] was decided upon.The Notice of Intent to discharge date d [DATE] identified a thirty (30) day notice was provided to Resident #9 as he/she no longer needed the services of the facility due to improved health and per family choice, family/resident had a discharge meeting and would like him/her to return back to his/her apartment.A social service's note by SW #1 dated [DATE] at 2:50 PM identified Resident #9 was discharged home.The New Discharge Notification File Confirmation email identified Resident #9's discharge was uploaded to Aging and Disability Services application portal on [DATE] at 3:14 PM, six (6) days after the Notice of Intent to Discharge was given to Resident #7.7.Resident #13 was admitted to the facility in October of 2024 and had diagnoses which included schizoaffective disorder, anxiety disorder, and Type 2 diabetes mellitus.A social service's note by SW #1 dated [DATE] at 1:14 PM identified a discharge meeting was held with Resident #13 and Money Follows the Person (MFP) as Resident #13 would be discharged to his/her new apartment on [DATE] and SW #1 had started a safe transition for Resident #13 in the community.The Notice of Intent to discharge date d [DATE] identified a thirty (30) day notice was provided to Resident #13 as his/her application for MFP was accepted and he/she provided housing. A social service's note by SW #2 dated [DATE] at 4:46 PM identified Resident #13 was discharged from the facility. The New Discharge Notification File Confirmation email identified Resident #13's discharge notice was uploaded to Aging and Disability Services application portal on [DATE] at 2:22 PM (thirty-seven (37) days after the Notice of Intent to discharge was given to Resident #13).Interview with SW #1 on [DATE] at 12:57 PM identified Resident #1's discharge was not reported to the Aging and Disability Services application portal as he/she considered him/her a transfer rather than a discharge to the hospital and would not have notified the ombudsman of a transfer. SW #1 further indicated the timeframe required to upload discharge notices to the Aging and Disability Services application portal varied, and that there was no specific date or timeframe the discharge notice was to be created and uploaded into the portal by. Interview with the DNS on [DATE] at 10:01 AM failed to identify when the facility was to inform/upload the notice of discharge into the Aging and Disability Services application portal. The Transfer/Discharge policy dated [DATE] identified before the facility transfers the resident, the facility must notify the resident and their representative of the transfer or discharge, the reason for the move in writing in a language the resident understands, and the regional long term care ombudsman should be notified by the long term care portal (Aging and Disability Services application portal).The Centers for Medicare Services Transfer and Discharge Documentation Regulation directed the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible, and the copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #14) reviewed for significant weight loss, the facility failed to ensure the comprehensive assessment accurately reflected the resident's significant weight loss greater than ten (10) percent (%) in the last six (6) months at the time of the assessment. The findings include: Resident #14's diagnoses included vascular dementia without behavioral disturbances and adult failure to thrive.A weight of 122.0 pounds (lbs) was obtained on 5/13/25.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required setup assistance for eating and was independent for bed mobility, transfers and ambulation.The Resident Care Plan (RCP) dated 6/10/25 identified Resident #14 was at risk for malnutrition related to a history of adult failure to thrive, altered nutrition related bloodwork, body mass index less than 23 and significant weight changes. Interventions included assessing intakes, bloodwork and weights, monitoring weight for significant changes and encouraging and monitoring meal, snack and medication pass intakes. A weight of 108.6 lbs was obtained on 11/16/25 signifying a 13.4 lb (10.984%) weight loss in six (6) months compared to the 5/13/25 weight.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance for eating and bed mobility and was dependent on staff for transfers. The MDS did not identify Resident #14 had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six (6) months.Interview with the Registered Dietician (RD) on 3/19/26 at 10:59 AM identified she was responsible for completing Section K (Swallowing and Nutritional Status) of the MDS. The RD acknowledged that Section K of the 12/4/25 MDS for Resident #14 was coded incorrectly. She reported she used an incorrect baseline weight and failed to calculate the resident's weight change using the appropriate six (6) month look-back period from the Assessment Reference Date. The RD stated that based on the 5/13/25 weight of 122.0 lbs and the 11/16/25 weight of 108.6 lbs, Resident #14 experienced a weight loss greater than ten (10) percent (%) in six (6) months, and the MDS should have identified a significant weight loss.Interview with the DON on 3/19/26 at 12:45 PM identified the MDS should accurately reflect a resident's care for all sections, including Swallowing and Nutritional status. The DON stated Resident #14's MDS dated [DATE] did not accurately reflect Resident #14's significant weight loss of more than 10%.Although requested, a policy on Comprehensive Assessments was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for supplemental oxygen, the facility failed to assess the resident and notify the provider when Resident #2 experienced Shortness of Breath (SOB) related to the facility's lack of oxygen concentrators and emergency tank supplies. The facility failed to ensure continuous, functioning supplemental oxygen and failed to provide timely, appropriate intervention for Resident #2's acute respiratory distress, resulting in Resident #2's condition deteriorating to acute respiratory arrest, ultimately leading to death. The failures resulted in the finding of Immediate Jeopardy. The findings include: Resident #2's diagnoses included acute respiratory failure with hypercapnia (excess carbon dioxide in the bloodstream), Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and dependence on supplemental oxygen. A physician's order dated [DATE] directed to administer continuous oxygen at 3.0 liters per minute via nasal cannula for a diagnosis of COPD. The order noted the oxygen may be removed for brief periods. Interventions per the Resident Care Plan dated [DATE] directed to provide supplemental oxygen per physician's order, monitor for signs and symptoms of respiratory distress and report to the provider, and to check oxygen saturation levels as needed and report abnormal values to the provider. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating Resident #2 had no memory recall deficits, was alert and oriented to person, place, and required supervision assistance with personal care and transfers. The late entry nurse's note dated [DATE] at 2:37 PM identified at 10:40 AM the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, had walked onto the unit to see the charge nurse, Licensed Practical Nurse (LPN) #1, when a nurse aide, Nurse Aide (NA) #1, yelled out Resident #2 was calling out for help, stating he/she could not breathe. The note indicated the Nurse Practitioner (NP) was on the unit, immediately assessed Resident #2 and ordered staff to call 911. The note identified Resident #2 was noted to be sitting in a chair, breathing heavily using accessory muscles, RN #1 requested staff to bring a portable oxygen tank and Resident #2 was switched from the concentrator via nasal cannula to the portable tank and a non-rebreather mask at fifteen (15) liters per minute was applied. The note indicated Resident #2 was transferred to bed, became unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by RN #1 and the NP, at approximately 10:45 AM, Emergency Medical Services (EMS) arrived and took over the CPR and despite continued CPR efforts, Resident #2 was pronounced deceased at 11:15 AM. Review of the clinical record failed to identify Resident #2's vital signs and oxygen saturation levels were obtained from [DATE] through [DATE]. The clinical record indicated there were no orders to obtain vital signs and oxygen saturation levels. Interview with LPN #4 on [DATE] at 11:13 AM identified on [DATE] she worked the 3-11PM shift. LPN #4 indicated when she switched Resident #2 from the oxygen concentrator to a portable oxygen cylinder, she did not check the oxygen concentrator for functioning, and she did not document Resident #2's oxygen saturation level after she switched the oxygen sources. LPN #4 identified she did not personally speak with the 3-11PM nursing supervisor, RN #3, during her shift regarding Resident #2 because she thought RN #3 was already aware Resident #2 needed a new oxygen concentrator. Interview with the 3-11PM nursing supervisor, RN #3, on [DATE] at 11:18 AM identified LPN #4 did not notify her nor was she aware Resident #2 had been receiving oxygen via the portable oxygen tanks instead of the concentrator throughout the 3-11PM shift on [DATE] and had she been made aware she would have assessed Resident #2, checked the oxygen concentrator for function, and located a functioning concentrator within the facility. Interview with LPN #3 on [DATE] at 1:33 PM identified when she arrived for her 11PM-7AM shift on [DATE] into [DATE], LPN #4 reported to her that Resident #2's oxygen concentrator was not working, and Resident #2 was on bottled oxygen. LPN #3 stated although she should have, she did not look for an oxygen concentrator or check Resident #2's oxygen saturation level throughout the shift. LPN #3 indicated she also did not notify the 11PM-7AM nursing supervisor, RN #2, that Resident #2 was utilizing bottled oxygen or that the concentrator was not working, stating she assumed RN #2 was already aware. Interview with RN #2 on [DATE] at 1:40 PM identified that she was not aware Resident #2's concentrator was not functioning or that Resident #2 was utilizing bottled oxygen starting on the 3-11PM shift. RN #2 identified neither the 3-11PM nursing supervisor, RN #3, nor the 11PM-7AM charge nurse, LPN #3, had notified her of an issue with the concentrator. RN #2 reported had she been notified, she would have ensured Resident #2 had a functioning oxygen concentrator and Resident #2 was in no distress. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA ) #1, on [DATE] at 2:16 PM identified on [DATE] Resident #2 had already been hooked up to the portable oxygen tank and within the first forty-five (45) minutes of the shift Resident #2 started complaining of being Shortness of Breath (SOB) so she notified the charge nurse, LPN #1, immediately and her co-workers, NA #2 and NA #3, switched out the portable oxygen tank with new ones. NA #1 identified at about 10:30 AM, she was caring for the resident next door to Resident #2 when she heard someone yelling help so she ran into the hallway and Resident #2 continued yelling and stated he/she needed help and he/she could not breathe. NA #1 explained she yelled for help to LPN #1 and RN #1 who were down the hallway near the nurse's station and RN #1 ran into the room and directed her to call 911 and to bring additional portable oxygen cylinders. NA #1 reported all of the tanks in the oxygen closet on the unit were empty as well as the oxygen tank on the crash cart, so NA #3 ran upstairs to obtain full tanks. NA #1 identified nurse aides can deliver new oxygen tanks and take away old oxygen tanks from an area, but the nurse was supposed to hook up the oxygen and turn it on and off and when LPN #1 was not responsive, she, NA #2, and NA #3 worked together to ensure Resident #2 had oxygen. NA #1 identified looking back, they should have notified the nursing supervisor, RN #1, when LPN #1 was not responding to Resident #2's issues. Interviews with NA #2 and NA #3 on [DATE] identified Resident #2 was complaining of SOB by 7:45 AM on [DATE], so they notified the charge nurse, LPN #1, ensured there was oxygen in the portable tank, and brought two (2) additional portable tanks to the room. They identified they did not see LPN #1 enter Resident #2's room, reporting she continued to give medications. NA #2 reported Resident #2 continued to complain of SOB, so she notified LPN #1 again around 9:00 AM. NA #2 stated she was able to locate a functioning concentrator and changed out the portable tank with the concentrator and Resident #2 stated he/she felt better. NA #2 explained when NA #1 went to check on Resident #2 around 10:40 AM, Resident #2 reported to be SOB and was requesting help. They identified when RN #1 requested a portable oxygen tank, they went to the oxygen closet and although there were portable tanks in the closet, all of the tanks were empty, including the tank on the emergency cart and NA #3 had to run upstairs to retrieve two (2) tanks and bring them down to the unit. NA #3 reported that it took her about five (5) minutes to retrieve the portable oxygen cylinders. Interview with the 7AM-3PM charge nurse, LPN #1, on [DATE] at 9:39 AM identified on [DATE], the 11PM-7AM charge nurse, LPN #3, notified her in report Resident #2's oxygen concentrator was not functioning, and was using portable oxygen tanks. LPN #1 explained the nurse aides had notified her shortly after the start of the shift Resident #2 was SOB and although she directed they bring two (2) portable tanks to Resident #2, she did not check on or assess Resident #2 and indicated she should have taken vital signs, assessed Resident #2 and then notify the provider and nursing supervisor but she did not. LPN #1 identified sometime after 10:00 AM, NA #1 started yelling for help from Resident #2's room, she and the nursing supervisor ran down to the room to find Resident #2 was sitting in the chair and was starting to fall over. Interview with the 7AM-3PM nursing supervisor, RN #1, on [DATE] at 12:15 PM identified on [DATE] she was rounding on Resident #2's unit around 9:20 AM, and LPN #1 had not reported any issues, stating she had asked LPN #1 if she needed anything and LPN #1 reported she did not. RN #1 explained at 10:40 AM she was by the nurse's station with LPN #1 when NA #1 yelled to them Resident #2 could not breathe and needed help. RN #1 identified she ran down to the room, followed by the Nurse Practitioner (NP) and Resident #2 was noted to be sitting in the wheelchair, with the nasal cannula attached to the oxygen concentrator gasping and using accessory muscles to breathe. RN #1 identified she immediately put the non-rebreather on Resident #2 and attached it to the portable oxygen tank and directed NA #1 to call 911 and bring additional portable oxygen tanks. RN #1 indicated she was unaware the staff were unable to locate any additional oxygen tanks on the unit. RN #1 explained Resident #2 started to lean to the side and lose consciousness, she and the NP transferred Resident #2 into the bed and they started CPR. RN #1 stated prior to 10:40 AM, LPN #1 did not notify her Resident #2 was having SOB, there were issues with Resident #2's concentrator and portable oxygen tanks were being used. RN #1 identified LPN #1 reported to her she did not conduct a respiratory assessment or take vital signs or oxygen saturation levels that shift. RN #1 identified had LPN #1 notified her immediately of Resident#2's change in condition at 7:45 AM, she would have assessed Resident #2, notified the provider and transferred Resident #2 to the Emergency Department, as Resident #2 had a history of respiratory exacerbations. Interview with the Nurse Practitioner, NP, on [DATE] at 10:44 AM identified he was not aware Resident #2 had been reporting shortness of breath since around 7:45 AM on [DATE], and he should have been notified immediately so Resident #2 could have been transferred to the ED. The NP identified he was unable to recall which oxygen source Resident #2 was connected to when he first responded, but he did remember staff reporting they could not locate full portable oxygen tanks on the unit, and they had to go upstairs. Interview with the Administrator on [DATE] at 11:17 AM identified on [DATE] she was unaware Resident #2 had a change in condition three (3) hours prior to Resident #2's death. The Administrator explained LPN #1 should have attended to Resident #2 immediately after staff notified her Resident #2 could not breathe and then notify the nursing supervisor and provider. The Administrator identified full portable oxygen cylinders are delivered to the facility every Thursday and the staff on the units are responsible for notifying maintenance staff, either through the maintenance log or in-person when the supply is getting low. The Administrator identified the nurse aides are not permitted to switch a resident back and forth between a concentrator and a portable tank or turn the oxygen on and off, the licensed nurse was responsible for that and if LPN #1 was not responsive to their reports, they should have notified the nursing supervisor. Review of the Change of Condition policy dated [DATE] directed, in part, that for a significant change in the resident's physical, mental or psychosocial status the facility must immediately consult with the resident's physician. It identified that all residents with a potential change of condition will be identified in a timely manner and any alteration in a resident's baseline indicates a potential change of condition. Any resident with a change of condition will receive timely and appropriate intervention. All staff are responsible for reporting any concerns about a resident to the charge nurse. The LPN is to collect data and administer provider ordered treatments or medications as indicated. The RN/supervisor is also to be notified accordingly who will then assess and determine if a change of condition has occurred. The RN will make the APRN or Medical Doctor (MD) aware of a resident's current condition by in-person notification or telephone call using the Situation-Background-Assessment-Recommendation (SBAR) format. Documentation will be noted in the resident's medical record and on the 24-hour report to ensure shift to shift communication and continuity of care. Review of the Oxygen Supply Management policy dated [DATE] directed, in part, that the facility is to ensure that all residents requiring supplemental oxygen have immediate access to functional equipment and that any change in respiratory status is assessed, documented and reported without delay. If there's a malfunction in oxygen equipment, the resident will be immediately placed on a portable tank, the supervisor and the provider will be notified and the malfunctioning concentrator will be removed from service. Any report of SOB triggers an immediate nursing assessment including vital signs, oxygen saturation and respiratory exam and then results are documented and reported to the provider and supervisor.

Based on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for a change in condition, the facility failed to notify the provider at the time Resident #2 reported shortness of breath until three (3) hours later. The findings include:Resident #2's diagnoses included acute respiratory failure with hypercapnia (excess carbon dioxide in the bloodstream), Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and dependence on supplemental oxygen. A physician's order dated [DATE] directed to administer continuous oxygen at three (3) liters per minute via nasal cannula for a diagnosis of COPD. The order noted the oxygen may be removed for brief periods. Interventions per the Resident Care Plan dated [DATE] directed to provide supplemental oxygen per physician's order, monitor for signs and symptoms of respiratory distress and report to the provider, and to check oxygen saturation levels as needed and report abnormal values to the provider. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating Resident #2 had no memory recall deficits, was alert and oriented to person, place, and required supervision assistance with personal care and transfers. The late entry nurse's note dated [DATE] at 2:37 PM identified at 10:40 AM the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, had walked onto the unit to see the charge nurse, Licensed Practical Nurse (LPN) #1, when a nurse aide, Nurse Aide (NA) #1, yelled out Resident #2 was calling out for help, stating he/she could not breathe. The note indicated the Nurse Practitioner (NP) was on the unit, immediately assessed Resident #2 and ordered staff to call 911. The note identified Resident #2 was noted to be sitting in a chair, breathing heavily using accessory muscles, RN #1 requested staff to bring a portable oxygen tank and Resident #2 was switched from the concentrator via nasal cannula to the portable tank and a non-rebreather mask at fifteen (15) liters per minute was applied. The note indicated Resident #2 was transferred to bed, became unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by RN #1 and the NP, at approximately 10:45 AM, Emergency Medical Services (EMS) arrived and took over the CPR and despite continued CPR efforts, Resident #2 was pronounced deceased at 11:15 AM. Interviews with three (3) nurse aides, Nurse Aide (NA) #1, #2 and #3, on [DATE] identified on [DATE], around 7:45 AM, Resident #2 started complaining of shortness of breath (SOB), so they notified the charge nurse, Licensed Practical Nurse (LPN) #1 immediately. NA #2 reported Resident #2 continued to complain of SOB, so she notified LPN #1 again around 9:00 AM. They identified that after 10:00 AM (10:40 AM) Resident #2 started yelling for help and stating he/she could not breathe. NA #1 explained she yelled for help to LPN #1 and RN #1 who were down the hallway near the nurse's station and RN #1 ran into the room. Interview with the 7AM-3PM charge nurse, LPN #1, on [DATE] at 9:39 AM identified on [DATE], the 11PM-7AM charge nurse, LPN #3, had notified her in report Resident #2's oxygen concentrator was not functioning, and he/she was utilizing portable oxygen. LPN #1 stated the nurse aides had notified her shortly after the start of the shift that Resident #2 was short of breath and although she directed them to bring two (2) portable tanks into Resident #2's room she did not check on or assess Resident #2. LPN #1 explained that she should have taken Resident #2's vital signs, assessed Resident #2 and then notified the provider and the nursing supervisor but she did not. Interview with the 7AM-3PM nursing supervisor, RN #1, on [DATE] at 12:15 PM identified on [DATE] she was rounding on Resident #2's unit around 9:20 AM, and LPN #1 had not reported any issues, stating she had asked LPN #1 if she needed anything and LPN #1 reported she did not. RN #1 explained at 10:40 AM she was by the nurse's station with LPN #1 when NA #1 yelled to them Resident #2 could not breathe and needed help. RN #1 identified she ran down to the room, followed by the Nurse Practitioner (NP) and Resident #2 was noted to be sitting in the wheelchair, with the nasal cannula attached to the oxygen concentrator gasping and using accessory muscles to breathe. RN #1 stated prior to 10:40 AM, LPN #1 did not notify her Resident #2 was having shortness of breath, there were issues with Resident #2's concentrator and portable oxygen tanks were being used. RN #1 identified LPN #1 reported to her she did not conduct a respiratory assessment or take vital signs or oxygen saturation levels that shift. RN #1 identified had LPN #1 notified her immediately of Resident#2's change in condition at 7:45 AM, she would have assessed Resident #2, notified the provider and transferred Resident #2 to the Emergency Department, as Resident #2 had a history of respiratory exacerbations. Interview with the Nurse Practitioner, NP, on [DATE] at 10:44 AM identified he was not aware Resident #2 had been reporting shortness of breath since around 7:45 AM on [DATE], and he should have been notified immediately so Resident #2 could have been transferred to the ED which could have prevented Resident #2's death. Interview with the Administrator on [DATE] at 11:17 AM identified on [DATE] she was unaware Resident #2 had a change in condition three (3) hours prior to Resident #2's death. The Administrator explained LPN #1 should have attended to Resident #2 immediately after staff notified her around 7:45 AM Resident #2 could not breathe and then notify the nursing supervisor and provider. Review of the Change of Condition policy dated [DATE] directed, in part, that all residents with a potential change of condition will be identified in a timely manner and any alteration in a resident's baseline indicates a potential change of condition. Any resident with a change of condition will receive timely and appropriate intervention. All staff are responsible to report any concerns about a resident to the charge nurse. The LPN is to collect data and administer provider ordered treatments or medications as indicated. The RN/supervisor is also to be notified accordingly who will then assess and determine if a change of condition has occurred. The RN will make the APRN or Medical Doctor (MD) aware of a resident's current condition by in-person notification or telephone call using the Situation-Background-Assessment-Recommendation (SBAR) format. Documentation will be noted in the residents' medical record and on the 24-hour report to ensure shift to shift communication and continuity of care.

Based on clinical record reviews, observations, facility policies and interviews for three (3) of seven (7) sampled residents (Residents #3, #4 and #5) who required supplemental oxygen use via a concentrator, the facility failed to ensure the oxygen tubing was changed every seven (7) days per facility policy. The findings include:1. Resident 3's diagnoses included acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #3 was alert and oriented to person, place and time. A physician's order dated 9/19/22 directed to administer oxygen via a nasal cannula or non-rebreather at two (2) to three (3) liters per minute every shift as needed for Shortness of Breath (SOB) to maintain an oxygen saturation level greater than 92 percent and to change and date the oxygen tubing once daily on Sunday on the 11PM-7AM shift. Observations of Resident #3 on 9/24/25 at 12:49 PM identified the oxygen concentrator to be running and set at three (3) liters, and the oxygen tubing label was dated 9/14/25 (10-days prior). Observations of Resident #3 with the Director of Nursing (DON) on 9/24/25 at 1:12 PM identified the oxygen concentrator to be running and set at three (3) liters, and the oxygen tubing label was dated 9/14/25 (10-days prior). Review of the September 2025 Treatment Administration Record (TAR) identified although the oxygen tubing was dated 9/14/25 on observations, the treatment was signed off as changed on 9/21/25 by the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1. 2. Resident #4's diagnoses included pneumonia, heart failure, COPD and anxiety disorder. A physician's order dated 4/11/25 directed to administer oxygen via a nasal cannula at three (3) liters per minute continuously every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) indicating Resident #4 had some memory recall deficits. Review of the active physician's orders failed to identify an order to change and date the oxygen tubing weekly. Observations of Resident #4 and interview with the DON on 9/24/25 at 1:12 PM identified the oxygen concentrator to be running and set to three (3) liters, and the oxygen tubing was labeled 9/14/25. The DON identified that the oxygen tubing should have been changed on 9/21/25 for both Residents #3 and #4 by the 11PM-7AM nurse for infection control purposes. 3. Resident #5's diagnoses included acute and chronic respiratory failure with hypoxia, Congestive Heart Failure (CHF), COPD and dependence on supplemental oxygen. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating Resident #5 was alert and oriented to person, place and time. A physician's order dated 9/10/25 directed to titrate the oxygen down to room air every shift to maintain oxygen saturation greater than 95 %. A provider's note dated 9/23/25 at 5:36 PM identified Resident #5 utilized oxygen at four (4) four liters. Upon further review, the active physician's orders failed to identify an order to change and date the oxygen tubing weekly. Observations of Resident #5 and interview with the DON on 9/24/25 at 1:47 PM identified the oxygen concentrator running and set at four (4) four liters and the oxygen tubing label was dated 9/7/25 (17-days prior). The DON identified that the oxygen tubing should have been changed weekly by the 11PM-7AM nurse for infection control purposes and the tubing had not been changed for greater than two (2) weeks. Interview with the Regional Nurse, Licensed Practical nurse (LPN) #5, on 9/30/25 at 9:25 AM identified the nursing staff are expected to change the oxygen tubing weekly on the 11PM-7AM shift per their policy and for infection control purposes, and the nurses should never sign off orders prior to completing/administering the medication or treatment. LPN #5 indicated residents who utilize oxygen should have had a physician's order directing to change the oxygen tubing weekly. Review of the Oxygen Tubing policy dated 01/19/18 directed, in part, that the facility will provide and maintain oxygen tubing in a manner consistent with manufacturer guidelines, infection prevention standards and resident care needs. Oxygen tubing will be changed, labeled, stored and disposed of in accordance with regulatory requirements and facility protocols. Standard nasal cannula/tubing will be changed every seven (7) days or sooner if visibly soiled, contaminated, or per manufacturer instructions. Tubing change dates will be documented in the resident's medical record.

Based on observations, clinical record reviews, facility policy and interviews, the facility failed to ensure a medication cart located in the hallway was locked and medication was secured to prevent unauthorized access. The findings include:Observations on the D1 unit on 9/25/25 at 10:17 AM identified a medication cart in the hallway to the left of the nurse's station, pushed up against the left side of the hall, about one-third of the way down. The medication cart was noted to be unlocked with the cart keys located on the top of the cart, as well as an open bottle of docusate sodium (stool softener), a glucometer, a bottle of glucometer test strips, five (5) empty blister packs of medication, six (6) pre-poured cups of water without covers, an orange cover to an insulin syringe and a cell phone. Upon further observations a resident was noted to walk by the cart and the charge nurse, Licensed Practical Nurse (LPN) #2, was noted to emerge from a resident's room, in which the door had been closed at 10:19 AM. Interview and observations of the medication cart with LPN #2 on 9/25/25 at 10:19 AM identified that although she should not have left any of the above items on the top of the cart with the cart unlocked and unsecured, she needed to attend to a resident quickly and she did not request the assistance of other staff although she was aware that she left the cart unlocked with the cart keys on top. Interview with the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, on 9/25/25 at 12:42 PM identified LPN #2 should not have left items on top of the cart, including the cart keys when the cart was unattended and the medication cart should be locked at all times when the nurse steps away from it. Review of the Medication Cart Management policy (undated) directed, in part, that medication carts shall be maintained in a clean, organized, locked and secured manner at all times. Medication carts are considered extensions of the facility's medication storage area and must comply with all security, sanitation and documentation requirements. Carts must remain locked when unattended, even for brief intervals. Keys are to remain in the possession of the assigned nurse. No food, drink, personal items or unrelated supplies may be stored on or in the cart.

Based on clinical record reviews, observations, facility documentation, facility policies and interviews for two (2) of seven (7) sampled residents (Residents #6 and #7) who required supplemental oxygen usage via a concentrator, the facility failed to ensure the oxygen concentrators were inspected annually for function and safety. The findings include:1. Resident #6's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Shortness of Breath (SOB) and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident rarely or never made decisions regarding tasks of daily life. A physician's order for 8/1/25 through 9/26/25 directed to administer oxygen via nasal cannula at two (2) liters per minute every shift to maintain oxygen saturation greater than 91 percent (%) and to prevent hypoxia (low levels of oxygen in the body's tissues). Observations with the Director of Nursing (DON) on 9/24/25 at 12:30 PM identified Resident #6 was receiving oxygen via the oxygen concentrator. A sticker on the oxygen concentrator identified the concentrator had last been inspected on 4/2024 and was due for inspection on 4/2025, indicating the inspection was five (5) months overdue. 2. Resident #7's diagnoses included chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), COPD, CHF, emphysema (a progressive lung disease that causes shortness of breath) and anxiety disorder. A physician's order dated 8/15/25 directed to administer humidified oxygen at five (5) liters per minute via nasal cannula continuously every shift. The annual Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating Resident #7 was alert and oriented to person, place and time. Observations with the DON on 9/24/25 at 1:40 PM identified Resident #7 was receiving oxygen via the oxygen concentrator. A sticker on the oxygen concentrator identified the concentrator had last been inspected on 4/2024 and was due for inspection on 4/2025, indicating the inspection was five (5) months overdue. Upon further observations, the filter on the side of the concentrator was noted with a thick covering of dust. Observations and interview with the Administrator on 9/24/25 at 3:25 PM identified a sticker on both Resident #6 and Resident #7's oxygen concentrators identified the concentrators had last been inspected on 4/2024 and were next due for inspection on 4/2025. The Administrator identified the facility owns the concentrators, which are to be inspected annually by an outside company, and she was unaware there were concentrators that were overdue for inspection and the maintenance staff were responsible for cleaning the filters. Interview with Person #2 (the oxygen concentrator servicing vendor) on 9/26/25 at 11:59 AM identified 2025 was the first year they serviced the facility. Person #2 explained they were not given a list of how many concentrators were in the building or where the concentrators were located, stating they went room to room and completed biomed testing (ensuring the units were functioning and there was no electrical leakage issues) of all the units they were able to locate. Person #2 identified if units have been observed recently that have not been inspected since 2024, they were not accessible to them at the time of their visit. Person #2 indicated they are not contracted to clean the filters on the concentrator units, and it is recommended the inside filters are replaced every two (2) years and the outside filters are cleaned every two (2) to three (3) weeks. Interview with the Director of Environmental Services on 9/26/25 at 12:11 PM identified although the concentrators are required to be serviced annually, he did not do a walk through with the vendor at the time the vendor was in the facility. The Director of Environmental Services explained he would have the company come back to the facility and he would do a walk through with them to ensure all units were up to date with annual service. The Director of Environmental Services identified maintenance checks the filters weekly for debris and housekeeping was responsible for monitoring the oxygen concentrators filters daily when they clean the room and will notify maintenance of the need to be cleaned. The Director of Environmental Services identified he was unsure why the filter on Resident #7's concentrator was noted with thick dust. Review of the Fire Safety and Prevention policy dated 1/19/18 directed, in part, to ensure that any cleaning, repair or filling of oxygen equipment is performed by qualified, properly trained staff. All personnel must report observations of malfunctioning equipment and supplies and any unusual incidents. Although requested, policies on servicing of and cleaning oxygen concentrators were not provided.

Based on clinical record reviews, observations, review of facility policy and interviews for one (1) of three (3) sampled residents (Resident #3) reviewed for supplemental oxygen usage, the facility failed to develop a care plan to address Resident #3's need for oxygen use. The findings include:Resident #3's diagnoses included acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. A physician's order dated 9/19/22 directed to administer oxygen via a nasal cannula or non-rebreather at two (2) to three (3) liters per minute every shift as needed for Shortness of Breath (SOB) to maintain an oxygen saturation level greater than 92 percent. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #3 was alert and oriented to person, place, and time, was independent with activities of daily living, and utilized oxygen therapy. Observations of Resident #3 on 9/24/25 at 12:49 PM identified an oxygen concentrator to be running and set at three (3) liters via the nasal cannula. Review of the clinical record on 9/25/25 and 9/26/25 failed to identify a Resident Care Plan (RCP) that addressed Resident #3's respiratory diagnoses and oxygen utilization. Upon further review, on 9/29/25, a care plan was developed and interventions implemented. Interview with the Regional Nurse, Licensed Practical Nurse (LPN) #5, on 9/30/25 at 9:25 AM identified a care plan should have been in place identifying Resident #3's respiratory diagnoses and oxygen utilization. LPN #5 explained the Interdisciplinary Team was responsible for reviewing and revising care plans and he was unsure why a care plan was not in place. Review of the Comprehensive Care-Planning policy dated 1/30/25 directed, in part, that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, incorporates identified problem areas and risk factors associated with identified problems, reflects treatment goals, timetables and objectives in measurable outcomes, identifies the professional services that are responsible for each element of care and reflects currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The IDT must review and update the care plan when there's been a significant change in the resident's condition, when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of twenty-one (21) randomly selected residents (Residents #5 and #11), the facility failed to ensure blood work was obtained per the physician's order. The findings include:1. Resident #5's diagnoses included pneumonia, acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), Congestive Heart Failure (CHF), anemia (low levels of healthy red blood cells to carry oxygen throughout the body), generalized edema (severe buildup of fluid in the tissues of several parts of the body) and hypocalcemia (low calcium levels in the blood). A physician's order dated 9/10/25 directed on 9/12/25 to obtain a Basic Metabolic Panel (BMP) and a Complete Blood Count (CBC) with differential. Review of Resident #5's clinical record failed to identify the blood work was obtained or Resident #5 had refused the blood work. A new physician's order dated 9/25/25 directed to obtain a Comprehensive Metabolic Panel (CMP) and a CBC with differential on 9/26/25 and there were no significant abnormalities. 2. Resident #11's diagnoses included alcohol abuse, hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone) and peripheral vascular disease (narrowing of blood vessels due to deposit buildups which reduces blood flow to the limbs). A physician's order dated 8/30/25 directed on 9/3/25 to obtain a BMP and a CBC with differential. Review of Resident #11's clinical record failed to identify the blood work was obtained or that Resident #11 refused the blood work. Interview with the Regional Nurse, Licensed Practical Nurse (LPN) #5, on 9/30/25 at 12:05 PM identified he was unable to locate documentation the blood work was obtained for Residents #5 and #11, explaining the blood work should have been obtained per the physician's order or the provider should have been notified and rescheduled to a different date with a new physician's order. Interview with the Nurse Practitioner (NP) on 10/2/25 at 11:22 AM identified that he was unaware the bloodwork was not obtained per the physician's orders for both Residents #5 and #11, explaining the physician's orders should have been followed or he should have been notified the bloodwork was not obtained so he could have placed a new order. The NP identified that nursing staff should have documented in the clinical record why the bloodwork was not obtained, provider notification and any follow-up orders. Review of the Laboratory and Blood Work Services policy dated 01/19/18 directed, in part, that the facility is to ensure that laboratory and bloodwork services are provided in accordance with physician's orders, resident rights, federal regulations and Connecticut Public Health code standards. All bloodwork will be obtained and processed in a manner that ensures resident safety, accuracy, timeliness and professional standards of quality. Results will be returned to the ordering physician and entered into the resident's medical record. Nursing staff must promptly review results, notify the physician of abnormal or critical values and document the notification.

Based on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for supplemental oxygen, the facility failed to assess the resident when staff reported Resident #2 was experiencing shortness of breath. The findings include:Resident #2's diagnoses included acute respiratory failure with hypercapnia (excess carbon dioxide in the bloodstream), Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and dependence on supplemental oxygen. A physician's order dated [DATE] directed to administer continuous oxygen at three (3) liters per minute via nasal cannula for a diagnosis of COPD. The order noted the oxygen may be removed for brief periods. Interventions per the Resident Care Plan dated [DATE] directed to provide supplemental oxygen per physician's order, monitor for signs and symptoms of respiratory distress and report to the provider, and to check oxygen saturation levels as needed and report abnormal values to the provider. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating Resident #2 had no memory recall deficits, was alert and oriented to person, place, and time, and required supervision assistance with personal care and transfers. The late entry nurse's note dated [DATE] at 2:37 PM identified at 10:40 AM the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, had walked onto the unit to see the charge nurse, Licensed Practical Nurse (LPN) #1, when a nurse aide, Nurse Aide (NA) #1, yelled out Resident #2 was calling out for help, stating he/she could not breathe. The note indicated the Nurse Practitioner (NP) was on the unit, immediately assessed Resident #2 and ordered staff to call 911. The note identified Resident #2 was noted to be sitting in a chair, breathing heavily using accessory muscles. The note indicated Resident #2 was transferred to bed, became unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by RN #1 and the NP, at approximately 10:45 AM, Emergency Medical Services (EMS) arrived and took over the CPR and despite continued CPR efforts, Resident #2 was pronounced deceased at 11:15 AM. Interviews with three (3) nurse aides, Nurse Aide (NA) #1, #2 and #3, on [DATE] identified on [DATE], around 7:45 AM, Resident #2 started complaining of shortness of breath (SOB), so they notified the charge nurse, Licensed Practical Nurse (LPN) #1 immediately. The nurse aides identified they did not observe LPN #1 enter Resident #2's room at the time they notified her. NA #2 reported Resident #2 continued to complain of SOB, so she notified LPN #1 again around 9:00 AM and did not observe LPN #1 enter Resident #2's room at that time. The nurse aides identified after 10:00 AM (10:40 AM) Resident #2 started yelling for help, stating he/she could not breathe. NA #1 explained she yelled for help to LPN #1 and RN #1 who were down the hallway near the nurse's station and RN #1 ran into the room. Interview with the 7AM-3PM charge nurse, LPN #1, on [DATE] at 9:39 AM identified on [DATE], the 11PM-7AM charge nurse, LPN #3, had notified her in report Resident #2's oxygen concentrator was not functioning, and he/she was utilizing portable oxygen. LPN #1 stated the nurse aides had notified her shortly after the start of the shift that Resident #2 was short of breath and although she directed them to bring two (2) portable tanks into Resident #2's room she did not check on or assess Resident #2. LPN #1 explained that she should have taken Resident #2's vital signs, assessed Resident #2 and then notified the provider and the nursing supervisor but she did not. Interview with the 7AM-3PM nursing supervisor, RN #1, on [DATE] at 12:15 PM identified on [DATE] she was rounding on Resident #2's unit around 9:20 AM, and LPN #1 had not reported any issues, stating she had asked LPN #1 if she needed anything and LPN #1 reported she did not. RN #1 explained at 10:40 AM she was by the nurse's station with LPN #1 when NA #1 yelled to them Resident #2 could not breathe and needed help. RN #1 identified she ran down to the room, followed by the Nurse Practitioner (NP) and Resident #2 was noted to be sitting in the wheelchair, with the nasal cannula attached to the oxygen concentrator gasping and using accessory muscles to breathe. RN #1 stated prior to 10:40 AM, LPN #1 did not notify her Resident #2 was having shortness of breath, there were issues with Resident #2's concentrator and portable oxygen tanks were being used. RN #1 identified LPN #1 reported to her she did not conduct a respiratory assessment or take vital signs or oxygen saturation levels that shift. RN #1 identified had LPN #1 notified her immediately of Resident#2's change in condition at 7:45 AM, she would have assessed Resident #2, notified the provider and transferred Resident #2 to the Emergency Department, as Resident #2 had a history of respiratory exacerbations. Interview with the Administrator on [DATE] at 11:17 AM identified LPN #1 should have attended to Resident #2 immediately after staff notified her Resident #2 could not breathe and then notified the nursing supervisor and the provider immediately. Review of the Change of Condition policy dated [DATE] directed, in part, that all residents with a potential change of condition will be identified in a timely manner and any alteration in a resident's baseline indicates a potential change of condition. Any resident with a change of condition will receive timely and appropriate intervention. All staff are responsible to report any concerns about a resident to the charge nurse. The LPN is to collect data and administer provider ordered treatments or medications as indicated. The RN/supervisor is also to be notified accordingly who will then assess and determine if a change of condition has occurred. The RN will make the APRN or Medical Doctor (MD) aware of a resident's current condition by in-person notification or telephone call using the Situation-Background-Assessment-Recommendation (SBAR) format. Documentation will be noted in the resident's medical record and on the 24-hour report to ensure shift to shift communication and continuity of care.

Based on clinical record review, facility documentation review, facility policy review and interviews for three of six residents (Residents #1, Resident #14 and Resident #16) reviewed for medication administration, the facility failed to ensure medications were available and administered in accordance with physician orders. The findings include: Based on clinical record review, facility documentation review, facility policy review and interviews for three of six residents (Residents #1, Resident #14 and Resident #16) reviewed for medication administration, the facility failed to ensure medications were available and administered in accordance with physician orders. The findings include: 1. Resident #1 was admitted with diagnoses that included chronic pain syndrome, opioid dependance, osteomyelitis of the vertebra (back bone infection), and bacteremia (blood infection). A hospital Discharge summary dated [DATE] identified Resident #1 was discharged on Cefazolin (antibiotic) two (2) grams (gms) per fifty (50) milliliters (mls) intravenous (IV) solution every eight (8) hours, to stop on July 16, 2025. A physician order dated 6/20/2025 directed to administer Cefazolin two (2) gms per 50 mls IV every 8 hours, at 6:00 AM, 2:00 PM and 10:00 PM. Nursing admission assessment identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 6/21/2025 identified Resident #1 had an infection. Interventions directed to administer medication as per MD orders and report to APRN/MD as needed. Medical record review of the Medication Administration Record (MAR) identified LPN #12 documented on 6/21 and 6/22/2025 that Resident #1 did not receive did not receive the Cefazolin two (2) gms on 6/21 and 6/22/2025 at 2 PM in accordance with physician orders. The MAR indicated Resident #1 was unavailable as he/she was out of the facility on leave of absence (LOA). Review of the facility grievance form dated 6/23/2025 identified Resident #1 reported he/she had missed medications. Interview with LPN #12 on 8/12/2025 at 9:39 AM identified she was the charge nurse for Resident #1 on 6/21/2025 from 7:00 AM to 7:00 PM, and on 6/22/2025 from 7:00 AM to 300 PM. LPN #12 stated Resident #1 was transferred to the hospital on 6/21 and 6/22/2025 at about 10 AM to receive another medication and she did not administer the Cefazolin two (2) gms at 2 PM as ordered because Resident #1 had not returned from the hospital at the scheduled 2 PM time. Further, she did not notify the nursing supervisor because she thought the supervisor knew Resident #1 was at the hospital, and she did not notify the physician or APRN because she thought the supervisor would do that. Interview with RN #3 and medical record review on 8/11/2025 at 12:15 PM identified she was the supervisor on 6/21/2025 from 7:00 AM to 7:00 PM. RN #3 stated she was aware Resident #1 was transferred to the hospital for medication in the morning, she was not aware he/she did not receive the scheduled Cefazolin. RN #3 stated if a medication is omitted, the nurse should notify the supervisor. RN #3 further stated if she had known about the missed dose of Cefazolin, she would have notified the APRN. Interview with RN #2 on 8/12/2025 at 10:10 AM identified she was the supervisor on 6/22/2025 from 7:00 AM to 7:00 PM and she did not remember if the charge nurse notified her of any missed/omitted medications. RN #2 stated if she was notified, she would have notified the APRN. Interview and medical record review with APRN # 1 on 8/12/2025 at 10:42 AM identified he saw Resident #1 on 6/23/2025 and he was not aware the Cefazolin due to be administered on 6/21 and 6/22/2025 at 2 PM were not administered as ordered. APRN #1 stated he would have expected to be notified, and if he was notified, he would have called the Infectious Disease consultant to determine if the treatment plan needed to be adjusted. Interview with the DON on 8/13/2025 at 10:13 AM identified that if a Resident missed an antibiotic dose, the APRN should be notified. The DON stated the supervisor, APRN and herself should have been notified and she did not know why it was not done. 2. Resident #14 was admitted to the facility with diagnoses that history of substance use disorder. Review of the hospital Discharge summary dated [DATE] identified Resident #14 was to continue taking the medication of Methadone (used to treat Opioid Use Disorder) 115 milligrams (mg) daily. admission nursing note dated 8/6/2025 at 9:18 PM identified Resident #14 alert and oriented. A physician order dated 8/6/2025 directed Methadone 115 mg oral once a day at 6:00 AM. Review of the August 2025 Medication Administration Record (MAR) identified LPN #16 signed that Methadone 115 mg oral at 6:00 AM was not administered, as ordered, at the facility on 8/7, 8/8, 8/9 and 8/10/2025 because the drug was unavailable. Record review failed to identify why the prescribed Methadone was not available in the facility. Nursing note written by RN #2 dated 8/9/2025 (Saturday) at 10:39 AM identified the APRN was notified the Methadone was unavailable, and new orders were obtained to transfer Resident #14 to the hospital to receive the ordered Methadone on 8/9 and also on 8/10/2025 (Sunday), and then to follow up with the Methadone clinic on 8/11/2025. The note further indicated Resident #14 was transferred to the hospital. Nursing note dated 8/9/2025 at 6:10 PM identified Resident #14 returned from the hospital following Methadone administration in the emergency room. Plan to return to the hospital on 8/10/2025 for another dose. Record review identified Resident #14 was transferred to the hospital on 8/10/2025. Review of the hospital emergency department note dated 8/10/2025 identified Resident #14’s diagnosis was Methadone withdrawal, and was administered Methadone 100 mg. Record review identified Resident #14 returned to the facility on 8/10/2025. APRN #1 note dated 8/11/2025 at 10:18 AM identified Resident #14 missed ordered doses of Methadone on 8/7 and 8/8, and then was sent to the hospital and received correction doses at the hospital after missing additional doses of Methadone on 8/9 and 8/10/2025. Interview with RN #3 on 8/20/2025 at 12:40 PM identified she was the RN supervisor on 8/7, 8/8 and 8/9/2025, and stated she was not notified that Methadone was not available for Resident #14, as prescribed. RN #3 stated if she was notified, she would have notified the provider and made arrangements for the resident to obtain the Methadone. RN #3 stated when a resident is admitted on Methadone, the hospital sends a dose and then the facility schedules visits with the Methadone clinic. Further, the facility has a nurse that obtains the required Methadone for residents from the Methadone clinic. Interview with RN #2 on 8/20/2025 at 1:56 PM identified she was notified on 8/9/2025 (Saturday) that the Methadone was not available for Resident #14 on 8/9/2025, and she notified the APRN and transferred Resident #14 to the hospital to obtain the Methadone. RN #2 stated the Methadone nurse is responsible to obtain the prescribed Methadone from the clinic and transport it to the facility for residents. Interview with LPN #15 on 8/20/2025 at 2:20 PM identified she was the facility Methadone nurse (obtains the Methadone from the clinic for residents on weekdays) and she was not aware that Resident #14 did not have his/her prescribed Methadone available on 8/7, 8/8 and 8/9/2025. LPN #15 stated if she was aware, she would have obtained the Methadone. LPN #15 stated the facility process for admissions from the hospital with Methadone ordered is for the hospital to send a dose of Methadone with the patient on a weekday, and if it were a weekend, then the hospital sends a three day supply. LPN #15 stated Resident #14 was transferred to the hospital on 8/9/2025 after missing prescribed doses of Methadone on 8/7 and 8/8/2025. Interview with APRN #1 on 8/20/2025 at 2:00 PM identified medications should be administered in accordance with physician/APRN orders. APRN #1 stated he was not notified on 8/7 and 8/8/2025 that Resident #14 did not receive his/her prescribed Methadone. Further, after two (2) missed doses of Methadone, the resident should be transferred to the hospital because withdrawals can begin around day three (3) of missing Methadone. Interview with the DNS on 8/20/2025 at 2:30 PM identified Resident #14 should have received his/her Methadone as ordered. The DNS stated residents admitted on Methadone should come from the hospital with a dose of Methadone, and then the facility would obtain subsequent doses from the Methadone clinic. The DON was unable to identify if Resident #14 was admitted from the hospital with any doses of Methadone, and why subsequent doses were not obtained timely from the Methadone clinic. 3. Resident #16 was admitted to the facility with diagnoses that included opioid abuse. A physician order dated 5/23/2025 directed Methadone 75 mg oral once a day at 6:00 AM. The Resident Care Plan (RCP) dated 5/23/2025 identified Resident #16 received Methadone for maintenance for a history of substance use disorder. Interventions directed to maintain required contacts/sessions with outside Methadone agency as needed and provide resident with Methadone as ordered. The admission MDS dated [DATE] identified Resident #16 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was receiving an opioid. Review of the MAR for August 2025 identified Resident #16 did not receive Methadone 75 mg oral at 6:00 AM on 8/12/2025; LPN #16 documented the Methadone was unavailable. Record review failed to identify why Resident #16’s prescribed Methadone was not available for administration. Interview and record review on 8/20/2025 at 12:40 PM with RN #3 identified she was the supervisor on 8/12/2025 (11 PM to 7 AM on 8/12/2025) when Resident #16’s Methadone was due to be administered at 6 AM. RN #3 stated she was not aware the Methadone was not administered as ordered, and failed to identify why the Methadone was unavailable. Although attempted, an interview with LPN #16 was not obtained during survey. Interview with APRN #1 on 8/20/25 at 2:00 PM identified the Methadone should have been administered as ordered. Interview with the DNS on 8/20/2025 at 2:30 PM identified Resident #16 should have received his/her Methadone as ordered. The DNS was unable to explain why the Methadone was not available in the facility for administration as ordered. Review of the Methadone Maintenance policy dated 9/16/2020 directed in part, to provide continued access to Methadone. The Policy further directed, after admission to the facility, a licensed nurse will retrieve the resident’s Methadone bottles for administration until the resident’s next scheduled clinic day. Review of the Change of Condition policy dated 1/30/2025 directed in part, that the LPN is to administer provider ordered medications as indicated

Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, 12, and 13) reviewed for medication administration, the facility failed to ensure services provided met professional standards to include controls of narcotic medications as per facility policy. The findings include:Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, 12, and 13) reviewed for medication administration, the facility failed to ensure services provided met professional standards to include controls of narcotic medications as per facility policy. The findings include: Although requested, the facility was unable to provide the facility monthly or bi-monthly audits of controlled substances as per facility policy for June or July 2025 and indicated any audits could not be located at time of survey. Interview and documentation review with the DON on 8/13/2025 at 10:13 AM identified that staff signed Hydromorphone medication out on the Controlled Substance Distribution Record (CSDR) to indicate the drug was removed from the controlled/narcotic box on the following dates:Resident #1: 6/24, 6/25, 6/27, 6/28 and 6/29.Resident #12: 7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/10, 7/11, 7/13 and 7/14.Resident #13: 7/21, 7/23, 7/26, 7/27, 8/4 and 8/9. Further interview identified the controlled drug was wasted/destroyed on 6/27/2025, and medication was signed out on the CSDR sheets on 7/26 and 7/27/2025 when there were no physician orders.The DON was unable to provide documentation in the resident's medical records and Medication Administration Records (MAR) that the residents received the medication on the dates signed out on the CSDR. The DON stated nurses should sign the MAR to indicate when it is administered, and she did not know why it was not done on the dates listed. The DON further stated for narcotics/controlled medication, if there was a need to waste a pill for any reason; another nurse other than the nurse who originally pulled the medication needed sign accordingly on the CSDR sheet as a witness to the destruction. Further, the DON stated a controlled medication should not have been signed out on the CSDR if there was no physician order for the medication, and she did not know why the medication was signed out.The DON stated the facility conducted monthly narcotic control audits to verify the count matched the CSDR but was unable to explain how the audits were actually conducted. The DON indicated the audits were conducted by the prior ADNS who no longer worked at the facility, and she was unable to provide documentation of any audits that were conducted. She stated any policy exceptions such as a lack of a second signature at the time of a narcotic pill waste should be observed through the audit process and addressed at that time. The DON stated spot checks were also done on a sample of residents MARs to verify that the nurses were documenting administration but did not include if that spot check also compared the MAR to the CSDR. She did not know why the ADNS had not identified any issues during the audits and indicated she could not produce the audits conducted for June or July 2025, as requested for review during the survey. She continued that a copy of the original CDSR sheets and the completed CDSRs are maintained in the medical records office. The DON further stated that discontinued controlled drugs are maintained on the units, secured under double lock until such time they are collected by nursing leadership and destroyed as per policy. Please reference F602. Interview and observation on 8/13/2025 at 4:15 PM with the Administrator completed CDSR sheets were stacked by date and alphabet on a desk in the medical record office, to the left of the door. Observation identified multiple large stacks of white and yellow papers bundled together. Each bundle had a bright pink paper on top of the bundle and was labeled drug sheets 2025. Bundles were further labeled as Jan to June A -G, H - Z. Additional bundles had pale green paper on the top of each bundle labeled 2025. The bundles were stacked as high as standard 3-ring facility notebooks that were upright next to them (approximately 11.5 to 12 inches high). The initial CDSR signed facility receipt of narcotics from the pharmacy were in notebooks (by unit location) behind the stacks of completed CDSRs. There were no audit results or documentation of audits completed observed in the medical records area. Interview failed to identify a process with a tracking system for current audits of controlled medications in the facility. The facility Controlled Substance Handing Policy, dated 1/19/2018, directed in part, directed monthly audits that monitor for discrepancies in counts, unexplained wastage and patterns of high usage. Additionally, the policy directed that a controlled substance accountability records and audit records should be kept on file for period no less than five (5) years and that discontinued controlled drugs are returned to the nursing office after the count was verified.

Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, #12, and #13) reviewed for medication administration, the facility failed to ensure the resident was free from misappropriate of resident property. The findings include:Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, #12, and #13) reviewed for medication administration, the facility failed to ensure the resident was free from misappropriate of resident property. The findings include:A. Resident #1 was admitted with diagnoses that included chronic pain syndrome, opioid dependance, osteomyelitis of the vertebra (back bone infection), and bacteremia (blood infection). The Resident Care Plan (RCP) dated 6/21/2025 identified Resident #1 had pain. Interventions directed to administer pain medication as ordered. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) and was alert and oriented, and experienced pain frequently in the last five (5) days. A physician order dated 6/24/2025 directed to administer Hydromorphone (narcotic pain medication) three (3), two (2) milligram (mg) tablets for six (6) mg total by mouth every three (3) hours as needed for moderate pain. A physician order dated 6/24/2025 directed to administer Hydromorphone eight (8) mg tablets by mouth every three (3) hours as needed for moderate pain. 1. Review of the Medication Administration Record (MAR) and the Controlled Substance Distribution Record (CSDR) #1428681 identified thirty (30) tablets of Hydromorphone eight (8) mg were received by the facility from the pharmacy on 6/24/2025, with eight (8) tablets remaining. The Hydromorphone CSDR sheet identified one (1) tablet was signed out to indicate administered to Resident #1, but was not signed as administered to Resident #1 on the MAR on the following dates: 6/24/2025 at 10:00 AM by LPN #1 6/24/2025 at 3:40 PM by LPN #1 6/25/2025 at 2:00 AM by LPN #4 6/25/2025 at 6:00 AM by LPN #1 6/25/2025 at 9:00 AM by LPN #1 6/25/2025 at 12:00 PM by LPN #1 6/28/2025 at 8:00 AM by LPN #1 6/28/2025 at 12:00 PM by LPN #1 6/28/2025 at 6:00 PM by LPN #3 6/29/2025 at 8:00 AM by LPN #1 6/29/2025 at 11:00 AM by LPN #1 6/29/2025 at 6:00 PM by LPN #3 Reconciliation of CSDR #1428681 to Resident #1's June 2025 MAR identified that 30 tablets were received with eight (8) doses remaining. Twenty-two (22) doses of Hydromorphone 8 mg were signed out on CDSR #1428681 and only ten (10) doses were documented as administered to Resident #1; twelve (12) doses were unaccounted for (not documented in the MAR/medical record as administered to Resident #1. 2. A review of Resident #1's MAR and CSDR 1428756, identified thirty (30) tablets of Hydromorphone 2 mg were received by the facility from the pharmacy on 6/25/2025 with eleven (11) doses remaining. Four (4) tablets were signed out on the CSDR but were not signed as administered to Resident #1 on the June MAR on the following dates: 6/25/2025 at 11:00 AM by LPN #1 6/27/2025 at 12:00 PM by LPN #2, additional review identified one (1) additional tablet was documented as wasted without the signature of another nurse as a witness to the destroyed medication. 6/28/2025 at 5:30 PM by LPN #1 6/29/2025 at 10:30 PM by LPN #3 with 3 tablets signed out; MD order was for 4 tablets. Reconciliation of CSDR #1428756 to Resident #1's June MAR identified that 30 tablets were received with eleven doses remaining. Seventeen (17) doses (4 tablets on each day listed above plus one additional on 6/27/2025) were signed out on CDSR #1428756 to identify they were removed the from narcotic drawer, and all of the doses listed above were not documented as administered (not documented in the MAR/medical record to indicate they were administered to Resident #1). B. Resident #12 was admitted with diagnoses that included endocarditis and post traumatic stress syndrome. A physician order dated 6/30/2025 directed to administer Hydromorphone eight (8) mg tablets by mouth every four (4) hours as needed for pain. The RCP dated 7/1/2025 identified Resident #12 was at risk for pain. Interventions directed to administer pain medication as ordered. An admission MDS dated [DATE] identified Resident #12 was alert and oriented (BIMS 15), and experienced pain frequently in the last five (5) days. Review of Resident #12's MAR with the CSDR #1442827 identified thirty (30) tablets of Hydromorphone eight (8) mg was received by the facility on 7/1/2025 and on 7/8/2025, a CSDR #1418161 identified that the facility received an additional twenty-eight tablets (28) of the same medication (total of 58 tablets). One (1) tablet of the eight (8) milligram (mg) tablets was signed out for a dosage of eight (8) mg on the CSDR but not signed on the MAR as administered to Resident #1 on the following dates: 7/2/2025 at 1:00 AM by LPN #5 7/2/2025 at 12:30 PM by LPN #6 7/3/2025 at 12:30 AM by LPN #7 7/4/2025 at 5:00 AM by LPN #7 7/5/2025 at 12:00 AM by LPN #3 7/5/2025 at 5:00 AM by LPN #3 7/5/2025 at 8:00 PM by LPN #6 7/6/2025 at 1:00 AM by LPN #7 7/6/2025 at 6:00 AM by LPN #7 7/6/2025 at 10:00 AM by LPN #6 7/6/2025 at 2:00 PM by LPN #6 7/6/2025 at 6:00 PM by LPN #6 7/7/2025 at 10:00 AM by LPN #8 7/7/2025 at 8:00 AM by LPN #6 7/7/2025 at 2:00 PM by LPN #6 7/10/2025 at 10:00 AM by LPN #9 7/10/2025 at 10:00 PM by LPN #7, (another dose was signed on the MAR at 9:00 PM) 7/11/2025 at 7:00 AM by LPN #6 7/11/2025 at 3:00 PM by LPN #6 7/11/2025 at 7:30 PM by LPN #7 7/13/2025 at 11:00 AM by LPN #7 7/14/2025 at 5:00 AM by LPN #10 Reconciliation of CSDR #1442827 and #1442827 to Resident #12's July MAR identified that fifty-eight (58) doses of Hydromorphone 8 mg were signed out on CDSR #1442827 and #1418161; all the doses were not documented as given with twenty-two (22) doses unaccounted for (signed on the CDSR as removed from the narcotic drawer, but not signed on the MAR as administered to Resident #12). C. Resident #13 was admitted diagnoses that included closed fracture of the left foot, fracture of the toes on the right foot, and polyneuropathy. A physician order dated 6/28/2025 directed to administer Hydromorphone two (2) mg, one (1) tablet by mouth every four (4) hours as needed for moderate pain (1-5 on scale of 10) and two tablets for a 4 mg dose every 4 hours as needed for moderate to severe pain (6-10 on a scale of 10). The RCP dated 7/1/2025 identified Resident #12 was at risk for pain. Interventions directed to administer pain medication as ordered. An admission MDS dated [DATE] identified Resident #13 was alert and oriented (BIMS 14), and experienced pain frequently in the last five (5) days. A physician order dated 7/24/2025 directed to discontinue the Hydromorphone as needed for pain. A physician order dated 7/30/2025 directed to administer Hydromorphone two (2) mg, one (1) tablet by mouth every eight (8) hours as needed. A review of Resident #13's medication administration record (MAR) with the CSDR #1419206 identified thirty (30) tablets of Hydromorphone 2 mg was received by the facility on 7/4/2025 with 10 tablets remaining. One (1) tablet of (2) mg of Hydromorphone was signed on the CSDR but not signed on the MAR to indicate it was administered to Resident #1 on the following dates: 7/21/2025 at 8:30 PM by LPN #11 7/23/2025 at 2:00 PM by LPN #7 7/23/2025 at 10:00 PM by LPN #7 7/26/2025 at 9:00 PM by LPN #10, additionally there was not a physician order in place for this medication on 7/26/2025. 7/27/2025 at 9:00 PM by LPN #10, additionally there was not a physician order in place for this medication on 7/27/2025. 8/4/2025 at 8:00 PM by LPN #11 8/9/2025 at 6:00 PM by LPN #10 Reconciliation of CSDR #1419206 to Resident #13's July and August 2025 MARs identified that of the twenty (20) doses of Hydromorphone 2 mg were signed out on CDSR #1419206; all the doses were not documented as administered. Seven doses were signed out on the CSDR to indicate the medication was removed from the narcotic drawer, but seven (7) doses were not signed on the MAR/medical record to indicate they were administered for Resident #13, and the doses were unaccounted for. Interview with the DON on 8/13/2025 at 10:13 AM identified that she was unaware that there was no documentation in Resident #1's, Resident #12 and Resident #13's MARs of administration of the pain medication. She identified that she expected the nursing staff to document all medication administered to a Resident in the Resident's MAR and did not know why the nurses did not sign the MAR to indicate medication was administered to a resident after they signed it out on the CSDR sheet. She stated that if it is not documented it was not done and could not identify where the unaccounted doses were. Further, the DON stated if a controlled medication needs to be destroyed (wasted) for any reason, another nurse needed to witness the destruction of the medication and sign for the destruction on the CSDR, and she did not know why there was not a witness signature for the medication that was destroyed. The DON stated if a resident did not have a current physician order, the narcotic medication should not have been signed out on the CSDR, and should not be administered to the resident. The DON stated she did not know why the narcotic medication was signed out for a resident when there was no current physician/APRN order for the administration. The facility Controlled Substance Handing Policy, dated 1/19/2018, directed in part, that licensed nurses must document (administration) immediately in the MAR. The Policy further directed if destruction is needed it should be destroyed by two (2) nurses. The facility Medication Administration Policy dated 2/16/2018 directed in part, that medication should only be prepared at the intended time of administration. After administering the medication, the person administering the medication should document in the electronic medical record that it was given. The facility policy Resident Abuse, Mistreatment, Neglect, Exploitation, Misappropriation and retaliation dated 1/19/2017 directed in part that is the policy of the facility to ensure residents are free from misappropriation. The Policy further directed, misappropriation means intentional wrongful misplacement of a resident's belongings.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Residents #1) reviewed for medication administration, the facility failed to ensure the physician/APRN was notified timely when medications were not administered in accordance with orders, and for two (2) of three (3) residents (Resident #14 and Resident #16) reviewed for medication administration, the facility failed to notify the physician/APRN timely when medications were not available for administration in accordance with physician orders. The findings include: The findings include:Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Residents #1) reviewed for medication administration, the facility failed to ensure the physician/APRN was notified timely when medications were not administered in accordance with orders, and for two (2) of three (3) residents (Resident #14 and Resident #16) reviewed for medication administration, the facility failed to notify the physician/APRN timely when medications were not available for administration in accordance with physician orders. The findings include: The findings include: 1. Resident #1 was admitted with diagnoses that included chronic pain syndrome, opioid dependance, osteomyelitis of the vertebra (back bone infection), and bacteremia (blood infection). A hospital Discharge summary dated [DATE] identified Resident #1 was discharged on Cefazolin (antibiotic) two (2) grams (gms) per fifty (50) milliliters (mls) intravenous (IV) solution every eight (8) hours, to stop on July 16, 2025. A physician order dated 6/20/2025 directed to administer Cefazolin two (2) gms per 50 mls IV every 8 hours, at 6:00 AM, 2:00 PM and 10:00 PM. Nursing admission assessment identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 6/21/2025 identified Resident #1 had an infection. Interventions directed to administer medication as per MD orders. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) and was alert and oriented, and experienced pain frequently in the last five (5) days. Medical record review of the Medication Administration Record (MAR) identified LPN #12 documented on 6/21 and 6/22/2025 that Resident #1 did not receive did not receive the Cefazolin two (2) gms on 6/21 and 6/22/2025 at 2 PM in accordance with physician orders. The MAR indicated Resident #1 was unavailable as he/she was out of the facility on leave of absence (LOA). Review of the facility grievance form dated 6/23/2025 identified Resident #1 reported he/she had missed medications. Interview with LPN #12 on 8/12/2025 at 9:39 AM identified she was the charge nurse for Resident #1 on 6/21/2025 from 7:00 AM to 7:00 PM, and on 6/22/2025 from 7:00 AM to 300 PM. LPN #12 stated Resident #1 was transferred to the hospital on 6/21 and 6/22/2025 about 10 AM to receive Methadone, and she did not remember when Resident #1 returned to the facility. LPN #12 stated she did not administer the Cefazolin two (2) gms on 6/21 and 6/22/2025 at 2 PM as ordered because Resident #1 was not in the facility. LPN #12 further stated that she did not notify the APRN the doses were omitted, and calls to the on-call physician/APRN were usually done by the supervisor. LPN #12 indicated she did not notify the supervisor the Cefazolin was omitted because she thought the supervisor already knew because Resident #1 was out of the building. Interview with RN #3 and medical record review on 8/11/2025 at 12:15 PM identified she was the supervisor on 6/21/2025 from 7:00 AM to 7:00 PM and she was aware Resident #1 was transferred to the hospital for medication was she saw Resident #1 in the facility about 5:30 PM. RN #3 stated that Resident #1 had informed her that he/she would be going back to the hospital on 6/22/2025 for an additional dose of medication. RN #3 stated she was not notified the Cefazolin was not administered at 2 PM, and if a medication is omitted the nurse should notify the supervisor. RN #3 further stated if she had known about the missed doses of Cefazolin, she would have notified the APRN. Interview with RN #2 on 8/12/2025 at 10:10 AM identified she was the supervisor on 6/22/2025 from 7:00 AM to 7:00 PM and she did not remember if the charge nurse notified her of any missed/omitted medications. RN #2 stated if she was notified, she would have notified the APRN. Interview and medical record review with APRN # 1 on 8/12/2025 at 10:42 AM identified he saw Resident #1 on 6/23/2025 and he was not aware the Cefazolin due to be administered on 6/21 and 6/22/2025 at 2 PM were not administered as ordered. APRN #1 stated he would have expected to be notified, and if he was notified, he would have called the Infectious Disease consultant to determine if the treatment plan needed to be adjusted. Interview with the DON on 8/13/2025 at 10:13 AM identified that if a Resident missed an antibiotic dose, the APRN should be notified. The DON stated the supervisor, APRN and herself should have been notified and she did not know why it was not done. The facility policy Change of Condition dated 1/30/2025 directed in part, that licensed nurses must notify the physicians/APRNs for missed (medication) doses and any deviation from physician's orders. 2. Resident #14 was admitted to the facility with diagnoses that history of substance use disorder. Review of the hospital Discharge summary dated [DATE] identified Resident #14 was to continue taking the medication of Methadone (used to treat Opioid Use Disorder) 115 milligrams (mg) daily. admission nursing note dated 8/6/2025 at 9:18 PM identified Resident #14 alert and oriented. A physician order dated 8/6/2025 directed Methadone 115 mg oral once a day at 6:00 AM. Review of the August 2025 Medication Administration Record (MAR) identified LPN #16 signed that Methadone 115 mg oral at 6:00 AM was not administered at the facility on 8/7, 8/8, 8/9 and 8/10/2025 because the drug was unavailable. Record review failed to identify the physician/APRN was notified the Methadone was not administered on 8/7 and 8/8/2025. Nursing note written by RN #2 dated 8/9/2025 (Saturday) at 10:39 AM identified the APRN was notified the Methadone was unavailable, and new orders were obtained to transfer Resident #14 to the hospital to receive the ordered Methadone on 8/9 and also on 8/10/2025 (Sunday) and then to follow up with the Methadone clinic on 8/11/2025. Record review failed to identify why the prescribed Methadone was not available in the facility. Review of the hospital emergency department note dated 8/10/2025 identified Resident #14's diagnosis was Methadone withdrawal, and was administered Methadone 100 mg. Record review identified Resident #14 returned to the facility on 8/10/2025. APRN #1 note dated 8/11/2025 at 10:18 AM identified Resident #14 missed ordered doses of Methadone on 8/7 and 8/8, and then was sent to the hospital and received correction doses at the hospital after missing doses of Methadone on 8/9 and 8/10/2025. Interview with RN #3 on 8/20/2025 at 12:40 PM identified she was the RN supervisor on 8/7, 8/8 and 8/9/2025, and stated she was not notified that Methadone was not available for Resident #14, as prescribed. RN #3 stated if she was notified, she would have notified the provider and made arrangements for the resident to obtain the Methadone. RN #3 stated when a resident is admitted on Methadone, the hospital sends a dose and then the facility schedules visits with the Methadone clinic. Interview with RN #2 on 8/20/2025 at 1:56 PM identified she was notified that the Methadone was not available for Resident #14 on 8/9/2025 and she notified the APRN and transferred Resident #14 to the hospital. Interview with LPN #15 on 8/20/2025 at 2:20 PM identified she was the facility Methadone nurse (obtains the Methadone from the clinic for residents on weekdays) and she was not aware that Resident #14 did not have his/her prescribed Methadone available on 8/7, 8/8 and 8/9/2025. LPN #15 stated if she was aware, she would have obtained the Methadone. LPN #15 stated the facility process for admissions from the hospital with Methadone ordered is for the hospital to send a dose of Methadone with the patient on a weekday, and if it were a weekend, then the hospital sends a three day supply. LPN #15 stated Resident #14 was transferred to the hospital on 8/9/2025 after missing prescribed doses of Methadone on 8/7 and 8/8/2025. Interview with APRN #1 on 8/20/2025 at 2:00 PM identified he was not notified on 8/7 and 8/8/2025 that Resident #14 did not receive his/her prescribed Methadone. APRN #1 stated he was notified on 8/9/2025, and he expected to be notified when a resident misses a medication. APRN #1 stated after two (2) missed doses of Methadone, the resident should be transferred to the hospital because withdrawals can begin around day three (3) of missing Methadone. Interview with the DNS on 8/20/2025 at 2:30 PM identified Resident #14 should have received his/her Methadone as ordered, and when it was not available the physician or APRN should have been notified. The DNS was unable to explain why the physician/APRN was not notified on 8/7 or 8/8/2025. 3. Resident #16 was admitted to the facility with diagnoses that included opioid abuse. A physician's order dated 5/23/2025 directed Methadone 75 mg oral once a day at 6:00 AM. The Resident Care Plan (RCP) dated 5/23/2025 identified Resident #16 received Methadone for maintenance for a history of substance use disorder. Interventions directed to maintain required contacts/sessions with outside Methadone agency as needed and provide resident with Methadone as ordered. The admission MDS dated [DATE] identified Resident #16 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was receiving an opioid. Review of the MAR for August 2025 identified Resident #16 did not receive Methadone 75 mg oral at 6:00 AM on 8/12/2025; LPN #16 documented the Methadone was unavailable. Record review failed to identify why Resident #16's prescribed Methadone was not available and if the physician/APRN was notified. Interview and record review on 8/20/2025 at 12:40 PM with RN #3 identified she was the supervisor on 8/12/2025 (11 PM to 7 AM on 8/12/2025) when Resident #16's Methadone was due to be administered at 6 AM. RN #3 stated the charge nurse did not notify her that there was no Methadone available for administration for the 6 AM dose. She stated if she was notified, she would have arranged for Resident #16 to go to the Methadone clinic to obtain the medication. Although attempted, an interview with LPN #16 was not obtained during survey. Interview with the DNS on 8/20/2025 at 2:30 PM identified Resident #16 should have received his/her Methadone as ordered, and when it was not available the physician or APRN should have been notified. The DNS was unable to explain why the physician/APRN was not notified on 8/12/2025. The facility policy Change of Condition dated 1/30/2025 directed in part, to administer provider ordered treatments and medications as indicated.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for elopement risk, the facility failed to perform elopement risk assessments in accordance with facility policy and failed to prevent a resident with dementia, who ambulated independently, and had previous exit seeking behaviors, from leaving the building unescorted resulting in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses included encephalopathy, dementia without behavioral disturbance, insomnia, and adjustment disorder. Resident #1 resided on the second floor of the facility and needed to pass through two connecting units to utilize the main elevator (wander guard alarmed) to travel to the main lobby. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition and was independent without assistive devices for ambulation. The Resident Care Plan dated 12/07/22 identified Resident #1 was at risk for elopement related to exit searching or desire to go home. Interventions included psychiatry consult, observe for increase changes in mood/behavior, alert staff, physician, and family or changes, redirect resident to own room or day room if observed attempting to leave the facility, alert all departments/staff of resident's risk for elopement and observe whereabouts on/off unit, and conduct immediate search if resident is not found/initiate search as per facility protocol. a. A nursing progress note by RN #1 dated 12/07/2022 at 5:10 PM identified Resident #1 was alert/oriented and was exit seeking. An elopement risk was performed, and the resident was placed on every 30-minute safety checks until wander guard became available. Review of the elopement risk assessment dated [DATE] at 5:01 PM by RN #1 identified Resident #1's elopement score was a 9.0 which indicated the resident was at risk for elopement. Interventions identified on this assessment that a wander guard needs to be implemented, every 30-minute checks for monitoring, the care plan was updated, and the comment section indicated safety checks until wander guard available. Review of the physician orders dated 12/07/22 at 5:17 PM directed to apply a wander guard when available, check for placement every shift and function on the 11 PM -7 AM shift, and safety checks every 30-minutes until wander guard available. Although the Treatment Administration Record dated 12/7/22 identified that licensed staff signed off that Resident #1 was monitored every 30 minutes until 12/08/22, the facility was unable to provide documentation as to when the checks were initiated, who completed the checks, and when the monitoring checks were discontinued. In addition, the record lacked evidence that a wander guard was applied on the resident in accordance with the plan of care. Review of the elopement risk assessment dated [DATE] and RN #1's progress note dated 12/07/22 noted that they were both invalidated by RN #2 (prior director of nursing) and discontinued on 12/08/22, absent an assessment and a physician's order to do so. Interview with RN #1 on 06/06/23 at 10:35 AM stated she performed the elopement risk assessment on 12/07/22 after being notified by facility staff that the resident was located at the main front entrance lobby attempting to leave the building. RN #1 noted she went down to the main lobby and re-directed Resident #1 back to his/her room with no issues. RN #1 identified Resident #1 would wander all over the unit and units adjoining and would ambulate independently throughout the building. RN #1 identified the resident was deemed an elopement risk per the assessment calculator tool, and indicated the resident needed a wander guard. RN #1 went to obtain a wander guard but was unable to find one as the facility did not have a wander guard available at that time. The previous DNS (RN #2) noted the facility needed to purchase more wander guards and were not available currently. RN #1 then implemented every 30-minute checks until the wander guard became available. Interview with RN #3 on 06/14/23 at 1:40 PM identified the facility did not have documentation that 30-minute checks were performed on Resident #1 on 12/7 to 12/8/22. RN #3 identified every 30-minute checks should be documented on paper with the date, timeframes, and whereabouts of the resident and was unable to provide documentation the checks were completed. The facility does not have a policy that directs frequent monitoring checks. Interview with RN #2 (prior DNS) on 06/06/23 at 11:35 AM identified he invalidated RN #1's elopement assessment, progress note, and discontinued the MD order dated 12/7/22 but was unable to recall why. RN #2 stated an attempted elopement by any resident would be considered a change of condition, and the expectation would be that the nursing staff perform an elopement risk assessment to determine the next possible steps. The Elopement Policy dated 11/1/2021 identified the resident elopement assessment will be done by the RN upon admission/readmission/quarterly/annually/and for any significant change in status. It will then be reviewed, and care planned for by the IDT team. b. A nursing progress note dated 01/01/2023 at 10:07 PM identified LPN #2 was notified by the nursing supervisor/ADNS that Resident #1 was at the front desk attempting to leave building. Upon arriving downstairs, Resident #1 was observed standing by the window and verbalizing, I'll wait right here, My parents are coming to pick me up to take me out, I'll call you when they get here so you can meet them. Resident #1 posed no risk of elopement. Resident #1 arrived back on unit at 10:23 PM. Review of Resident #1's clinical record failed to identify that a wander guard was in place in accordance with the plan determined on 12/07/2023 and that an elopement risk assessment was conducted in accordance with facility policy. Review of the facility documentation identified an invoice from the wander guard company dated 03/30/23 confirming a purchase order for ten (10) Wander Guard Bracelets. c. A nursing progress note dated 04/07/2023 at 2:32 PM by the ADNS identified nursing was notified that Resident #1 was able to leave the building when other visitors were coming through the front lobby door. Security attempted to verbally stop the resident, however, he/she kept walking. Resident #1 was always in the visual site of staff and did not leave the parking lot. Resident #1 was returned into the building with a nurse who was in the parking lot at the same time. Review of Resident #1's clinical record failed to identify that an elopement risk assessment was conducted in accordance with facility policy. Interview with the Administrator and RN #3 on 06/06/23 at 3:00 PM identified upon Resident #1's elopement from the building on 04/07/22, facility staff performed an IDT (inter-disciplinary team) meeting on the same day. The team determined Resident #1 did not need a wander guard due to the potential for increased agitation absent an assessment and/or documentation to make this determination. The IDT indicated they updated the communication book at the security's desk (located in the main lobby) and included Resident #1's photograph in the book with the list of residents who required a wander guard for heightened awareness. The Administrator and RN #3 were unable to identify measures implemented to prevent further elopement attempts. d. Review of the Facility Reported Incident and Summary Form identified on 05/19/23 at 1:02 AM, staff were unable to locate Resident #1 within the facility. The RN supervisor initiated the code purple and began the search throughout the building and around the perimeter of the building. The Administrator summoned the help of the rest of the interdisciplinary team to conduct a search in and around the community. Resident #1 was ultimately found by a staff member and was brought back to the facility at approximately 1:30 PM (approximately 12 hours since noted missing). Upon Resident #1's return, an elopement risk assessment was completed, the resident was determined to be at risk for elopement, and a wanderguard bracelet was implemented. Review of the facility investigation identified statements from the staff along with the videotape footage revealed that Resident #1 was let out the facility by Security Guard #2 through the front door at 1:02 AM. Security Guard #2's statement noted he did not realize that Resident #1 was a resident and assumed the resident was a staff member. Security Guard #2 was immediately terminated as he did not act in the best interest of the resident or the facility. A nursing progress note dated 05/19/2023 at 6:10 AM by LPN #3 (charge nurse for the 11PM-7AM shift) identified Resident#1 was alert and confused. Resident #1 was visible on the unit at the beginning of the shift, was in and out of his/her room and was redirected to bed several times. The nurse aide assigned to the resident had tucked Resident #1 in bed at around 1:30 AM and when discovered to be missing, searched the unit. A nursing progress note dated 05/19/2023 at 3:02 PM by RN #5 identified Resident #1 was found and returned to the building by staff at approximately 1:22 PM. Body check was done during shower and wander guard applied to right ankle. Interview with RN #2 (previous DNS) on 06/06/23 at 11:35 AM identified an elopement risk assessment should be completed upon admission, readmission, quarterly and with a change of condition. RN #2 identified an attempted elopement by any resident would be considered a change of condition, and the expectation would be that the nursing staff perform an elopement risk assessment to determine the next possible steps. Interview with NA #1 on 06/06/22 at 1:35 PM identified Resident #1 has never utilized a wander guard prior to the recent event on 05/19/23 and will usually ambulate/pace up and down independently around the unit or units at times. NA #1 identified Resident #1 was never on any every 30-minute checks, and it would be the nurse aide's responsibility to document the checks in the electronic charting system if part of the plan of care. Interview with Security Guard #1 (SG #1) on 06/06/23 at 1:45 PM identified security personnel work around the clock, 24/7 and are always positioned at the front desk. SG #1 indicated the wander guard system is located on the main front door and elevator. SG #1 noted that it's securities responsibility to ensure that any resident upon coming to the front desk, must provide documentation of leave of absence privileges to be approved to leave the facility. Security must manually press the release button on the front doors to open, and it would be SG #1's expectation on night shift that s/he would watch a staff member go to their vehicle to ensure their safety. SG #1 confirmed that Resident #1's information was included in the wander guard/elopement book after the event on 04/07/23. Although attempted, interview with Security Guard #2 was unable to be obtained. The facility failed to perform elopement risk assessments in accordance with facility policy following multiple elopement attempts (12/7/22, 1/1/23, and 4/7/23) and on 5/19/23, the Security Guard posted at the main lobby door, allowed Resident #1 to leave the facility at 1:02 AM when thought to believe the resident was an employee although the resident's picture was in the wander guard book as at risk for elopement. The resident was away from the facility during the period of 1:02 AM until found by a facility staff member approximately one mile away and returned to the facility at 1:22PM. As a result, Immediate Jeopardy was identified. On 5/19/2023, the facility assessed all residents for elopement risk, residents wearing wander guards were assessed, staff education commenced on 5/19/23 to include: elopement, wander guard and person-centered care. Audits were initiated to review elopement assessments of new admissions, wander guard functionality and placement, elopement books were created and added to all units and the elopement book at security desk was updated. 2. Resident #12 had diagnoses that included orthopedic aftercare following amputation, major depressive disorder, anxiety disorder, and alcohol and opioid dependence. The quarterly MDS assessment dated [DATE] identified Resident #12 had severely impaired cognition and required extensive assistance with one-person assistance with locomotion on and off unit. The Resident Care Plan (RCP) dated 06/07/23 identified Resident #12 was at risk for falls related to poor safety awareness and impaired mobility. Interventions included monitor and report changes in anxiety, sleep patterns, behavior, and or mood. A nursing progress note dated 06/08/2023 at 1:41 PM by LPN #4 identified the Resident was out of bed to wheelchair and self-propelling on unit. Wander guard requested. Safety maintained. A nursing progress note dated 06/08/2023 at 2:30 PM by the ADNS identified she was called to assess Resident #12 for the need for a wander guard. The Resident was alert and self-propels around the second floor independently. Resident #12 exhibits no exit seeking behavior or anger towards being in the facility. Resident #12 is extremely social and finds other residents to talk to and visit. Discussed with team and at this time a wander guard is not warranted. Review of Resident #12's clinical record failed to identify that an elopement risk assessment was conducted in accordance with facility policy. Interview with ADNS on 06/15/23 at 12:00 PM identified LPN #4 requested an evaluation for Resident #12 in regards for a wander guard on 06/08/23. ADNS indicated the team and herself discussed the resident's case and determined he/she was not at risk for elopement due to no exit seeking behaviors, verbalization of exit seeking or aggression towards the facility at that time on 06/08/23. The ADNS confirmed an elopement risk assessment should have been performed to verify Resident #12's elopement risk status. Attempts to interview LPN #4 were unsuccessful. Although the facility implemented immediate measures on 05/19/2023 to prevent elopements, the plan failed to include elopement risk assessments be conducted when a change in behaviors was noted. On 6/09/2023, the facility's Immediate Jeopardy removal plan identified a supply of wander guard bracelets with a par level of fifteen (15) will be maintained. The supervisor will notify the DNS and Administrator when the par level reaches five (5). All nurses will contact the supervisor if a resident is identified as needing a wander guard bracelet. Upon admission, readmission, quarterly and when there is a change in condition, all residents will be thoroughly assessed to identify the risk of wandering or elopement. If a resident is exit seeking or wandering in the lobby/facility, and assessment is to be done and an intervention must be put into place immediately, i.e., put resident on one to one. During the onsite visit on 6/09/2023, the corrective action plan was verified as implemented and Immediate Jeopardy was removed on 6/09/2023.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of six residents (Residents #1, 2, 3 and 12) reviewed for a change in condition, the facility failed to provide adequate psychosocial oversight to ensure residents received adequate emotional and behavioral services to address their dependency for residents who were identified to have possession of contraband or required administration of [MEDICATION(S)]. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission assessment dated [DATE] identified Resident #1 was alert and oriented and was ambulatory. The Resident Care Plan (RCP) 11/18/2021 identified a problem of psychosocial well-being and [MEDICATION(S)] (used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record identified an undated Admission Agreement regarding contraband signed by Resident #1. The contraband form indicated any use or possession of controlled substances, possession of alcohol, firearms, knife or other weapon, cigarettes, cigars, pipes, e-cigarettes, or fire sources and all smoking materials must be kept in the facility designated location, and violations would lead to involuntary discharge at the discretion of facility administration. Additionally, if there was a reasonable suspicion that the agreement was violated, residents may be subjected to a non-invasive pocket search, a search of their room and possessions, and may be sent to the hospital for an intoxication evaluation. If a person was found to be in possession of drugs or other illegal substance, the police would be notified and may be subject to criminal charges. The contraband form indicated the facility reserved the right to implement restrictions on visitation in addition to ongoing random room searches if necessary to prevent violations of the contraband policy. Further, the facility reserved the right to restrict or revoke LOA privileges to ensure resident safety. Recent history of drug abuse may be grounds for reasonable suspicion and dictate room searches or other restrictions. The psychological services progress note dated 1/27/2022 written by SW #2 identified there was no significant change because of psychotherapy and supportive psychotherapy was offered to improve quality of life with a plan to continue to monitor for depression and re-evaluate within two weeks. The psychiatric evaluation and consultation evaluation dated 1/28/2022 identified a chief complaint of opioid abuse disorder and Resident #1 was in remission. The psychiatric evaluation dated 2/2/2022 by APRN #3 identified opioid abuse, depression, and anxiety, and recommended to start [MEDICATION(S)] and Trazadone for [CONDITION(S)] and communicated with supportive care for targeted psychotherapy to be provided. The progress note written by SW # 2 dated 2/10/2022 identified Resident #1 reported he/she was very anxious lately and supportive psychotherapy was offered. Psychological services progress note, written by APRN #3, dated 2/14/2022 identified Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychological service note written by Licensed Addictive Drug Counselor (LADC) #1, dated 3/1/2022 identified he/she met with Resident #1 to discuss treatment and Resident #1 admitted to illicit drug use. Resident #1 was seeking recovery skills and the plan was for a follow up visit in one week and to offer group therapy. Review of the clinical record failed to identify group therapy was offered related to substance abuse. Additional clinical record review identified a Room Search form dated 3/2/2022 at 5:00 PM identified a search was conducted and the following drug paraphernalia was found: a used needle and razor blades were observed in Resident #1's closet. Additionally, the form identified Resident #1 indicated that someone borrowed his/her coat and did not know where the items came from. Additional Room Search forms dated 3/2 and 3/17/2022 identified no contraband was found. A nurse's note dated 3/3/2022 identified the DNS re-educated Resident #1 on the facility contraband policy. Interview with the DON on 3/21/2022 at 11:45 AM identified she was informed on 3/2/2022 that Resident #1 may have been doing drugs. Staff conducted a room search, and the following items were in the room: needles, razor blades, a pipe with black soot metal balls (pipe filters), two (2) lighters and two (2) [MEDICATION(S)] bottles labeled with Resident #1's name and dated within a few days prior to 3/2/2022 that contained a trace amount of green liquid observed the bottom of the containers. Interview with SW #1 on 3/22/2022 at 11:09 AM identified that during the facility morning report on 3/2/2022, an allegation was made that Resident #1 may have been selling drugs. She further indicated that she could not remember who made the allegation, and she along with the DON, the Director of Security, and RN #1 conducted a room search. She indicated that the following contraband items were found: a needle, a pipe, tow (2) bottles of [MEDICATION(S)] with a small amount of a green substance in the bottom, and lighters were found. Interview with SW #3 Psychological social worker on 3/24/2022 at 12:40 PM identified she was not aware of a positive urine toxicology result in February obtained when Resident #1 attended the pain clinic. SW #3 indicated that she was not aware of the allegation that Resident #1 was suspected of selling drugs and was found with contraband in his room on 3/2/2022. SW#3 indicated she would have expected to be notified; she indicated she would have met with Resident #1 to develop a safety plan regarding substance abuse and provided education because Resident #1 could potentially hurt him/herself or others. Interview identified although SW #3 provided treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review identified a history of cocaine and substance abuse. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] identified Resident #2 was alert and oriented and had an IV access site and was not able to safely attend appointments alone. The RCP dated 2/27/2022 identified a problem with active substance abuse and [MEDICATION(S)] maintenance treatment. Interventions directed to educate Resident #2 on the facility contraband policies to include the room search policy, provide psychological services and counseling as needed, offer substance abuse group, assist with transportation to [MEDICATION(S)] clinic, monitor resident for changes if [MEDICATION(S)] dose is adjusted and provide the resident with a daily dose of [MEDICATION(S)] for self-administration. The social services progress note dated 2/25/2022 identified Resident #2 was admitted for four (4) weeks of IV antibiotics with the plan to return home, was adjusting well to the facility, and had no concerns. The psychiatric evaluation and consultation dated 2/28/2022 identified Resident #2 had [CONDITION(S)] disorder without medication and recommended referral to psychotherapy. The nurse's note dated 3/2/2022 (7 days after admission to the facility) at 12:08 PM identified the DON assessed Resident #2 and noted Resident #2 was lethargic, unable to stay awake during conversation, had pinpoint pupils, slurred speech, and was agitated when asked questions. The intravenous PICC line dressing was observed to be almost totally off and multiple superficial scabs were noted all over Resident # 2's body. APRN #2 directed to transfer Resident #1 to the hospital for an evaluation. The APRN progress note dated 3/2/2022 at 12:08 PM identified Resident #2 had a new onset of lethargy, and Resident #2 aroused to loud stimuli with three (3) to four (4) attempts but then fell back asleep. Vital signs recorded were temperature: 97.5, blood pressure: 80/32, pulse: 84, and respirations: 20, and Resident #2 was transferred to the hospital. Review of a hospital urine drug screen dated 3/2/2022 at 5:43 PM identified Resident #2 tested positive for amphetamines (an addictive mood-altering drug used illegally as a stimulant and was a medication that as not medically prescribed and administered at the facility) and [MEDICATION(S)] (a medication that was prescribed at the facility). The hospital history and physical dated 3/2/2022 identified Resident #2 was awake and oriented when seen in the emergency room , remembered going for a smoke and feeling tired, and denied drug use. Further, Resident #2 was given [MEDICATION(S)] (used for the emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record failed to identify Resident #2 received psychotherapy as recommended on 2/28/2022, and failed to identify Resident #2 received psychosocial support after he/she was administered [MEDICATION(S)] on 3/2/2022. Interventions directed to educate Resident #2 on the facility contraband policies to include the room search policy, provide psychological services and counseling as needed, offer substance abuse group, assist with transportation to [MEDICATION(S)] clinic, monitor resident for changes if [MEDICATION(S)] dose is adjusted and provide the resident with a daily dose of [MEDICATION(S)] for self-administration. The psychiatric evaluation and consultation dated 2/28/2022 identified Resident #2 had [CONDITION(S)] disorder without medication and recommended referral to psychotherapy. Interview with APRN #2 on 3/22/2022 at 10:42 AM identified while Resident #2 was prescribed [MEDICATION(S)] in the facility, he/she was not prescribed amphetamines. 3. Resident #3 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was alert and oriented and required supervision for walking. The RCP dated 1/26/2022 identified Resident #3 had a history or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions for substance abuse-alcoholism directed referral to psychological services as needed and offer option of attending a substance abuse group when they are available. Review of the Psychiatric social work notes identified Resident #3 attended a supportive psychotherapy group session for alcohol/substance abuse and depression on 1/19/2022 and identified Resident #3 as first time attending group. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's notes dated 2/12/2022 at 11:25 PM identified Resident #3 was found on the floor unresponsive. Nurse's note dated 2/13/2022 at 12:09 AM, written by RN #3, indicated 911 was called and Resident #3 was transported to the hospital. Hospital record review identified on 2/12/2022 Resident #3 required one dose of [MEDICATION(S)] intranasally, and two doses intravenous (IV) while being transported by EMS, to become responsive. The hospital record further indicated that Resident #3 reported to hospital staff that he drank one pint of vodka yesterday. Resident #3 also denied use of any other elicit substance. Hospital toxicology report dated 2/12/2022 identified Resident #3 tested positive for [MEDICATION(S)] and [MEDICATION(S)]. Clinical record review from the facility from 2/1/2022 through 3/21/2022 failed to identify orders for [MEDICATION(S)] or [MEDICATION(S)]. Additional clinical record review identified that while Resident #3 was followed by Psychiatric services, and upon admission on 10/13/2020 the RCP directed to offer substance abuse services, the clinical record failed to identify any group support services were offered outside of the 1/19/2022 group meeting which was Resident #3's first time in attendance. Psychiatric support services note dated 2/25/2022 indicated that Resident #3 recently returned to the facility following an overdose, and the plan directed supported psychotherapy to decrease isolation and depression, and Social Work would continue to monitor for depression and reevaluate within two weeks. Additional psychosocial services notes dated 3/4, 3/11, 3/18, and Psych APRN note dated 3/21/2022 failed to identify any additional support services, interventions, or plan to address Resident #3's recent use of alcohol and narcotics and overdose requiring hospitalization . 4. Resident #12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 was alert and oriented and had no behaviors. The Resident Care Plan (RCP) dated 12/14/2021 identified an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record identified a Psychiatric APRN progress note written by APRN #3 indicated although Resident #12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical APRN progress note dated 1/13/2022 identified Resident #12 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Psychiatric APRN note dated 1/19/2022 at 5 PM, written by APRN #3, identified she was asked to see Resident #12 by the ADNS (current DON) due to the resident going on LOA and using drugs and feeling guilty. Staff nurse advised APRN #3 that Resident #12 overdoses and [MEDICATION(S)] was administered. APRN discussion with Resident #12 was at first evasive when asked about yesterday's events (1/18/2022), but when APRN advised Resident #12 that she was told he/she had used (drugs) when on LOA, Resident #12 admitted to the use of [MEDICATION(S)] or Heroin (resident was unsure which). The note further indicated that Resident #12 went back to the facility, and then back out (on another LOA) and took a bump (snorted). Review of Psychiatric physician note dated 1/20/2022 Resident #12 was seen for supportive therapy as he/she had recently used heroin and required [MEDICATION(S)] for recovery. The note further indicated that issues of support needs were addressed and included coping skills. During an interview and clinical record review with APRN #3 on 3/23/2022, APRN #3 indicated that the current DON had asked her to see Resident #12 on 1/19/2022 and staff had informed her that Resident #12 had required [MEDICATION(S)] to be administered on 1/18/2022. APRN #3 further indicated that during her interview with Resident #12, Resident #12 had informed her that he/she had used drugs on 1/18/2022. Additional clinical record review identified although Resident #12 was followed by Psychiatric services, and the RCP directed to offer substance abuse group support, the review failed to identify substance abuse group support was provided. Review identified Resident #12 was seen by Psychiatric APRN #3 on 1/3, 1/11, 1/19, 1/20, 1/26, 1/28, and on 1/20/2022 by Psychiatric social services, the clinical record review failed to identify any additional support services were provided for substance abuse to address his/her dependency. Interview with the DON on 3/22/2022 at 10:12 AM identified although Resident #1 was found with drug paraphernalia, and Residents #2, 3 and 12 had a change in condition that required [MEDICATION(S)] administration, she was unable to explain how the residents were was able to obtain the items. Interview with the Medical Director on 3/23/2022 at 5 PM identified he was aware of similar situations in the past where residents had been found with contraband or required the administration of [MEDICATION(S)], he was unable to identify the specific incidents with Residents #1, 2, 3 and 12. Review of the clinical records of Residents #1, #2, #3 and #12 identified the facility failed to ensure adequate psychosocial oversight to ensure residents received adequate emotional and behavioral services to address their dependency. The failures resulted in a finding of Immediate Jeopardy. The facility Social Work Provision of Support with Substance Abuse History Policy dated 4/18/2018 directed in part, the facility will provide support for psychological, social, emotional, and spiritual needs of the residents particularly those with substance abuse histories. The Policy further directed the social worker will meet with residents upon admission to identify residents with a history of substance abuse for the potential of individual psychotherapy. Information is provided about individual substance abuse groups facilitated by the psychiatric services partner. The social worker reviews admissions quarterly and as needed for provision of additional substance abuse support. A review of the facility's corrective action plan on 3/28/2022 identified all staff will be educated by the facility psychiatric team on identifying residents with an increased need. The facility psychiatric team will add an additional day of substance support group to the facility, and the psychiatric team will implement behavior programming. Identified residents will be monitored for participation. If a resident is identified not engaged in programming, they will be assessed for additional services and barriers to participation. Audits of resident participation will be conducted daily for four weeks, weekly for four weeks, monthly for four months and then quarterly with results brought to quarterly QAPI for review. As a result of the corrective action that was implemented and verified as complete, the Immediate Jeopardy was identified as removed on 3/28/2022.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of six residents (Resident #1) reviewed for a change in condition, the facility failed to ensure adequate supervision was provided to ensure a resident was free from possession of drug paraphernalia, and for three of six residents (Residents #2, 3, and 12) reviewed for a change in condition, the facility failed to ensure adequate supervision to ensure residents did not have access to contraband which resulted in the residents requiring administration of [MEDICATION(S)], and failed to follow facility leave of absence policy. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses included a history of opioid use and chronic pain related to chronic lower extremity venous ulcers. Clinical record review identified a Leave of Absence Policy form dated 11/17/2021, signed by Resident #1, indicated Resident #1 was educated regarding the Leave of Absence (LOA) policy, and an undated Admission Agreement regarding contraband signed by Resident #1. The admission assessment dated [DATE] identified Resident #1 was alert and oriented and was ambulatory. The Resident Care Plan (RCP) dated 11/18/2021 identified psychosocial well-being and [MEDICATION(S)] (used for the treatment of drug addiction) maintenance treatment. Interventions directed to refer Resident #1 to psychological services as needed, provide daily [MEDICATION(S)] for self-administration, monitor for changes, offer a substance abuse group if available. The physician orders dated February 2022 directed Resident #1 may smoke and directed independent leave of absences (LOA). Psychological services progress note, written by APRN #3, dated 2/14/2022 identified Resident #1 had a history of snorting heroin and had progressed to IV drug use. Additional clinical record review identified a Room Search form dated 3/2/2022 at 5:00 PM identified a search was conducted and the following drug paraphernalia was found: a used needle and razor blades were observed in Resident #1's closet. Interview with the DON on 3/21/2022 at 11:45 AM identified she was informed on 3/2/2022 that Resident #1 may have been involved in drug activity. Staff conducted a room search, and the following items were located in the room: needles, razor blades, a pipe with black soot metal balls (pipe filters), two (2) lighters and two (2) [MEDICATION(S)] bottles labeled with Resident #1's name and dated within a few days prior to 3/2/2022 that contained a trace amount of green liquid observed the bottom of the containers. Further, the DON identified residents don't always sign out when they leave the facility for an LOA. The DON further indicated that although Resident #1 had a history of substance abuse and had contraband items found in his/her possession on 3/2/2022, a reassessment of LOAs for Resident #1 was not completed. She indicated that Resident #1 indicted the items belonged to someone else. The DON identified Resident #1 should not have had the contraband items and was unable to provide documentation that Resident #1's LOA privilege was re-assessed following the discovery of the contraband. Interview with the Administrator on 3/22/2022 at 8:59 AM identified the facility changed their LOA process in 1/2022. He indicated that although residents were required to sign a log on the unit, to make the process easier for the residents and staff, residents were no longer required to sign out at the security desk. Review of the facility Contraband Violations Policy directed in part, any use or possession of controlled substances, possession of alcohol, firearms, knife or other weapon, cigarettes, cigars, pipes, e-cigarettes, or fire sources and all smoking materials were contraband items. The Policy further directed, when a resident is found to be in possession of any substances indicated as contraband, the facility reserves the right to room and person searches and an accident and incident report will be completed for each contraband violation. Additionally, to prevent further violation, the facility will impose person searches after every LOA for a period of 90 days and then randomly and will conduct ongoing random room searches and the resident care plan will be updated to reflect these interventions. Further, the facility reserves the right to impose other restrictions dependent on circumstances including restricting visitation and LOA privileges. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses which included psychoactive substance abuse, nicotine dependence and endocarditis. The physicians' orders dated 2/24/2022 directed to administer [MEDICATION(S)] 10mg/5ml (130mg) orally once a day. Review of the February 2022 physician's orders failed to identify a LOA order. The admission nursing assessment dated [DATE] identified Resident #2 was alert and oriented and had an IV access site and was not able to safely attend appointments alone. The RCP dated 2/27/2022 identified active substance abuse and [MEDICATION(S)] maintenance treatment. Interventions directed to educate Resident #2 on the facility contraband policies to include the room search policy, provide psychological services and counseling as needed, offer substance abuse group, assist with transportation to [MEDICATION(S)] clinic, monitor resident for changes if [MEDICATION(S)] dose is adjusted and provide the resident with a daily dose of [MEDICATION(S)] for self-administration. The nurse's note dated 3/2/2022 (7 days after admission to the facility) at 12:08 PM identified the DON assessed Resident #2 and noted Resident #2 was lethargic, unable to stay awake during conversation, had pinpoint pupils, slurred speech, and was agitated when asked questions. The intravenous PICC line dressing was observed to be almost totally off and multiple superficial scabs were noted all over Resident # 2's body. APRN #2 directed to transfer Resident #1 to the hospital for an evaluation. The APRN progress note dated 3/2/2022 at 12:08 PM identified Resident #2 had a new onset of lethargy, and Resident #2 aroused to loud stimuli with three (3) to four (4) attempts but then fell back asleep. Vital signs recorded were temperature: 97.5, blood pressure: 80/32, pulse: 84, and respirations: 20, and Resident #2 was transferred to the hospital. Additional clinical record review failed to identify [MEDICATION(S)] was administered prior to Resident #2's transfer to the hospital. The hospital history and physical dated 3/2/2022 identified Resident #2 was awake and oriented when seen in the emergency room , remembered going for a smoke and feeling tired, and denied drug use. Further, Resident #2 was given [MEDICATION(S)] (used for the emergency treatment of opioid overdose), an unspecified number of doses and unspecified times of administration, with good response. The hospital urine drug screen dated 3/2/2022 at 5:43 PM identified Resident #2 tested positive for amphetamines (an addictive mood-altering drug used illegally as a stimulant and was not a medication prescribed and administered at the facility) and [MEDICATION(S)] (a medication that was prescribed at the facility). Interview with APRN #2 on 3/22/2022 at 10:42 AM identified while Resident #2 was prescribed [MEDICATION(S)] in the facility, he/she was not prescribed amphetamines. Interview with the DON on 3/22/2022 at 10:12 AM identified although Resident #2 had a change in condition and tested positive for [MEDICATION(S)] and amphetamines, she indicated that she was not aware of the urine toxicology screen; she indicated that she does not review toxicology screens when a resident is transferred to the hospital. She was unable to explain how Resident #2 was able to obtain amphetamines as the resident did not have LOA privileges and she did not complete an investigation regarding the event. Subsequent to surveyor inquiry, the DON indicated an incident report with investigation was initiated. 3. Resident #3 diagnoses included hepatic failure, [CONDITION(S)], [CONDITION(S)] C, and alcohol abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was alert and oriented and required supervision for walking. The RCP dated 1/26/2022 identified Resident #3 had a history or active diagnosis of substance abuse-alcoholism at risk for psychosocial well-being. Interventions for substance abuse-alcoholism directed referral to psychological services as needed and offer option of attending a substance abuse group when they are available. A physician's order dated 1/31/22 directed Resident #3 could have leave of absence (LOA) from the facility. The nurse's notes dated 2/12/2022 at 11:25 PM identified Resident #3 was found on the floor unresponsive. Nurse's note dated 2/13/2022 at 12:09 AM, written by RN #3, indicated 911 was called and Resident #3 was transported to the hospital. Hospital record review identified on 2/12/2022 Resident #3 required one dose of [MEDICATION(S)] intranasally, and two doses intravenous (IV) while being transported by EMS, to become responsive. The hospital record further indicated that Resident #3 reported to hospital staff that he/she drank one pint of vodka yesterday and denied use of any other substances. Hospital toxicology report dated 2/12/2022 identified Resident #3 tested positive for [MEDICATION(S)] and [MEDICATION(S)]. Clinical record review from the facility from 2/1/2022 through 3/21/2022 failed to identify orders for [MEDICATION(S)] or [MEDICATION(S)]. Interview with the DNS on 3/22/22 at 10 AM identified she was unaware Resident #3 had a positive toxicology screen at the hospital on 2/12/2022. The DNS indicated that she thought Resident #3 may have obtained the contraband while on an LOA from the facility and identified staff did not perform a room search after Resident #3 was transferred to the hospital on 2/12/2022. Further, she indicated that she did not investigate the incident. The facility was not able to identify how the resident obtained [MEDICATION(S)] or [MEDICATION(S)]. Subsequent to surveyor inquiry, the DON indicated an incident report with investigation was initiated. a. Clinical record review identified Resident #3 was readmitted to the facility on [DATE]. Hospital Discharge Summary dated 2/23/2022 identified Resident #3 was readmitted with a PICC line in place for IV therapy for endocarditis. Discharge orders directed IV [MEDICATION(S)] every 8 hours until 3/29/2022. Physician orders dated 2/23/2022 (following readmission) directed that the orders for LOA were discontinued. Review of the current facility LOA list from 2/23 (Resident #3's readmission) through 3/22/22 identified that Resident #3 was listed as approved for LOAs from the facility. Interview with the Administrator on 3/22/2022 at 9:10 AM identified although Resident #3's LOA orders were discontinued on 2/23/2022, he did not know why Resident #3 was still on the approved facility LOA list. Although he indicated a room search should have been conducted when Resident #3 had the positive toxicology results on 2/12/2022, he was unable to provide documentation that room searches were conducted. 4. Resident #12's diagnoses included endocarditis and a history of opioid and cocaine abuse. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 was alert and oriented and had no behaviors. The Resident Care Plan (RCP) dated 12/14/2021 identified an active diagnosis of substance abuse. Interventions directed to refer to psychological services as needed, offer substance abuse group when they are available and seek support from family and friends to support once Resident #12 returns to the community. Physician orders dated 1/13/2022 directed Resident #12 may have Leave of Absence (LOA), to administer [MEDICATION(S)] 80 mg by mouth daily, and to administer [MEDICATION(S)] 4 mg one spray in one nostril for suspected opioid overdoes, may repeat in two (2) minutes in the other nostril with a new device if minimal or no response. Review of the clinical record identified a psych APRN progress note written by APRN #3 indicated although Resident #12 had a history of polysubstance abuse, Resident #12 refused [MEDICATION(S)] offered for cocaine cravings. Medical APRN progress note dated 1/13/2022 identified Resident #12 was admitted with a diagnosis of polysubstance abuse due to an overdose with rhabdomyolysis, and [CONDITION(S)] Sensitive Staph Aureus (MSSA) bacteremia. Review of Psychological APRN note dated 1/19/2022 at 5 PM, written by APRN #3, identified she was asked to see Resident #12 by the ADNS (current DON) due to the resident going on LOA and using drugs and feeling guilty. Staff nurse advised APRN #3 that Resident #12 overdoses and [MEDICATION(S)] was administered. APRN discussion with Resident #12 was at first evasive when asked about yesterday's events (1/18/2022), but when APRN advised Resident #12 that she was told he/she had used (drugs) when on LOA, Resident #12 admitted to the use of [MEDICATION(S)] or Heroin (resident was unsure which). The note further indicated that Resident #12 went back to the facility, and then back out (on another LOA) and took a bump (snorted). Review of Psychological physician note dated 1/20/2022 Resident #12 was seen for supportive therapy as he/she had recently used heroin and required [MEDICATION(S)] for recovery. Additional review of the clinical record failed to identify any reference to the LOAs or administration of [MEDICATION(S)]. Interview with the DON on 3/21/2022 at 11:45 AM identified residents don't always sign out when they leave the facility for an LOA. During an interview and clinical record review with the DON (ADNS on 1/19/2022) and Administrator on 3/23/2022 at 2:51 PM, the DON indicated that she had no information regarding the incident described in the Psychological APRN note dated 1/19/2022. During an interview and clinical record review with APRN #3 on 3/23/2022, APRN #3 indicated that the current DON had asked her to see Resident #12 on 1/19/2022 and staff had informed her that Resident #12 had required [MEDICATION(S)] to be administered on 1/18/2022. APRN #3 further indicated that during her interview with Resident #12, Resident #12 had informed her that he/she had used drugs on 1/18/2022. Interview and record review with Regional Nurse/RN #2 on 3/22/2022 at 12:45 PM identified facility investigations should have been conducted after the described incidents with Residents #1, 2, 3 and 12. Interview and clinical record reviews with the Administrator and the DON on 3/23/2022 at 2:51 PM failed to identify investigations were completed after the incidents occurred with Residents #1, 2, 3 and 12. Review of the clinical records of Residents #1, #2, #3 and #12 identified the facility failed to ensure adequate supervision to ensure residents did not have access to drug paraphernalia and contraband that resulted in [MEDICATION(S)] administration, and the facility failed to reassess resident's LOA privileges were re-assessed. The failures resulted in a finding of Immediate Jeopardy. Review of the facility Accidents and Incidents Reporting Policy dated 9/16/2018, directed in part, that all accidents and incidents involving residents shall be investigated and reported to the Administrator. The charge nurse or supervisor shall promptly initiate, and document investigation of the incident. A review of the facility's corrective action plan on 3/28/2022 identified licensed staff were educated on the LOA policy, [MEDICATION(S)] administration policy, and change of condition policy including that all residents that require [MEDICATION(S)] will be transferred to the hospital. Additionally, licensed staff were educated on signs and symptoms of a change in condition due to illicit substances. In the event a change of condition occurs due to possible illicit substance use, an investigation will be conducted to determine the root cause. The facility LOA assessment was revised to include appropriate eligibility for LOA, and all residents will be assessed for appropriateness of LOA orders utilizing the updated assessment tool. Audits of room search forms will be conducted with results brought to QAPI. Progress notes will be reviewed daily to identify any potential changes of condition related to illicit substance use and if identified a root cause analysis will be conducted. Audits will be complete daily for one month, weekly for four weeks, monthly for four months then quarterly. As a result of the corrective action that was implemented and verified as complete, the Immediate Jeopardy was identified as removed on 3/28/2022. Based on clinical record review, observations, facility policy review, and interviews for four of four residents (Resident #7, 8, 9 and 10) observed for smoking, the facility failed to ensure staff questioned residents upon return to the facility for cigarette lighters, and for one of five residents (Resident #11) reviewed for smoking, the facility failed to ensure the resident did not have independent access to a lighter. The findings include: 1. Resident #7's diagnoses included nicotine dependence and history of opioid abuse. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #7 was alert and oriented and was able to walk with supervision. The Resident Care Plan (RCP) dated 2/15/2022 identified Resident #7 was a smoker. Interventions directed Resident #7 would not possess any smoking or lighting material in his/her room or on his/her person. The physician's order dated 3/20/2022 directed Resident #7 may go on Leave of Absence (LOA). The smoking assessment dated [DATE] identified Resident #7 was able to smoke safely on an independent LOA. 2. Resident #8's diagnoses included dementia and history of alcohol abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #8 was alert and oriented and was able to walk independently. The physician's order dated 3/3/2022 directed Resident #8 may go on LOA independently. The RCP dated 3/10/2022 identified Resident #8 was a smoker. Interventions directed Resident #8 would not possess any smoking or lighting material in his/her room or on his/her person. The smoking assessment dated [DATE] identified Resident #8 was able to smoke safely on an independent LOA. 3. Resident #9's diagnoses included [CONDITION(S)] and asthma. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #9 had moderately impaired cognition was able to walk with supervision. The RCP dated 2/1/2022 identified Resident #9 was a smoker. Interventions directed Resident #9 would not possess any smoking or lighting material in his/her room or on his/her person. The interventions further directed Resident #9 would participate in the facility supervised smoking program. The physician's order dated 3/3/2022 directed Resident #9 may go on LOA. The smoking assessment dated [DATE] identified Resident #9 was able to smoke safely on an independent LOA. 4. Resident #10's diagnoses included [CONDITION(S)]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #10 was alert and oriented and used a wheelchair for mobility. The RCP dated 2/17/2022 identified Resident #10 was a smoker. Interventions directed Resident #10 would not possess any smoking or lighting material in his/her room or on his/her person. The interventions further directed Resident #10 would participate in the facility supervised smoking program. The physician's order dated 3/3/2022 directed Resident #10 may go on LOA. The smoking assessment dated [DATE] identified Resident #10 was able to smoke safely on an independent LOA. 5. Resident #11's diagnoses included hypertension. The nursing admission assessment dated [DATE] identified that Resident #11 was alert and oriented and required supervision for walking. The RCP dated 3/10/2022 identified Resident #11 was a smoker. Interventions directed Resident #11 would not possess any smoking or lighting material in his/her room or on his/her person. The interventions further directed Resident #11 would participate in the facility supervised smoking program. Review of the physician's orders failed to identify an order for LOAs. The smoking assessment dated [DATE] identified Resident #11 was able to smoke safely on an independent LOA. Continuous observations on 3/22/2022 at 9:30 AM identified Residents #7, 8, 9 and 10 were on the left side of the sidewalk at the end of the facility driveway smoking cigarettes. As surveyor approached the residents, they were putting out their cigarettes and Security Guard #1 came from the building and directed the residents to move away from the side of the driveway. All residents then walked back inside the facility with Security Guard #1 and surveyor. Continued observations identified three (3) residents walked past Security Guard #1 and down the hall toward the elevator as one (1) resident gave Security Guard #1 a pack of cigarettes and then walked toward the elevator. Interview with Security Guard #1 at the time of the observation identified he did not ask Resident #7, 8, 9 and 10 if they had a cigarette lighter upon their return into the building. He indicated that he did not ask them for a lighter because when he gave them the cigarettes, he did not give them any lighters. He further indicated that he had no cigarette lighters in the cigarette cart. When surveyor asked how the residents could have lit their cigarettes, he indicated that he did not know. When queried as to how he knew the residents did not have any lighters when they returned to the building if he did not ask, Security Guard #1 then walked down the hall to the elevator to ask the residents if they had a lighter. When he returned to the lobby, he indicated the residents had told him that a person on the street had lit the cigarettes for them. Continued observations identified Resident #11 approached the Security Desk and asked Security Guard #1 for cigarettes. Security Guard #1 was observed to give a pack of cigarettes to Resident #11 and then asked Resident #11 if he/she had a lighter. Resident #11 responded that he/she did have a lighter and patted his/her right pocket. Resident #11 was then observed to leave the facility. Interview with Security Guard #1 (as Resident #11 was leaving the facility) identified Resident #11 did inform him that he/she had a lighter, and Security Guard #1 indicated he did not know where Resident #11 got the lighter from. Administrator joined the interview, and Surveyor and Administrator walked to the sidewalk to interview Resident #11. Observations identified Resident #11 was standing on the right side of the sidewalk next to the facility driveway smoking a cigarette. Interview with Resident #11, with the Administrator present, at the time of the observation, identified Resident #11 had a lighter that he/she kept in his/her pocket and confirmed that he/she had the lighter when he/she approached Security Guard #1 for the cigarettes. Resident #11 indicated that he/she kept the lighter in his/her pocket when he/she was in the facility and in his/her room. Resident #11 further indicated that he/she did not know if he/she was supposed to keep the lighter. Interview with the Administrator while walking back into the facility identified Resident #11 should not have a lighter, and that residents should get lighters from security when they leave the facility to smoke. Continued observation and interview on 3/22/2022 identified Resident #11 returned to the facility at 9:50 AM, and Security Guard #1 took Resident #11's cigarettes and lighter and placed them both inside the smoking cart. Further observations identified the smoking cart held thirteen (13) boxes of cigarettes, and the only lighter was the one (1) lighter that Security Guard #1 had just taken from Resident #11. Security Guard #1 indicated that he had no other lighters to provide for residents when they leave the facility to smoke independently. Interview with RN #2/Regional RN on 3/22/2022 at 10:22 AM identified any resident with leave of absence orders (LOA) who was identified as an independent smoker could obtain smoking materials from the security guard and leave the facility to smoke independently. He indicated that lighters should be kept by the security guard and he would expect the security guard to ask returning residents if they have a lighter. Further, RN #2 indicated that Resident #11 should not have had a lighter on his/her person; all lighters were to be kept by security. Subsequent to surveyor inquiry, RN #2 indicated that all residents who smoke would be check to ensure they did not have possession of a lighter in the facility. Review of facility documentation dated 3/22/2022 identified resident room searches were conducted for residents that smoke. Interview with the DON and RN #2 on 3/24/2022 at 2:54 PM identified Resident #11 did not have a physician's order for LOA from the facility and should have an order in place to leave the facility to smoke. Review of facility Smoking Policy, dated 11/1/2021, directed in part that all smoking materials, cigarettes, and lighting materials are maintained by security and kept at the front desk. The Policy further directed that if a resident has an order for independent leave of absence, cigarettes and lighting materials are kept at the front desk and will be retuned to the front desk when the resident returns.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4), reviewed for diabetes management, the facility failed to ensure staff reviewed hospital insulin recommendations for a new admission, and the facility failed to ensure staff notified the provider timely of an elevated blood sugar for a resident receiving insulin when the blood sugar was equal to or greater than 200, and the resident had a change in condition resulting in a hospital admission with the blood sugar over 600, and for one of three residents (Resident #12) reviewed for a change in condition, the facility failed to ensure the resident was transferred to the hospital for evaluation after the administration of [MEDICATION(S)]. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident # 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Admission assessment dated [DATE] identified Resident #4 was alert and oriented, and had diabetes. The Resident Care Plan (RCP) dated 2/6/2022 identified an alteration in nutrition status. Interventions directed to provide diet as ordered. Review of the hospital diabetic management consult dated 2/6/2022 identified Resident #4 had type 2 diabetes and his/her hospital stay was complicated by [CONDITION(S)]. Diabetic consult recommendations directed in part, to start [MEDICATION(S)] insulin (hormone to lower blood glucose) 5 units at bedtime and to continue [MEDICATION(S)] (insulin hormone to lower blood glucose) low-dose sliding scale before meals three times a day and blood glucose monitoring before meals 3 times a day and at bedtime. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4's blood glucose twice a day at 9 AM and 9 PM. Additional review failed to identify any parameters were included for blood glucose monitoring to direct staff when to notify the physician with results. An additional physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional clinical record review failed to identify the provider reviewed the hospital recommendation to implement a low-dose sliding scale insulin upon admission. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] = 150; 2/7 at 9:33 AM = 142; 2/7 at 9:20 PM = 210; and 2/8/2022 at 9:35 AM = 200 (normal reference range 70 to 100). Additional clinical record review identified Resident #4 was provided with his/her lunch meal on 2/8/2022 at mid-day. The nurse's note dated 2/8/2022 at 2:37 PM identified Resident #4 was lethargic, unable to respond verbally and observed with shortness of breath and labored breathing. Oxygen was initiated at three (3) liters per minute with minimal effect and Resident #4 was transferred to the hospital for evaluation. Review of the clinical record failed to identify that the provider was notified of the elevated blood sugar levels on 2/7 and 2/8/2022. Hospital admission record dated 2/8/2022 identified Resident #4 had a blood glucose of 633 on arrival and was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review identified Resident #4 was readmitted to the facility on [DATE]. Interview with APRN #2 and RN #4 on 3/23/2022 at 10:16 AM identified APRN #2 was not aware that Resident #4 had hospital recommendations for sliding scale insulin coverage. APRN #2 indicated that she would expect to be notified for blood glucose levels on a diabetic resident that were below 70 or 200 and above. APRN #2 also indicated she couldn't remember if she had been notified about any of Resident #4's blood glucose levels, and if she had known she would have increased the insulin. APRN #2 indicated the typical admission process would include a review of hospital notes/recommendations. RN #4 indicated that nurses review the hospital discharge W-10 information but indicated that no staff were responsible to reconcile the W-10 with the written hospital recommendations. Interview with MD #1 (attending physician) on 3/24/22 at 1:00 PM identified that there should have been sliding scale insulin orders in place for Resident #4, with blood glucose perimeters to direct staff when to notify the provider. Additionally, MD #1 indicated a provider (MD or APRN) should have been notified for the elevated blood sugar results. Review of the facility Insulin Administration Policy dated September 2014, directed in part, to notify the physician if the resident has signs or symptoms of [CONDITION(S)]. The policy failed to provide staff with guidance regarding notification to the physician/APRN when residents have an elevated glucose level and no parameters for notification in the physician orders. 2. Resident #12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 12/3/2021 identified a history or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 was alert and oriented and had no behaviors. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Psychological APRN note dated 1/19/2022 at 5 PM, written by APRN #3, identified she was asked to see Resident #12 by the ADNS (current DON) due to the resident going on LOA and using drugs and feeling guilty. The note identified a staff nurse advised APRN #3 that Resident #12 overdosed and [MEDICATION(S)] was administered. APRN discussion with Resident #12 was at first evasive when asked about yesterday's events (1/18/2022), but when APRN advised Resident #12 that she was told he/she had used (drugs) when on LOA, Resident #12 admitted to the use of [MEDICATION(S)] or Heroin (resident was unsure which). The note further indicated that Resident #12 went back to the facility, and then back out (on another LOA) and took a bump (snorted). Review of Psychological physician note dated 1/20/2022 Resident #12 was seen for supportive therapy as he/she had recently used heroin and required [MEDICATION(S)] for recovery. Interview and clinical record review with APRN #3 on 3/23/2022, APRN #3 identified the current DON had asked her to see Resident #12 on 1/19/2022 and staff had informed her that Resident #12 had required [MEDICATION(S)] to be administered on 1/18/2022. APRN #3 indicated that during her interview with Resident #12, Resident #12 had informed her that he/she had used drugs on 1/18/2022. Additional review of the clinical record failed to identify Resident #12 was transferred to the hospital after the reported change in condition that required administration of [MEDICATION(S)] on 1/18/2022. Interview and clinical record review with the DON (ADNS on 1/19/2022) and Administrator on 3/23/2022 at 2:51 PM, identified if a resident required the administration of [MEDICATION(S)], the resident should be transferred to the hospital, and she was unable to provide documentation that Resident #12 was transferred after the reported incident. Interview, clinical record review, and review of hospital records with RN #4 on 3/23/2022 at 5:13 PM identified Resident #12 had no hospital admissions or emergency room visits during 1/2022. Review of facility [MEDICATION(S)] Policy dated 11/19/2018, directed in part, if an RN assessment conclusion is that the resident is suffering the effects of an opioid substance or similar substrate, immediately the emergency medical system is activated, that is, 911 is called and an emergency ambulance is requested prior to the administration of [MEDICATION(S)]. The Policy further directed, [MEDICATION(S)] is only administered with the implicit intent to immediately send the resident to the nearest hospital emergency room via urgent emergency ambulance. A review of the facility's corrective action plan on 3/28/2022 identified all licensed staff will be educated on appropriate review of hospital admission paperwork specifically in regard to insulin orders with finger sticks. When verifying admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Audits will be conducted daily for one month, weekly for four weeks, monthly for four months and then quarterly with results reviewed by QAPI quarterly. As a result of the corrective action that was implemented and verified as complete, the Immediate Jeopardy was identified as removed on 3/28/2022.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of six residents (Residents #1, 2, 3, and 12) reviewed for a change in condition, the facility failed to ensure comprehensive resident care plans were developed related to a substance use disorder including assessing leave of absence status for residents who were identified with contraband or required administration of [MEDICATION(S)]. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Leave of Absence Policy form dated 11/17/2021, signed by Resident #1, indicated Resident #1 was educated regarding the Leave of Absence (LOA) policy. The LOA risk assessment dated [DATE] signed by LPN #8 (no other staff signed) identified Resident #1 requested to be allowed LOA's, was evaluated by a medical provider and therapy, and was deemed safe for LOAs. Additional review identified although the form was signed only by LPN #8, the form indicated the interdisciplinary team approved LOAs. Admission assessment dated [DATE] identified Resident #1 was alert and oriented and was ambulatory. The Resident Care Plan (RCP) 11/18/2021 identified a problem of psychosocial well-being, history of substance abuse, and [MEDICATION(S)] (used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional clinical record review identified a Room Search form dated 3/2/2022 at 5:00 PM identified a search was conducted and the following drug paraphernalia was found: a used needle and razor blades were observed in Resident #1's closet. Additionally, the form identified Resident #1 indicated that someone borrowed his/her coat and did not know where the items came from. Additional Room Search forms dated 3/2 and 3/17/2022 identified no contraband was found. A nurse's note dated 3/3/2022 identified the DNS re-educated Resident #1 on the facility contraband policy. Further, the clinical record failed to document that the LOA was reassessed. Subsequent, to the identification of contraband on 3/2/2022, a care plan was initiated that identified Resident #1 was a smoker. Interventions directed to educate Resident #1 regarding when staff were concerned that he/she may have room searches conducted for smoking paraphernalia. The care plan failed to include the contraband that was found and failed direct a reassessment of Resident #1's LOA privileges. The care plan failed to identify a plan for smoking prior to 3/2/2022, and failed to identify active illicit drug use, leave of absence, and reassessments of both when contraband was found on 3/2/2022. Further, the plan failed to address when to conduct room searches and resident belonging searches. Interview with the DON on 3/21/2022 at 11:45 AM identified she was informed on 3/2/2022 that Resident #1 may have been doing drugs. Staff conducted a room search, and the following items were in the room: needles, razor blades, a pipe with black soot metal balls (pipe filters), two (2) lighters and two (2) [MEDICATION(S)] bottles labeled with Resident #1's name and dated a few days prior to 3/2/2022 that contained a trace amount of green liquid observed the bottom of the containers. The DON further identified Resident #1 should not have had possession of the contraband items and the leave of absence was not reassessed. The DON identified Resident #1 did not have a care plan that thoroughly addressed the substance abuse history. She indicated a care plan that addressed the opioid addiction and potential contraband and LOAs should have been initiated upon admission by the charge nurse, and she did not know why it was not initiated. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] identified Resident #2 was alert and oriented, had an IV access site and was not able to safely attend appointments alone. The RCP dated 2/27/2022 identified a problem with active substance abuse and [MEDICATION(S)] maintenance treatment. Interventions directed to educate Resident #2 on the facility contraband policies to include the room search policy, provide psychological services and counseling as needed, offer substance abuse group, assist with transportation to [MEDICATION(S)] clinic appointments, monitor for changes if [MEDICATION(S)] dose is adjusted, and provide the resident with a daily dose of [MEDICATION(S)] for self-administration. The plan of care failed to address the administration of [MEDICATION(S)], or interventions surrounding intravenous therapy and leave of absence. The nurse's note dated 3/2/2022 (7 days after admission to the facility) at 12:08 PM identified the DON assessed Resident #2 and noted Resident #2 was lethargic, unable to stay awake during conversation, had pinpoint pupils, slurred speech, and was agitated when asked questions. The intravenous PICC line dressing was observed to be almost totally off and multiple superficial scabs were noted all over Resident #2's body. APRN #2 directed to transfer Resident #1 to the hospital for an evaluation. Review of a hospital urine drug screen dated 3/2/2022 at 5:43 PM identified Resident #2 tested positive for amphetamines (an addictive mood-altering drug used illegally as a stimulant that as not medically prescribed and administered at the facility) and [MEDICATION(S)] (a medication that was prescribed at the facility). The hospital history and physical dated 3/2/2022 identified Resident #2 was given [MEDICATION(S)] (used for the emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record failed to identify the RCP was a comprehensive and person centered care plan to address the incident on 3/2/2022, to include new interventions related to substance abuse. During an interview with the DON on 3/22/2022 at 10:12 AM the DON was unable to provide documentation that the RCP was updated related to substance abuse after the incident on 3/2/2022. 3. Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #3 was alert and oriented, and required supervision for walking. The Resident Care Plan (RCP) dated 1/26/2022 identified Resident # 3 had a history or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP also identified Resident #3 was at risk for alteration of psychosocial well-being. Interventions for substance abuse-alcoholism included referral to psychological services as needed and offer the option of attending a substance abuse group when they are available. The nurse's notes dated 2/12/2022 at 11:25 PM identified that Resident #3 was found on the floor unresponsive. Further review of the clinical record identified the nurses note written by RN #3 on 2/13/22 at 12:09 AM identified 911 was called and Resident #3 was transported to the hospital. Clinical record review of the hospital documentation dated 2/12/2022 identified that Resident #3 required three (3) doses of [MEDICATION(S)]; one (1) dose intranasal, and two (2) subsequent doses intravenous to become responsive. The hospital records also identified after [MEDICATION(S)] was administered and Resident #3 became alert, he/she reported to hospital staff that he/she drank one pint of vodka yesterday, and denied use of any other substances such as [MEDICATION(S)] or Marijuana. Hospital toxicology report dated 2/12/2022 identified Resident #3 tested positive for [MEDICATION(S)] and [MEDICATION(S)]. Review of the clinical record failed to identify the care plan was reviewed and revised to address substance abuse and LOAs after Resident #3 was found unresponsive and required three (3) doses of [MEDICATION(S)] (with positive toxicology results) on 2/12/2022. During an interview with the DON on 3/22/2022 at 10 AM the DON indicated Resident #3 did not have a care plan that thoroughly addressed the substance abuse history. She indicated a care plan that addressed the substance abuse history and potential contraband and should have been initiated upon admission by the charge nurse, and she did not know why it was not initiated. 4. Resident #12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 12/3/2021 identified a history or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 was alert and oriented and had no behaviors. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Psychological APRN note dated 1/19/2022 at 5 PM, written by APRN #3, identified she was asked to see Resident #12 by the ADNS (current DON) due to the resident going on LOA and using drugs and feeling guilty. Staff nurse advised APRN #3 that Resident #12 overdosed and [MEDICATION(S)] was administered. The note indicated APRN discussion with Resident #12 was at first evasive when asked about yesterday's events (1/18/2022), but when APRN advised Resident #12 that she was told he/she had used (drugs) when on LOA, Resident #12 admitted to the use of [MEDICATION(S)] or Heroin (resident was unsure which). The note further indicated that Resident #12 went back to the facility, and then back out (on another LOA) and took a bump (snorted). During an interview and clinical record review with APRN #3 on 3/23/2022, APRN #3 indicated that the current DON had asked her to see Resident #12 on 1/19/2022 and staff had informed her that Resident #12 had required [MEDICATION(S)] to be administered on 1/18/2022. APRN #3 indicated that during her interview with Resident #12, Resident #12 had informed her that he/she had used drugs on 1/18/2022. Review of Psychological physician note dated 1/20/2022 Resident #12 was seen for supportive therapy as he/she had recently used heroin and required [MEDICATION(S)] for recovery. Additional review of the clinical record failed to identify Resident #12's LOA order was reviewed to include assessment of the risk of drug use during LOAs. Additional review failed to identify interventions were initiated after the reported incident on 1/18/2022. Please cross reference F684, F689, and F740. During an interview with the DON on 3/21/2022 at 11:45 AM the DON was unable to provide documentation that comprehensive care plans were developed for substance use for Residents #1, 2, 3 and 12 after they were identified to have contraband or required the administration of [MEDICATION(S)]. She indicated that the care plans should include substance abuse history and indicated care plans that addressed addiction and potential contraband should have been initiated upon admission. The DON further identified it was the responsibility of the nurse to initiate the care plans and the MDS nurse would review them. She identified the care plans were not done because the facility had vacant nursing positions. Interview with the Medical Director on 3/23/2022 at 5:05 PM identified that he would not give independent LOA orders for residents with a history of substance abuse. During an interview and record review with the DON and RN #2 on 3/24/2022 at 2:54 PM the facility was unable to provide documentation that the resident care plans were reviewed and revised after the incidents involving drug paraphernalia or [MEDICATION(S)] administration and that the LOA status was reviewed. Review of the facility Contraband Violations Policy directed in part, any use or possession of controlled substances, possession of alcohol, firearms, knife or other weapon, cigarettes, cigars, pipes, e-cigarettes, or fire sources and all smoking materials were contraband items. The Policy further directed, when a resident is found to be in possession of any substances indicated as contraband, the resident care plan will be updated to reflect these interventions. The facility Comprehensive Care Planning Policy dated 9/16/2018, directed in part ,that nursing was to develop and implement a comprehensive person-centered care plan that includes the measurable objectives, and timetables to meet the residents highest practicable physical, psychosocial, and functional needs and the comprehensive care plan must be developed no later than 21 days after admission. Assessments of residents are ongoing and care plans must be revised as the condition changes. The interdisciplinary team must review and update the plan of care with a significant change in condition, when the desired outcome is not met, when a resident is readmitted for m the hospital and at least quarterly in conjunction with the MDS assessment. A review of the facility's corrective action plan on 3/28/2022 identified all licensed staff will be educated on reviewed care plan implementation and appropriate interventions for residents with substance use disorders. Facility psychiatric team will provide education on interventions for residents with substance use disorders. Audits will be complete daily for one month, weekly for four weeks, monthly for four months then quarterly. As a result of the corrective action that was implemented and verified as complete, the Immediate Jeopardy was identified as removed on 3/28/2022. Based on clinical record review, observations, facility policy review, and interviews for one of three residents (Resident #15), reviewed for medication administration, the facility failed to ensure a comprehensive care plan to include resident medication refusals, and for one of three residents (Resident #4) reviewed for diabetes, the facility failed to ensure a comprehensive care plan for diabetes management, and for five of five residents (Resident #7, 8, 9, 10 and 11) reviewed for smoking, the facility failed to ensure a comprehensive smoking care plan was developed for residents that smoked. The findings include: 1. Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 had moderate cognitive impairment and was totally dependent on facility staff for bed mobility, toileting, dressing and required the limited assistance of one staff with eating. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 12/9/2021 identified a failure to follow a therapeutic plan of care related to refusals of care, showers, and weights. Although Resident #15 had a care plan for refusal of care, showers and weights, the care plan failed to identify Resident #15's intermittent refusals to take prescribed medications, the risk of the refusals, or interventions for medication non-compliance such as education. Review of APRN #1's notes, Psychiatric APRN #3 notes, and Psychiatric APRN #4's notes dated 1/5, 2/10, and 3/17/2022 identified that staff were reporting Resident #15 was intermittently non-compliant with medication administration. Review of the nurse's note dated 12/1/2021 through 3/24/2022 failed to identify that Resident #15 had any corresponding nurse's notes related to refusals of medications. Interview and review of progress notes with APRN #3 on 3/24/2022 at 1:26 PM identified that on 1/6/2022 she directed facility staff to administer [MEDICATION(S)] 12.5 milligrams per milliliter (mg/2 ml) once a day on Fridays every two (2) weeks. APRN #3 noted that she was informed on 1/14/2022, during a facility visit, that Resident #15 refused his/her [MEDICATION(S)] due on 1/7/2022. According to APRN #3, the 7:00 AM to 3:00 PM charge nurse on 1/14/2022 indicated that Resident #15's [MEDICATION(S)] remained in the refrigerator and that the resident had refused the administration on 1/7/2022. APRN #3 indicated that she would have been the prescribing practitioner to whom the facility should have reported the refusal. APRN #3 identified that in addition to psychiatric medications, Resident #15 had also been refusing other primary care practitioner prescribed medications. APRN #3 indicated that if she had been informed that Resident #15 refused to take his/her [MEDICATION(S)] on 1/7/2022, she would have changed the date of administration to the next weekday, 1/10/2022. Interview and clinical record review with RN #2/Regional Nurse on 3/24/2022 at 3:40 PM failed to identify that Resident #15 had a care plan or interventions for medication refusals. RN #2 indicated that given Resident #15's history of refusals, a care plan with interventions should have been in place and he did not know why it was not developed. Review of facility Comprehensive Care Planning Policy, directed in part, assessments of residents are ongoing and care plans must be revised as the condition changes. 2. Resident # 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/6/2022 Nursing admission assessment identified Resident #4 was alert and oriented and required one staff assist for transfers and sit/stand with rolling walker. The Resident Care Plan (RCP) dated 2/6/22 identified Resident #4 had a history or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions for substance abuse directed referral to psychological services as needed and offer option of attending a substance abuse group when they are available. Review of the RCP failed to identify any care plans or interventions related to Resident #4's history of diabetes with ketoacidosis. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #4's medication orders included [MEDICATION(S)] ([MEDICATION(S)]) 50-1,000 mg (used to lower blood glucose levels) tablet once a day & [MEDICATION(S)] (hormone to lower blood glucose levels) injection 5 units nightly at bedtime. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note from 2/8/2022 at 2:37 PM identified Resident #4 was lethargic, unable to respond verbally, and short of breath with labored breathing. Blood pressure was 112/82, pulse 70, and respiration 20. Oxygen was initiated at three (3) liters with minimal effect and Resident #4 was transferred to the hospital for further evaluation. A review of hospital records dated 2/8/2022 identified Resident #4 had a blood glucose of 633 on admission to the hospital, was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review identified Resident #4 was readmitted to the facility from the hospital on 2/15/2022. Additional review failed to identify the RCP was updated after readmission to the facility to include blood glucose monitoring. Review of the facility Comprehensive Care Planning Policy dated 9/16/18, directed, in part, that care planning should incorporate identified problem areas and risk factors associated with identified problems. The Policy further directed that care planning should aid in preventing or reducing decline in the resident's functional status and/or functional levels. The care plan must be reviewed and updated when there has been a significant change in the resident's condition and when the resident has been readmitted to the facility from a hospital stay. 3. a. Resident #7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified that R #7 was alert and oriented and was able to walk with supervision. The Resident Care Plan (RCP) dated 2/15/2022 identified Resident #7 was a smoker. Interventions directed supervised smoking. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The smoking assessment dated [DATE] identified Resident #7 may safely smoke on an independent LOA. b. Resident #8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #8 was alert and oriented and was able to walk independently. The RCP dated 3/10/2022 identified Resident #8 was a smoker. Interventions directed Resident #8 would participate in the facility supervised smoking program. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The smoking assessment dated [DATE] identified Resident #8 may safely smoke on an independent LOA. c. Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #9 had moderately impaired cognition was able to walk with supervision. The RCP dated 2/1/2022 identified Resident #9 was a smoker. Interventions directed Resident #9 would participate in the facility supervised smoking program. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The smoking assessment dated [DATE] identified Resident #7 may safely smoke on an independent LOA. d. Resident #10's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #10 was alert and oriented and used a wheelchair for mobility. The RCP dated 2/17/2022 identified a identified Resident #10 was a smoker. Interventions directed Resident #10 would participate in the facility supervised smoking program. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The smoking assessment dated [DATE] identified Resident #10 was able to smoke safely on an independent LOA. e. Resident #11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #11 was alert and oriented and required supervision for walking. The RCP dated 3/10/2022 identified Resident #11 was a smoker. Interventions directed Resident #11 would participate in the facility supervised smoking program. The smoking assessment dated [DATE] identified Resident #11 was able to smoke safely on an independent LOA. Continuous observations on 3/22/2022 at 9:30 AM identified Residents #7, 8, 9 and 10 were on the left side of the sidewalk at the end of the facility driveway smoking cigarettes. Continued observations identified Resident #11 approached the Security Desk and asked Security Guard #1 for cigarettes. Security Guard #1 was observed to give a pack of cigarettes to Resident #11 and Resident #11 was then observed to leave the facility. Continued observation identified Resident #11 was standing on the right side of the sidewalk next to the facility driveway smoking a cigarette independently. Review of the clinical records identified although the residents were observed smoking independently, and the smoking assessments identified the residents could smoke when on LOA from the facility, review of the resident care plans failed to identify smoking independently while on a LOA was included in the smoking care plans for Residents #7, 8, 9, 10 and 11. Interview and clinical record review with the DON and RN #2 on 3/24/2022 at 2:54 PM identified although the RCP for Residents #7, 8, 9, 10 and 11 all directed supervised smoking, the smoking assessments indicated the residents could smoke independently. Interview identified the care plans should have included the residents could smoke independently while on LOA from the facility, and the DON indicated she did not know why it was not addressed in the care plans. Subsequent to surveyor inquiry, RN #2 indicated the care plans would be updated for Residents #7, 8, 9, 10 and 11, and all smoker's care plans would be reviewed to ensure they were accurate. Review of facility Comprehensive Care Planning Policy dated 9/16/2018, directed in part, assessments of residents are ongoing and care plans must be revised as the condition changes.

Based on clinical record review, review of facility documentation, review of facility policies and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was free from contraband drug use, and/or the facility failed to complete a thorough investigation after a resident was found unresponsive. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicative of no cognitive impairment, felt depressed, hopeless nearly every day and walked independently. Review of the Resident Care Plan (RCP) dated 6/11/18 identified a history of or active [DIAGNOSES REDACTED]. Review of the care conference note dated 6/11/18 identified Resident #1 had cravings for illicit substances and stated he/she would smoke marijuana. a. Review of the nurse's note dated 6/17/18 at 6:55 PM identified that Resident #1 was found lying on the ground and not responding to verbal stimuli, APRN was notified and ordered the resident to be transferred to the hospital. Review of facility documentation dated 6/17/18 at 7:00 PM identified that Resident #1 was observed in the courtyard lying on the ground with increased lethargy, diminished responses to stimuli and was transferred to the hospital. Review of the facility investigation identified when Resident #1 was found, Resident #2, Resident #7 and Resident #8 were all standing near Resident #1 in the courtyard. Review of the statement taken from Resident #7 dated 6/18/18 and signed by the ADON identified that Resident #7 had witnessed Resident #2 purchase weed on 6/17/18. Review of the statement taken from Resident #1 dated 6/19/18 and signed by the ADON identified that on 6/17/18 he/she smoked a joint obtained from Resident #2. Resident #1 stated she/he sent Resident #2 out to get it for him/her, and that he/she had some drinks before the joint. Review of the hospital history and physicial dated 6/18/18 identified Resident #1 was found by nursing home staff unresponsive, had respirations of eight (8), blood pressure in the 80's systolic, and dilated pupils 5 millimeters. R #1 was given 0.4 milligrams of [MEDICATION NAME] with improvement in blood pressure and respiratory rate. Review of the hospital blood toxicology results indicated that they were positive for Cannabinoids, Alcohol, and Cocaine. Resident #1 was readmitted to the facility on [DATE]. Review of facility documentation, clinical record and interview with the ADON on 10/29/18 at 1:00 PM identified that Resident #1 obtained the contraband substance from Resident #2 and the facility believed Resident #2 obtained the contraband when Resident #2 went on an LOA on 6/17/18 at 6 PM and returned at 6:42 PM. The ADON further stated the contraband should not have been brought into the facility. Review of facility Contraband Violations Policy identified in part, contraband included use or possession of a controlled substance or illegal drug and any use or possession of alcohol. b. Review of the nurse's note dated 6/17/18 at 6:55 PM identified Resident #1 was found lying on the ground and not responding to verbal stimuli, APRN was notified and ordered the resident to be transfered to the hospital. Review of facility documentation dated 6/17/18 at 7:00PM identified that Resident #1 was observed in the courtyard lying on the ground with increased lethargy and diminished responses to stimuli,and was transferred to the hospital. Review of the facility investigation identified when Resident #1 was found, Resident #2, Resident #7 and Resident #8 were all standing near Resident #1 in the courtyard. Review of the statement taken from Resident #7 dated 6/18/18 and signed by the ADON identified that Resident #7 had witnessed Resident #2 purchase weed on 6/17/18. Review of the statement taken from Resident #1 dated 6/19/18 and signed by the ADON identified on 6/17/18 he/she smoked a joint obtained from Resident #2. Resident #1 stated she/he sent Resident #2 out to get it for him/her, and that he/she had some drinks before the joint. Review of hospital history dated 6/18/18 identified that Resident #1 was found by nursing home staff unresponsive, had respirations of eight (8), blood pressure in the 80's systolic, and dilated pupils 5 millimeters. Resident #1 was given 0.4 milligrams of [MEDICATION NAME] with improvement in blood pressure and respiratory rate. Hospital blood toxicology results were positive for Cannabinoids, Alcohol, and Cocaine. Resident #1 was readmitted to the facility on [DATE]. Review of the clinical record, facility documentation and interview, clinical record review with the ADON on 10/30/18 at 11:01 AM identified when staff observed Resident #1 on 6/17/18 at 7:00 PM unresponsive with Resident #2, Resident #7 and Resident #8 standing near Resident #1, a search of the ground nearby was conducted with no findings, and no search of Resident #2, Resident #7 and Resident #8 was completed on 6/17/18. The ADON stated on 6/19/18 when Resident #1 stated he/she obtained contraband from Resident #1, a search of Resident #1 was conducted with no findings. The ADON also stated the facility was unable to identify the source of alcohol and the investigation did not include identifying how Resident #1 was able to light the contraband, and that the investigation should have included identifying how Resident #1 was able to light the contraband. Review of facility Accidents and Incidents- Investigating Reporting Policy, directed in part that all incidents involving residents shall be investigated.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled resident (Resident #1) who was at risk for elopement, the facility failed to ensure an appropriate safety device, a wanderguard, was implemented and/or the resident was supervised according to the plan of care to prevent the resident from wandering to other units and eloping for which the resident sustained [REDACTED]. Resident #1's [DIAGNOSES REDACTED]. The hospital discharge summary dated 8/2/17 identified Resident #1 was found wandering on the streets and was brought to the hospital related to mental status changes. A physician's orders [REDACTED]. The nursing admission elopement risk assessment dated [DATE] identified Resident #1 verbalized his/her intent to leave, was pacing, and restlessness. The assessment further identified the resident was placed on every fifteen (15) minute checks and a wanderguard needed to be implemented. Review of the physician orders [REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, exhibited physical behavioral symptoms directed towards others, did not exhibit wandering during the assessment period, was independent with ambulating and received an anti-depressant medication. Review of the interim care plans dated 8/2/17 and 8/10/17 failed to reflect the resident was at risk for elopement. Review of the nurse's notes from 8/2/17 through 8/14/17 identified Resident #1 had periods of confusion, was noted to wander aimlessly on unit, needed to be redirected and was on every fifteen (15) minute checks. The psychiatric progress note dated 8/14/17 identified Resident #1 had delusions of going home, moderate confusion that came and went and there was a question of the resident exit seeking. Additionally, the note identified the as needed medication Haldol, was decreased to 0.5 milligrams (mg) every eight (8) hours for agitation and to document the need and time the Haldol was given. The Reportable Event Form dated 8/14/17 at 10:35 PM identified Resident #1 jumped from a window to escape a man that was trying to kill him/her. The report identified Resident #1 was found in a seated position on the ground in the facility parking lot, the resident was assessed and transferred to the hospital for an evaluation. The documentation identified that the resident was having visual hallucinations and jumped from the dining room window on the S-2 unit. Additionally, the documentation identified the Porter saw a man on the S-3 unit walking through and shortly after that the same man was walking on the S-2 unit towards the dining room. Resident #1's room was on the A-2 unit. The hospital discharge summary dated 8/18/17 identified Resident #1 had sustained bilateral severely comminuted calcaneal, heel bone, fractures with intra-articular extension, acute Thoracic 11, 12, and Lumbar 1 vertebral body superior end plate compression fractures, acute Thoracic 9 and 10 right transverse process fractures, and possible acute non-displaced left anterolateral 3 third through fourth rib fractures. Interview with the psychiatric Physician's Assistant-Certified (PA-C) on 8/18/17 at 12:55 PM identified she saw the resident on 8/14/17 related to exit seeking behavior and not being able to sleep. The PA-C stated that she increased the anti-depressant medication, Trazodone, and directed staff to administer the as needed Haldol and to document the resident's behaviors and effect if he/she was exit seeking. Interview with a 3PM-11PM licensed nurse, Licensed Practical Nurse (LPN) #1, on 8/18/17 at 1:23 PM identified that she was returning from the parking lot and heard a man yelling Yo, help. LPN #1 stated she turned and saw a man sitting on the ground against the wall of the building who stated to her I jumped from the window. LPN #1 stated that she went over to the resident and began assessing the resident who was hallucinating and acting paranoid. LPN #1 identified the Nursing Supervisor came out at that time. Interview with a 3PM-11PM nurse aide, Nurse Aide (NA) #3, on 8/18/17 at 1:36 PM identified while she was walking from her car to the building she heard someone yelling Yo, call the cops, help. NA #3 stated that she saw the resident against the wall holding onto his/her ankles. NA #3 stated the resident told her he/she jumped out the window because someone was chasing him/her. Interview with LPN #2 on 8/22/17 at 10:00 AM identified that she was the charge nurse on the A-2 unit (Resident #1's unit) and the resident was on checks every fifteen (15) minutes for wandering. LPN #2 stated she did not see the resident wandering and/or leave the unit. LPN #2 stated after she was notified the resident was outside, she went out and noted the resident was talking but not answering questions appropriately. Interview with NA #1 on 8/22/17 at 10:45 AM identified she was assigned to Resident #1 on the evening of 8/14/17 and the resident was on fifteen (15) minute checks because of the wandering. NA #1 stated the resident was wandering a lot that evening and although she would direct the resident to sit down, the resident would get back up and wander around. NA #1 identified she tried to keep an eye on the resident but she was busy. NA #1 stated that she did not tell the charge nurse the resident was wandering. NA #1 identified that she thinks the last time she checked the resident was around 10:00 PM or 10:15 PM. NA #1 stated although she saw feet at the foot of the bed behind the resident's privacy curtain, she did not go into the room to see if the resident was in the bed because she was busy doing care and was in and out of resident rooms. Interview with the 3PM-11PM Porter on 8/22/17 at 1:15 PM identified that he started his rounds on the third floor units around 9:00 PM. The Porter stated that while he was on S-3 unit he passed by Resident #1 who was holding his/her pants up and had gripper socks on, and the resident was walking in a fast pace in the hallway around 9:15 PM. The Porter identified when he went to the second floor to do his rounds (approximately fifteen (15) minutes later) he again saw the resident on the S-2 unit walking towards the dining room. The Porter stated that while he was on the unit a nurse aide came out into the hallway and asked him if he had ever seen that person, Resident #1, and he told the nurse aide he had seen the person upstairs. Interview with NA #2 on 8/23/17 at 10:35 AM identified on 8/14/17, the resident was unpredictable that night. NA #2 stated Resident #1 would be calm one minute and agitated and acting strange the next. NA #2 stated the resident was up and down all shift wandering in and out of other resident rooms. Interview with NA #4 on 8/23/17 at 11:15 AM identified he was working on S-2 the evening of 8/14/17 and between 9:00 PM and 10:00 PM when he came out of a resident's room, a man walked by him going towards the nurse's station. NA #4 stated that he continued on after he saw the man and did not see where the man went. NA #4 stated although he knew he should find out if the person was a resident and tell the nurse, he was busy and continued on with providing resident care. Interview with the 3PM-11PM Nursing Supervisor, Registered Nurse (RN) #1 on 8/23/17 at 11:45 AM identified when Resident #1 was admitted on [DATE], she assessed the resident and found the resident to be an elopement risk. RN #1 stated that she went to the Director of Nursing (DON) three (3) times to get a wander guard bracelet because when she tested each bracelet against the key pad doors they did not sound, so she placed the resident on every fifteen minute checks. RN #1 stated she told the DON the bracelets did not function and the DON told her she would report the issue. RN #1 stated on 8/14/17 she received a call from someone that there was a problem but could not make out where and from who so she started doing rounds on all the units. RN #1 stated that she then heard an overhead page to come to the lobby, where she saw the resident sitting outside on the ground against the wall of the building. RN #1 stated security reported to her that Resident #1 had jumped from the second floor dining room window. RN #1 identified she assessed the resident, called 911 and the resident was transferred to the hospital for an evaluation. RN #1 stated that while assessing the resident, the resident kept pointing up to the window and saying someone was chasing him/her. Interview and review of the Safety Check Sheets with the Director of Nursing (DON) on 8/23/17 at 12:30 PM identified that from 8/2/17 through 8/14/17 the safety check sheets failed to reflect consistent documentation. The sheets identified that on 8/2/17 and 8/4/17 the safety checks were completed. Upon further review, the sheets were noted to have incomplete documentation for 8/10/17 on the 3-11 shift, 8/12/17 on the 11-7 shift, and on 8/13/17 both the 11-7 shift and 7-3 shift. Additionally, all of the documentation failed to reflect the residents whereabouts and who was monitoring the resident at that time. The DON stated that when a resident was to be monitored every fifteen (15) minute, the staff are to visually see the resident, document and sign for when and who saw the resident. The DON stated that after the incident the Maintenance Director came in, assessed the window and determined the screw from the window was missing and the chain was broken. Subsequent to this investigation, the facility developed an action plan that focused education on the utilization of a wanderguard, safety monitoring and identification of an unknown individual on the unit.

Based on clinical record reviews, review of facility documentation, policies and procedures and interviews for one of two sampled residents (Resident #1) who had a decline in condition, the facility neglected to assess the resident for signs and/or symptoms of dehydration, failed to adequately monitor and record fluid intake and outputs, and failed to ensure the physician was notified that the resident was not meeting the fluid goals prior to when the resident was found unresponsive at 11:30 AM. Although the Advanced Practice Registered Nurse (APRN) ordered bloodwork and Intravenous fluids, the APRN failed to conduct an assessment of the resident, at 11:30 AM to determine appropriate emergency interventions which resulted in a finding of immediate jeopardy. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. difficile is a bacterium that causes diarrhea and more serious intestinal conditions such as [MEDICAL CONDITION]). The nursing admission assessment dated [DATE] at 5:00 PM identified Resident #1 was oriented to person only, had long term memory deficits, was confused, restless, and anxious, the skin was warm to touch, the skin turgor had no tenting and a foley catheter related to bladder retention. The Nutritional assessment dated [DATE] identified Resident #1's fluid need was between 2000 cubic centimeters (cc) and 2400cc per day with a goal to consume greater than 75% of all oral intake and the house supplement at bedtime and twice a day. The admission care plan dated [DATE] identified the resident was at an increased risk for alterations in nutritional status secondary to the potential for dehydration and leaving more than 25% of meals uneaten. Interventions directed to monitor the oral intake at meals, snacks, and medication pass, to assess intake labs and weight and to monitor for signs and symptoms of dehydration. Review of the intake and output records from [DATE] through [DATE] failed to reflect the resident's fluid consumption and the urinary output for eleven (11) out of thirty-one (31) shifts. The records failed to reflect that Resident #1 had consumed a sufficient amount of fluids in a twenty-four (24) hour period, the fluid intake ranged between 0cc to 960cc for a 24 hour period. Review of the nurse's notes from [DATE] through [DATE] identified Resident #1 had poor fluid intake, fluids were encouraged, the urine was amber, tea colored, and the resident had some loose stools. The nurse's note dated [DATE], written at 3:53 AM, identified at 12:00 AM Resident #1 had a temperature of 101.4 Fahrenheit (F), an occasional non-productive cough, the lung sounds were clear to auscultation, the resident had loose stool and the urine was amber in color. The note identified the resident was resistant and combative. The note identified the Nursing Supervisor was updated and Tylenol was administered. At 2:00 AM the resident's temperature was retaken and was noted to be 99.7F. The Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified she was asked to evaluate the resident for cold symptoms, fever and being hoarse. The resident's lungs were assessed at that time and the resident was noted to have wheezes, rhonchi and the respirations were slightly labored. The APRN directed to administer [MEDICATION NAME] 500 milligrams (mg) every twelve (12) hours for a week, [MEDICATION NAME] 50mg daily for five (5) days, Acidophilus one (1) capsule every twelve (12) hours times ten (10), Tylenol 650mg every twelve (12) hours for five (5) days, and to obtain bloodwork in the morning, a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC). The nurse's note failed to reflect documentation the resident was assessed for signs and symptoms of dehydration. The APRN progress note identified at 11:30 AM she was called to see the resident who was unresponsive. The bloodwork was to be obtained immediately and an Intravenous (IV) of Normal Saline at 100cc times three (3) liters was ordered. The nurse's note dated [DATE] at 2:38 PM identified Resident #1 had mental status changes, was hard to awake, the bloodwork was drawn at 2:30 PM and the IV nurse would be coming between 5:,[DATE]:00PM. The nurse's note failed to reflect documentation the resident was assessed for signs and symptoms of dehydration. The nurse's note dated [DATE] at 4:08 PM identified the resident was hard to arise, the note failed to reflect documentation the resident had been assessed for signs and symptoms of dehydration. The procedure note for the IV identified the line was inserted by 5:20 PM. The lab report dated [DATE] identified critical results. The Sodium was 163 (normal range ,[DATE] mmo/L), the Chloride was 122 (normal ,[DATE] mmo/L), and the Blood Urea Nitrogen (BUN) was 55 (normal ,[DATE] mg/dL). The APRN progress note dated [DATE] at 6:30 PM identified the lab called with a critical Sodium level of 163 and although the IV line had been inserted the Normal Saline fluid had not been hung. The nurse's note dated [DATE] at 7:07 PM identified the resident was extremely lethargic, was not able to make needs known and was transferred to the hospital. A physician's orders [REDACTED]. The hospital discharge summary dated [DATE] identified Resident #1 had expired on [DATE] with the principal [DIAGNOSES REDACTED].#1 on [DATE] at 1:30 PM identified she initially saw the resident in the morning on [DATE] at around 8:30 AM for cold symptoms. APRN #1 stated she assessed the resident, identified wheezing and rhonchi and ordered medications and bloodwork. APRN #1 stated she was called back to the resident's room around 11:30 AM and observed the resident to be unresponsive. APRN #1 identified the resident did not respond when she called the resident's name and/or touched the arm. The APRN stated although she did not conduct any further assessment at that time, she ordered STAT labs and to start IV therapy. APRN #1 stated she left the resident and continued on with her rounds within the building. APRN #1 identified she was called back to the resident's room at approximately 5:30 PM because the resident was still unresponsive, the lab results identified the values were in the critical range and at that time sent the resident to the hospital. APRN #1 stated that she should have sent the resident to the hospital at 11:30 AM when the resident was first identified as unresponsive, however, she was waiting for the labs and was trying to treat the resident while in the facility. Interview with the former Acting Director of Nursing (DON) on [DATE] at 10:20 AM identified each shift monitored the resident's intake and output and the 3:,[DATE]:00 PM charge nurse tallied the 24-hour amounts. The former DON stated that if the resident did not meet the calculated fluid needs for two (2) to three (3) days the Nursing Supervisor was to complete a dehydration assessment and notify the physician. Review of Resident #1's clinical record with the former DON failed to reflect documentation that the Nursing Supervisor on ,[DATE]AM and/or the ,[DATE]PM shifts conducted any assessments Resident #1. Interview with the Medical Director on [DATE] at 10:50 AM identified when the resident was noted to be unresponsive, the APRN should have conducted a complete assessment and transferred the resident to the hospital. Interview with the 7:,[DATE]:00 PM Nursing Supervisor, Registered Nurse (RN) #1, on [DATE] at 1:20 PM identified she was not notified that Resident #1 was not meeting his/her fluid needs, had a poor intake and cold symptoms. RN #1 stated that had the charge nurse made her aware she would have assessed the resident and notified the physician of her findings. Interview with the 3:,[DATE]:00PM Nursing Supervisor, RN #2, on [DATE] at 1:50 PM identified she received report the resident had been seen by the APRN, STAT labs were drawn and IV therapy was ordered. Interview with the 11:,[DATE]:00AM Nursing Supervisor, RN #3 on [DATE] at 10:00 AM identified on [DATE] the charge nurse reported to her Resident #1 had a fever and had given the resident Tylenol. RN #3 stated she did not assess the resident because she was busy and didn't have a chance. RN #3 could not recall if she had reported to the oncoming shift of the resident's fever.

Based on clinical record reviews, facility documentation and staff interview for two sampled residents (Resident #1 and #2) who were reviewed for hydration, the facility failed to ensure intake and output were completed and/or ensure hydration assessments were completed when the residents were not meeting their fluid needs. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. difficile is a bacterium that causes diarrhea and more serious intestinal conditions such as [MEDICAL CONDITION]). The nursing admission assessment dated [DATE] at 5:00 PM identified Resident #1 was oriented to person only, had long term memory deficits, was confused, restless, and anxious, the skin was warm to touch, the skin turgor had no tenting and a Foley catheter related to bladder retention. The Nutritional assessment dated [DATE] identified Resident #1's fluid need was between 2000 cubic centimeters (cc) and 2400 cc per day with a goal to consume greater than 75% of all oral intake and the house supplement at bedtime and twice a day. The admission care plan dated [DATE] identified the resident was at an increased risk for alterations in nutritional status secondary to the potential for dehydration and leaving more than 25% of meals uneaten. Interventions directed to monitor the oral intake at meals, snacks, and medication pass, to assess intake labs and weight and to monitor for signs and symptoms of dehydration. Review of the intake and output records from [DATE] through [DATE] failed to reflect the resident's fluid consumption and the urinary output for eleven (11) out of thirty-one (31) shifts. The records failed to reflect that Resident #1 had consumed a sufficient amount of fluids in a twenty-four (24) hour period, the fluid intake ranged between 0 cc to 960 cc for a 24 hour period. Review of the nurse's notes from [DATE] through [DATE] identified Resident #1 had poor fluid intake, fluids were encouraged, the urine was amber, tea colored, and the resident had some loose stools. The nurse's note dated [DATE], written at 3:53 AM, identified at 12:00 AM Resident #1 had a temperature of 101.4 Fahrenheit (F), the resident had loose stool and the urine was amber in color. The note identified the Nursing Supervisor was updated and Tylenol was administered. At 2:00 AM the resident's temperature was retaken and was noted to be 99.7 F. The Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified she was asked to evaluate the resident for cold symptoms, fever and being hoarse and ordered bloodwork to be obtained in the morning, a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC). The APRN progress note identified at 11:30 AM she was called to see the resident who was unresponsive. STAT blood work was ordered and an Intravenous (IV) of Normal Saline at 100 cc times three (3) liters was ordered. The nurse's note dated [DATE] at 2:38 PM identified Resident #1 had mental status changes, was hard to awake, the bloodwork was drawn at 2:30 PM and the IV nurse would be coming between 5:,[DATE]:00 PM. The nurse's note failed to reflect documentation the resident was assessed for signs and symptoms of dehydration. The nurse's note dated [DATE] at 4:08 PM identified the resident was hard to arise, the note failed to reflect documentation the resident had been assessed for signs and symptoms of dehydration. The procedure note for the IV identified the line was inserted by 5:20 PM. The lab report dated [DATE] identified critical results. The Sodium was 163 (normal range ,[DATE] mmo/L), the Chloride was 122 (normal range ,[DATE] mmo/L), and the Blood Urea Nitrogen (BUN) was 55 (normal range ,[DATE] mg/dL). The APRN progress note dated [DATE] at 6:30 PM identified the lab called with a critical Sodium level. The nurse's note dated [DATE] at 7:07 PM identified the resident was extremely lethargic, was not able to make needs known and was transferred to the hospital. A physician's orders [REDACTED]. The hospital discharge summary dated [DATE] identified Resident #1 had expired on [DATE] with the principal [DIAGNOSES REDACTED]. The former DON stated that if the resident did not meet the calculated fluid needs for two (2) to three (3) days the Nursing Supervisor was to complete a dehydration assessment and notify the physician. Review of Resident #1's clinical record with the former DON failed to reflect documentation that the Nursing Supervisor on ,[DATE] AM and/or the ,[DATE] PM shifts conducted any assessments Resident #1. 2. Resident #2's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had severe cognitive impairment, inattention, disorganized thinking, required limited to total assistance with activities of daily living, the resident was independent with eating after set-up, was always incontinent of bowel and bladder, and on a mechanically altered therapeutic diet. The Resident Care Plan dated [DATE] identified an increased risk for alteration in nutrition secondary to potential weight loss, leaves more than 25% of meals uneaten, and was a potential for dehydration. Interventions directed to provide diet and supplements as ordered, to encourage and monitor oral intake at meals, snacks and medication pass, assess the resident's intake and monitor for signs and symptoms of dehydration. The Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified she was asked to see the resident by the family to evaluate cold symptoms the resident had for a couple of days. The note identified the resident was moaning and calling out during the exam and rhonchi was heard with the stethoscope resting on the residents back. The note identified the APRN ordered an antibiotic and [MEDICATION NAME], a corticosteroid drug. The APRN progress note dated [DATE] identified she was asked to see the resident for ongoing moaning and the family wanted the resident sent to the hospital. The note identified the resident was being treated at the facility, would take fluids for the family, labs were ordered to be obtained in the morning and a urinalysis with culture and sensitivity were ordered. The APRN progress note dated [DATE] identified Resident #2 was evaluated for abnormal lab values and an inconsistent oral intake. The bloodwork report identified a critical Blood Urea Nitrogen (BUN) of 95 mg/dL (normal range ,[DATE]), a creatinine level of 1.9 mg/dL (normal range 0XXX,[DATE].5) and an elevated [DIAGNOSES REDACTED] count of 84.9 (normal range ,[DATE]). The APRN note identified [MEDICAL CONDITION] and intravenous (IV) fluids, 1000cc bag of [MEDICATION NAME] 5% in 0.45% Normal Saline for three (3) liters via a midline catheter to run at 50cc/hour, and to redraw labs on [DATE]. The APRN note identified the resident was seen again on [DATE] for a pharmacy medication evaluation. The note identified currently being treated for [REDACTED]. The nurse's notes dated [DATE] through [DATE] identified the resident was receiving IV fluids, continued to have a poor intake, fluids encouraged, and vital signs were taken frequently. Review of intake and output sheets from [DATE] through [DATE] identified out of seventeen (17) shifts there was no documentation of fluid intake for ten (10) shifts and the resident's fluid intake was recorded to be between 60cc to 780cc. Review of the clinical record for February 2017 failed to reflect documentation that a dehydration assessment had been completed. Interview with the former Acting Director of Nursing (DON) on [DATE] at 10:20 AM identified each shift monitored the resident's intake and output and the 3:,[DATE]:00 PM charge nurse tallied the 24-hour amounts. The former DON stated that if the resident did not meet the calculated fluid needs for two (2) to three (3) days the Nursing Supervisor was to complete a dehydration assessment and notify the physician. Review of Resident #2's clinical record from [DATE] through [DATE] with the former DON failed to reflect documentation that dehydration assessments were completed.

Based on clinical record reviews, observations, continuous resident observations, review of policies and procedures, review of facility worksheets, and/or interviews for 9 of 10 sampled residents reviewed with pressure ulcers and/or at risk for pressure ulcers (R#1, 4, 96, 112, 115, 149, 152, 186, 221), the facility failed to assess pressure ulcers on discovery and at least weekly, and/or provide appropriate treatments, and/or provide pressure relief, repositioning and/or incontinent care, and/or failed to re-assess the plan of care and/or treatments when wounds declined or failed to improve, and/or failed to ensure adequate professional nursing oversight to a wound care program resulting in a finding of immediate jeopardy. The findings include: 1. Resident #96's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified the resident was severely cognitively impaired, totally dependent on two staff for bed mobility and transfers, always incontinent of bowel and bladder, and had one facility acquired, stage 4 pressure ulcer that measured 2.2 cm by 1.4 cm by 2.0 cm. Physician orders [REDACTED]. The care plan dated 12/10/16 identified the presence of a pressure ulcer. Interventions included to position resident for comfort, maintain head of bed as low as possible, turn and reposition every 2 hours if resident has mobility problem, and to keep clean and dry as possible. The pressure ulcer assessment dated [DATE] identified a facility acquired stage 4 pressure ulcer of the left ischium that measured 1.8 by 1.6 by 0.2 cm deep and was improving. No other skin issues were identified. Observation of incontinent care on 1/13/17 at 6 AM with NA#7 noted that the resident's dressing on the left ischium had come off and was visibly saturated with urine (yellow liquid) and serosanguinous drainage. NA#7 was observed to re-apply the soiled dressing to the wound and then apply a brief. Continuous observations after the incontinent care through 9:10 AM noted the resident in bed, lying on his/her back with heels resting directly on the mattress surface. No offloading devices were in the bed except a pillow between the legs. NA#6 entered the room at 9:10 AM and exited the room at 9:20 AM. Observation of R#96 at that time noted the resident continued to remain on his/her back with no offloading of the heels. Interview with NA#6 at that time (9:20 AM) indicated that the resident had refused to get out of bed. At 10 AM, NA#6 re-approached the resident who continued to refuse to get out of bed. At that time, NA#6 was asked about the condition of the resident's dressing on the ischium and replied that the dressing was intact and wasn't soiled. Constant observations continued until 10:55 AM when the surveyor inquired to LPN #3 and LPN# 4 (the wound nurses) regarding the resident's wound treatment. Observations with LPNs #3 and 4 at that time noted the resident continued to be on his/her back (6 AM-10:55 AM, 4 hours and 55 minutes), with legs contracted and heels resting on the mattress surface. Upon removal of the resident's brief, it was noted that no dressing was present on the wound or in the brief. LPN #4 indicated at that time that the pressure ulcer was facility acquired and had healed and re-opened. LPN#4 indicated that the NA did not report to the nurse that the dressing was missing/fell off. Assessment of the left ischium pressure ulcer at that time noted the wound had increased in size to 2.5 by 2.0 by .4 cm and now contained 50% slough with moderate amount of drainage and a macerated peri-wound. A subsequent observation of the pressure ulcer and skin assessment at the request of the surveyor with RN#3 and RN#4 on 1/17/17 at 12 noon noted that the wound bed had declined to 80% slough and the periwound remained macerated. A total skin assessment conducted at that time in the presence of the surveyor noted a new, unstageable pressure ulcer of the right heel that measured 4 cm by 5.5 cm covered with 100% eschar. The pressure ulcer had not been previously identified or documented. 2 darkened areas were also noted on the lateral right foot. Right and left outer ankles had non-blanchable reddened areas. Interview and clinical record review with RN#3 on 1/17/17 at 12:15 PM failed to provide documentation that the treatment/care plan had been reviewed and revised when the resident's wound declined. RN#3 was unable to provide documentation that the resident's heel pressure ulcer had been found and assessed prior to 1/17/17 when it was initially identified as a necrotic area. 2. Resident #1's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified that the resident was severely cognitively impaired, had no problem behaviors, was totally dependent on staff for bed mobility and transfers, was incontinent of bowel, and had 3 unstageable pressure ulcers. The care plan dated 10/8/16 identified pressure ulcers to the sacrum, left and right buttocks. Interventions included to turn and reposition every 2 hours, maintain air mattress and RoHo cushion, dietary supplements as ordered and provide incontinent care after each episode. The wound MD assessment dated [DATE] identified the sacral stage 4 pressure ulcer measured 0.6 by 0.6 by 0.2 cm and was 75-100% granulation with a macerated periwound that was improving. The left buttock stage 4 pressure ulcer measured 4 by 3.5 by 0.2 cm with no further description documented. The right buttock stage 4 pressure ulcer measured 4.5 by 1.8 by 0.1 cm with no further description documented. Constant observations initiated at 5:45 AM on 1/13/17, noted the resident in bed on his/her back with heels resting on the bed. The resident remained in this position with no incontinent care or repositioning except to elevate the head of the bed for breakfast until 10:10 AM (4 hours and 25 minutes) when NA #7 provided morning care. NA#7 indicated at that time that there were no dressings on any of the wounds, in the bed or in the brief when s/he went to provide care. The night nurse aide, NA#10, indicated during interview at 6:30 AM, that the resident had last received care and repositioning at 5:15 AM. Observations on 1/13/17 at 10:30 AM with LPN #3 and LPN #4 noted the resident's legs were contracted with no offloading of pressure to the heels/feet. Three open pressure ulcers were visible on the resident's buttocks and sacrum with no dressings present. The right buttock stage 4 pressure ulcer had declined to 6.5 by 2.4 by 0.2 cm with 40% slough in the wound bed and a macerated periwound. The sacral stage 4 pressure ulcer measured 1.5 by 1.3 by 0.6 cm with 100% slough present and macerated periwound. The left buttock stage 4 measured 8.2 by 5.5 by 0.5 cm with 40% slough with undermining at 10:00 and macerated periwound. Interview and review of the clinical record with RN#3 on 1/17/17 at 1:15 PM failed to provide documentation that the treatment program and/or plan of care had been reviewed / revised to enable healing of the wounds after the pressure ulcers were noted to have declined on 1/13/17. Review of the wound MD progress notes/assessments and orders dated 11/11/16 through 1/16/17 noted that the treatments for the three pressure ulcers remained calcium alginate {Calcium Alginate dressings are derived from seaweed and are used for full- or partial-thickness wounds with moderate to heavy exudate, including infected wounds or wounds with tunneling and/or undermining or Bleeding wound (helps achieve hemostasis)} despite no improvement. The wound MD's assessments done weekly failed to provide any further orders/recommendations for wound healing. 3. Resident #186's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] noted the presence of a deep tissue injury (closed and discolored areas) to the left heel measuring 5.5 by 5 cm and the right heel measuring 1.5 by 3 cm. Physician orders [REDACTED]. The quarterly MDS dated [DATE] identified that the resident was cognitively impaired, displayed no problem behaviors, required extensive assistance from 2 staff members for bed mobility and transfers, was always incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers, and had 2 venous or arterial ulcers. The care plan dated 11/27/16 noted a skin impairment of left heel and 2nd toe vascular wound. Interventions included monitor for deterioration, and follow up with vascular MD as indicated. A vascular surgery consult dated 12/20/16 noted that the left heel was a new pressure ulcer with directions to apply Santyl to the outer edge of the wound twice daily. Review of physician orders [REDACTED]. On 1/5/17 the wound assessment by LPN #4 noted the left heel was 5.2 by 4 cm with eschar (necrotic tissue), continue using skin prep as a treatment and to use off load boots. Observations with NA #9 on 1/10/17 at 11:15 AM noted the resident in bed on his/her right side. The resident's left heel was lacking a dressing and not offloaded. Boots were noted on the table in the resident's room. The left heel was noted with a large blister/necrotic area that was lifting around the edges with the wound edges noted red/pink in color. Interview and review of the clinical record with LPN #3 on 1/18/17 at 2 PM failed to provide documentation that the surgical consult orders had been followed up and/or initiated from 12/20/16 through 1/5/17, and/or that the wound had been re-assessed since 1/5/17 (last documented assessment), and/or that treatment orders had been initiated when the surgeon's orders were discontinued on 1/10/17. LPN#3 was unable to identify why the facility had classified the pressure ulcer as a vascular wound instead of pressure. 4. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #4 was cognitively impaired, totally dependent on staff for bed mobility and transfers, incontinent of bowel with an indwelling urinary catheter, and had a facility acquired stage 4 pressure ulcer. physician's orders [REDACTED]. The care plan dated 12/24/16 identified a stage 4 pressure ulcer on the sacrum which measured 1.4 cm x 0.8 cm x 0.4 cm. Interventions included to provide an alternating pressure mattress, turn and reposition every two hours, and avoid affected areas. The MD pressure wound assessment dated [DATE] identified a stage 3 pressure ulcer that measured 1.3 by 0.8 by 0.4 cm. Continuous observation of Resident #4 from 6:40 AM until 7:40 AM on 1/13/17 identified the resident in bed positioned on his/her back. At 7:40 AM, NA #4 was observed providing incontinent care. The resident was noted to have stool present as well as a dressing loosely hanging from the sacral area with an open area visible on the sacrum. The dressing fell off and it was rolled up in the dirty brief. A new brief was placed on the resident without the benefit of a dressing over his/her wound, and although a pillow was behind the resident's back, the sacral area remained in contact with the mattress. The resident was observed to remain in this position until 11 AM (3 hours and 20 minutes). Interview with LPN #4 on 1/13/17 at 10:50 AM identified that he/she had not been informed that a dressing needed to be done. Interview with LPN #3 on 1/13/17 at 10:55 AM identified that if a dressing falls off during the provision of care, the protocol is to call the treatment nurse to complete a dressing change. At 11 AM, subsequent to surveyor inquiry, LPN# 2 was notified that the dressing had fallen off of Resident #4 during the provision of incontinent care at 7:40 AM. LPN #2 identified that he/she was not aware that the resident's dressing had fallen off but would pre-medicate the resident and call the treatment nurse. LPN#2 identified that he/she should have immediately been informed that the dressing was missing. The resident was pre-medicated at 11 AM to have the dressing changed. Interview with NA#4 on 1/13/17 at 11:10 AM identified that he/she did not report that the resident did not have a dressing on his/her coccyx because he/she forgot. Observation of Resident #4's treatment on 1/13/17 at 11:37 AM identified that the resident had been incontinent of stool and lacking a dressing to protect the area. Interview with LPN#4 on 1/18/17 at 4 PM identified that resident's should be turned and positioned according to the physician's orders [REDACTED]. A subsequent pressure ulcer assessment with the surveyor on 1/19/17 at 11:45 AM noted that the wound had declined to 2.5 by 1.5 by 0.5 cm deep with undermining at 12 and 6 and tunneling at 9:00. The treatment orders had remained calcium alginate with no changes to the plan of care since admission. 5. Resident #152's [DIAGNOSES REDACTED]. The resident had been admitted to the acute care hospital on [DATE] for [MEDICAL CONDITION] and dehydration. Resident #152 was readmitted back to the facility from the acute care hospital on [DATE] with no pressure ulcers present. The care plan (RCP) dated 12/6/16 identified that the resident was at risk for skin breakdown and interventions included pressure ulcer prevention (PUP) protocol and skin surveillance weekly. The MDS dated [DATE] identified that the resident was severely impaired for daily decision making, was totally dependent for all activities for daily living (ADLs), incontinent of bowel and bladder, had no pressure ulcers and was at risk for pressure ulcer development. Nurse's notes dated 1/6/17 and facility documentation dated 1/6/17 identified that the resident was found with an open area on the right buttock that measured 1cm x 0.5 cm., the supervisor was notified and treatment was ordered (however, treatment identified the left buttock). The record failed to reflect the wound description and nursing assessment that included the type, stage of the ulcer, color and/or drainage. Facility pressure ulcer worksheets noted the area as unstageable when first discovered with no further description. Review of the Prediction of Residents at Risk for Development of Pressure Ulcers Policy indicated that the Skin Impairments/pressure ulcers were to be documented upon discovery, with significant change in wound appearance and at least every 7 days. No further wound documentation was noted in the record thereafter. The resident was transferred to the hospital on [DATE]. Review of the Prediction of Residents at Risk for Development of Pressure Ulcers Policy indicated that weekly skin assessments were completed on bath/shower day, documented in the Kardex and any changes were to be noted in nurse's notes and placed on the 24 hour report. Review of the clinical record and interview with LPN #3 on 1/19/17 at 2:00 PM failed to reflect that any weekly skin assessments had been completed in November 2016, December 2016 and January 2017. Additionally, the Policy indicated that the Registered Dietician would review the resident's record who had a change in condition, weight loss or decrease in hydration and make appropriate recommendations. Review of the record and interview with the RD on 1/19/17 at 1:30 PM failed to reflect any dietary evaluations, assessments and or consults. 6. R#115's [DIAGNOSES REDACTED].#115 was severely cognitively impaired, required extensive assistance with all activities of daily living (ADLs), was always incontinent of bowel and bladder, and was at risk for pressure ulcer development. Resident care plan (RCP) dated 10/13/2016 identified an alteration in skin integrity due to bowel and bladder incontinence. Interventions included to provide incontinent care and repositioning every two (2) hours. Continuous observation on 1/11/17 from 10:28 AM through 2:00 PM (3 hours and 30 minutes) noted R#115 seated in a custom wheel chair without the benefit of repositioning and/or incontinent care. Observation of R#115 during NA# 1 and NA#2 provision of incontinent care on 01/11/17 at 02:02 PM noted R#115's buttocks, hips and thighs were noted with deep lines of demarcation impressed into the resident's skin and the brief was noted heavily saturated with urine (blue line completely activated) and feces was smeared between and into the resident's perineal area. With R#115 positioned on his/her back, NA#1 proceeded with a wet disposable paper towel to pull feces from (between the resident's legs/perineal area) and/or from back/anus area through and over the front of the resident's vagina/urethra area. Subsequent to completion of incontinent care and re-placement of a clean brief, the brief was observed to be pulled tight between the resident's legs and at that time surveyor requested that the front of the brief be pulled back and the brief was noted soiled with feces. Interview with NA#1 on 01/11/2017 at 02:19 PM indicated that the last time R#115 received care and was taken out of bed was after 10:00 AM. Although NA#1 was unable to explain why R#115 did not receive care from 10:00 AM to 2:00 PM, NA#2 indicated that they were short staffed and very busy providing care. Interview with the unit charge nurse LPN#1 on 1/11/17 at 2:29 PM noted that although s/he was unable to explain why R#115 had not received care from 10:00 AM, review of the nurse aide care card and the attached pressure ulcer prevention (PUP) policy directed the provision of incontinent care and/or repositioning every two (2) hours and as needed. Interview and review of R#115's record with RN#3 at that time indicated that incontinent care should be provided every two (2) hours and as needed and that when providing incontinent care to always wipe from front to back to prevent infections like a urinary tract infection [MEDICAL CONDITION]. Subsequent to the surveyor's observations and inquiry related to R#115's lack of provision of incontinent/positioning care, corporate nurse #1 provided a revised version of the pressure sore prevention (PUP) plan. S/he indicated that facility staff had received re-training related to the revised pressure ulcer prevention. Upon review of the PUP it was noted that the provision of care and repositioning time frame had been altered/changed from every (2) two hours to every (2) two to (4) four hours and as needed. Corporate nurse #1 indicated that it was the standard in all of his/her other buildings. 7. Resident # 221's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] indicated the resident was in a persistent vegetative state, required total care of all ADL's, was at risk for developing pressure ulcers, and had no pressure ulcers. A resident care plan dated 12/27/16 identified R # 221 was at risk for skin breakdown. Interventions included turn and position, preventative skin care, ulcer care, and pillows for boney prominence. An interview with the DNS on 1/18/17 at 10:56 AM indicated no other care plans prior to 12/27/16 could be found. a. A nurse's note dated 6/23/16 indicated R # 221 returned from the hospital with a deep tissue injury on the right buttock and open area on the right hand. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Treatment to the right hand continued through 8/17/16 although no assessment or description of the area was found. The initial pressure ulcer assessment of the right buttock was not documented until 8/21/16 and was noted as a stage 2 pressure sore. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide an assessment of the deep tissue injury on the right buttock identified on 6/23/16 and/or the open area on the right hand identified on 6/23/16, and/or the open area identified on the physician's orders [REDACTED]. He/she was unable to provide an A & I report. b. A nurse's note dated 7/10/16 indicated a fluid filled blister was noted on R # 221's right foot. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide any record of assessments of the right lateral foot identified on 7/11/16 and/or the open area on the right lateral foot identified on 7/12/16. He/she indicated when a pressure ulcer is identified an accident and incident report is generated to initiate an assessment and/or treatment orders. He/she was unable to provide an A & I report. c. A nurse's note dated 8/22/16 indicated the right great toe was noted with drainage. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The initial assessment was conducted by the wound Physician on 10/6/16 and noted as abrasions on the right dorsal toes .2 cm [MEDICAL CONDITION]. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide any assessments of the to the right medial great toe open area identified on 8/23/16 and/or open area identified on the physician's orders [REDACTED]. He/she was unable to provide an A & I report. d. Review of an Infectious disease consult dated 8/25/16 indicated R # 221 had a bruise on his/her left heel. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide an assessment of the left heel bruise identified on 8/25/16. He/she indicated when the resident returned from the consult on 8/25/16 the nurse should have read the consult report and assessed the resident's left heel. e. Review of a podiatry consult dated 7/27/16 indicated R # 221's heels needed to be off the resting surface at all times. Review of a physician's orders [REDACTED]. Review of treatment records dated 6/23/16 - 6/30/16, 7/1/16 -7/31/16, 8/1/16 -8/31/16 indicated the preventative ulcer plan (PUP) (repositioning every 2 hours and off-loading heels) had been provided every shift and preventative foot care was provided weekly. Treatment records dated 9/18/16 - 9/30/16, and 10/1/16 - 10/31/16 noted the PUP had only been documented 3 times on 7 AM-3 PM shift and sixteen times on the 3-11 PM shift. Weekly preventative foot care was blank indicating it had not been provided. Review of the treatment records dated 11/1/16 - 11/30/16 noted the PUP was not provided on the 7 AM- 3 PM shift and only fifteen times on the 3 - 11 PM shift. The weekly preventative foot care was blank. 8. Resident #112's [DIAGNOSES REDACTED]. The admission/interim care plan dated 11/18/16 identified bilateral heel pressure ulcers. Interventions included to elevate heels off bed surface and float heels, no pressure on heels, provide off-loading boots, and turn and reposition every two hours. The Admission 5 day MDS assessment dated [DATE] identified the resident was without cognitive impairment, required the extensive assistance of two staff for bed mobility, was totally dependent for transfers, dressing and toileting, and had a suspected deep tissue injury (DTI). physician's orders [REDACTED]. Further orders directed the right heel pressure ulcer to be covered with non-adhesive dressing and dry clean dressing daily for 14 days and off load heels over edge of a pillow. On 12/3/16, physician's orders [REDACTED].U.P. policy. On 12/16/16, treatment orders directed to cleanse the left heel with normal saline, pat dry, skin prep to periwound, xeroform to wound bed followed by dry clean dressing, change every other day for 14 days. On 12/27/16 the treatment was continued. On 12/30/16 the treatment was changed to calcium alginate, with ABD pad and Kerlix wrap and change every day for 14 days. Weekly wound assessments of the right heel by the wound MD identified the following: 11/24/16 - Unstageable. 5 cm x 3.2 cm. Left heel not assessed. 12/1/16 - Stage 2 pressure ulcer. 6.4 cm x 6 cm x 0.2 cm. Left heel was not assessed. 12/8/16 - Deep tissue pressure injury. 6.2 cm x 6 cm and scant amount sero-sanguinous drainage noted, wound bed 51-75% [MEDICATION NAME] 1-25% eschar and was noted to be improving. The left heel was not assessed. 12/15/16 - 4 cm x 5 cm, wound bed 76-100% granulation and the left heel pressure ulcer measured 6 cm x 6 cm, and was a deep tissue pressure injury with scant sero-sanguineous drainage, 1-25% eschar and 51-75% [MEDICATION NAME]. 12/22/16 - 4 cm x 3.4 cm, wound bed 76-100% granulation, wound is improving. Left heel was documented as a deep tissue pressure injury that was 4.5 cm x 4 cm with scant serosanguinous drainage. Wound bed is 51-75% [MEDICATION NAME] 1-25% eschar, wound is improving. An outside hospital podiatry consultation note dated 12/28/16 identified that the resident's wounds were debrided, continue [DEVICE] to the left heel, [MEDICATION NAME] to the right heel, order for off-loading/podus boot for the right foot as the wound has increased in size. Recommendations were for off-loading boot bilaterally at all times, continue with [DEVICE] to the left foot three times per week, and [MEDICATION NAME] to the right heel daily. Observation of Resident #112 on 1/13/17 at 6 AM identified the resident in bed, on his/her back. White, off-loading booties were noted to be on the wheelchair as well as a pillow in the wheelchair. At 6:15 AM, NA#8 provided incontinent care and the resident was noted to have on slipper socks with both of his/her heels resting directly on the mattress and no sign of offloading devices in the bed or on the floor. Following care, the resident was repositioned back onto his/her back with the slipper socks heels resting on the mattress. NA#8 did not offer offloading or application of the booties at that time. The resident had a facial grimace and then verbalized a complaint of heel pain. NA#8 told LPN#6 that the resident was having heel pain. LPN#6 returned at 6:42 AM to inquire about the heel pain level, and the resident replied it was a 10 on a pain scale of 1-10 with 10 being the worst pain. LPN#6 failed to check the resident's heels. Resident #112 then began to cry. The nurse left and returned to administer pain medication, and again, failed to check the resident's heels or provide repositioning. At 6:55 AM, LPN#6 went in to recheck the resident and the resident stated he/she was still in pain. No interventions were initiated. At 7:02 AM, NA#8 went in to check on the resident's pain and the resident identified that he/she still had no relief. The resident continued to be constantly observed until 8:45 AM when a NA went in to deliver the resident's breakfast. The NA was observed to raise the head of the bed, set up the resident's tray and left the room. The resident's heels remained on the bed, the white booties and pillow remained on the wheelchair. The resident remained on his/her back with the white booties and pillow in the wheelchair and heels resting on the bed until 9:40 AM when NA #4 came in to provide AM care. Observation at that time noted the same slipper socks in place and the heels on the bed. Interview with NA#4 on 1/13/17 at 10 AM identified that the resident should have his/her heels on a pillow off of the bed. NA#4 asked Resident #112 if he/she had refused the pillow. Resident #112 replied that he/she had. NA#4 got Resident #112 up to the wheelchair and placed the white off-loading booties on the resident, without any objection from the resident. Interview with Resident #112 on 1/13/17 at 10:10 AM identified that the last time anyone had asked him/her if s/he wanted to off load his/her heels was on the 3-11 shift the previous evening. Resident #112 identified that s/he had never been offered any other measures to maintain off-loading since that time. Interview and review of facility documentation with LPN #3 and LPN #4 on 1/12/17 at 9:25 AM identified that there were no assessments of the resident's wound on admission (11/18/16-the nursing body assessment was blank) through 11/24/16 when the wound MD assessed the resident's right heel and the LPN documented an assessment of the resident left heel. The MD identified the left heel as resolved. LPN# 4 identified that the wound MD did not assess the left heel, at that time, because the hospital MD was responsible for the left heel and, although LPN#4 verbalized that the MD looked at the left heel, LPN#4 was the only one who documented any assessments of the resident's left heel wound on 11/24/16, 12/1/16, 12/8/16, 12/29/16, 1/5/16 and on 1/11/16. LPN#3 identified that he/she is in charge of the wound program and that LPN#4 does all the treatments weekly with the wound MD. Re-interview and clinical record review with LPN#4 on 1/18/17 at 1:20 PM failed to identify that the off-loading boots recommended by the hospital podiatry consult dated 12/28/16 were initiated and LPN #4 noted that they should have been put on the treatment kardex. LPN #4 indicated that although an outside physician consult for the wounds ordered [MEDICATION NAME], the facility did not use his/her orders on 12/28/16 and substituted Calcium Alginate as this was their protocol. The facility was unable to provide a wound treatment formulary. 9. Resident #149's [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] identified that the resident was severely cognitively impaired, displayed no problem behaviors, was totally dependent on 2 staff members for bed mobility and transfers, was incontinent of bowel and bladder, at risk for pressure ulcers and had no current pressure ulcers at that time. Review of physician wound documentation dated 11/3/16 identified a new stage 2 pressure ulcer of the left buttock that measured 1.6 by 1.4 cm. Treatment orders directed calcium alginate to the wound daily. On 11/10/16, physician wound documentation noted the wound was 1.8 by 1.4cm with maceration and no improvement. Treatment orders continued to direct calcium alginate daily. On 11/17/16, the MD wound assessment measured 2.0 x 0.5cm with no description of the wound documented. Treatment orders directed calcium alginate daily. The next MD wound assessment dated [DATE] noted measurement of 1.5 x 1.5. 0.3 cm depth; wound bed with 1-25% slough, The wound is improving. Periwound maceration. Treatment orders were unchanged with no new recommendations. On 12/15/16, the wound depth had increased to 0.5 cm and no treatment plan changes were recommended or initiated. On 12/22/16, the wound MD

Based on clinical record reviews, observations, continuous resident observations, review of policies and procedures, review of facility worksheets, and/or interviews for 9 of 10 sampled residents reviewed with pressure ulcers and/or at risk for pressure ulcers (R#1, 4, 96, 112, 115, 149, 152, 186, 221), the facility neglected to assess pressure ulcers on discovery and at least weekly, and/or provide appropriate treatments, and/or provide pressure relief, repositioning and/or incontinent care, and/or failed to re-assess the plan of care and/or treatments when wounds declined or failed to improve, and/or failed to ensure adequate professional nursing oversight to a wound care program resulting in a finding of immediate jeopardy. The findings include: 1. Resident #96's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified the resident was severely cognitively impaired, totally dependent on two staff for bed mobility and transfers, always incontinent of bowel and bladder, and had one facility acquired, stage 4 pressure ulcer that measured 2.2 cm by 1.4 cm by 2.0 cm. Physician orders [REDACTED]. The care plan dated 12/10/16 identified the presence of a pressure ulcer. Interventions included to position resident for comfort, maintain head of bed as low as possible, turn and reposition every 2 hours if resident has mobility problem, and to keep clean and dry as possible. The pressure ulcer assessment dated [DATE] identified a facility acquired stage 4 pressure ulcer of the left ischium that measured 1.8 by 1.6 by 0.2 cm deep and was improving. No other skin issues were identified. Observation of incontinent care on 1/13/17 at 6 AM with NA#7 noted that the resident's dressing on the left ischium had come off and was visibly saturated with urine (yellow liquid) and serosanguinous drainage. NA#7 was observed to re-apply the soiled dressing to the wound and then apply a brief. Continuous observations after the incontinent care through 9:10 AM noted the resident in bed, lying on his/her back with heels resting directly on the mattress surface. No offloading devices were in the bed except a pillow between the legs. NA#6 entered the room at 9:10 AM and exited the room at 9:20 AM. Observation of R#96 at that time noted the resident continued to remain on his/her back with no offloading of the heels. Interview with NA#6 at that time (9:20 AM) indicated that the resident had refused to get out of bed. At 10 AM, NA#6 re-approached the resident who continued to refuse to get out of bed. At that time, NA#6 was asked about the condition of the resident's dressing on the ischium and replied that the dressing was intact and wasn't soiled. Constant observations continued until 10:55 AM when the surveyor inquired to LPN #3 and LPN# 4 (the wound nurses) regarding the resident's wound treatment. Observations with LPNs #3 and 4 at that time noted the resident continued to be on his/her back (6 AM-10:55 AM, 4 hours and 55 minutes), with legs contracted and heels resting on the mattress surface. Upon removal of the resident's brief, it was noted that no dressing was present on the wound or in the brief. LPN #4 indicated at that time that the pressure ulcer was facility acquired and had healed and re-opened. LPN#4 indicated that the NA did not report to the nurse that the dressing was missing/fell off. Assessment of the left ischium pressure ulcer at that time noted the wound had increased in size to 2.5 by 2.0 by .4 cm and now contained 50% slough with moderate amount of drainage and a macerated peri-wound. A subsequent observation of the pressure ulcer and skin assessment at the request of the surveyor with RN#3 and RN#4 on 1/17/17 at 12 noon noted that the wound bed had declined to 80% slough and the periwound remained macerated. A total skin assessment conducted at that time in the presence of the surveyor noted a new, unstageable pressure ulcer of the right heel that measured 4 cm by 5.5 cm covered with 100% eschar. The pressure ulcer had not been previously identified or documented. 2 darkened areas were also noted on the lateral right foot. Right and left outer ankles had non-blanchable reddened areas. Interview and clinical record review with RN#3 on 1/17/17 at 12:15 PM failed to provide documentation that the treatment/care plan had been reviewed and revised when the resident's wound declined. RN#3 was unable to provide documentation that the resident's heel pressure ulcer had been found and assessed prior to 1/17/17 when it was initially identified as a necrotic area. 2. Resident #1's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified that the resident was severely cognitively impaired, had no problem behaviors, was totally dependent on staff for bed mobility and transfers, was incontinent of bowel, and had 3 unstageable pressure ulcers. The care plan dated 10/8/16 identified pressure ulcers to the sacrum, left and right buttocks. Interventions included to turn and reposition every 2 hours, maintain air mattress and RoHo cushion, dietary supplements as ordered and provide incontinent care after each episode. The wound MD assessment dated [DATE] identified the sacral stage 4 pressure ulcer measured 0.6 by 0.6 by 0.2 cm and was 75-100% granulation with a macerated periwound that was improving. The left buttock stage 4 pressure ulcer measured 4 by 3.5 by 0.2 cm with no further description documented. The right buttock stage 4 pressure ulcer measured 4.5 by 1.8 by 0.1 cm with no further description documented. Constant observations initiated at 5:45 AM on 1/13/17, noted the resident in bed on his/her back with heels resting on the bed. The resident remained in this position with no incontinent care or repositioning except to elevate the head of the bed for breakfast until 10:10 AM (4 hours and 25 minutes) when NA #7 provided morning care. NA#7 indicated at that time that there were no dressings on any of the wounds, in the bed or in the brief when s/he went to provide care. The night nurse aide, NA#10, indicated during interview at 6:30 AM, that the resident had last received care and repositioning at 5:15 AM. Observations on 1/13/17 at 10:30 AM with LPN #3 and LPN #4 noted the resident's legs were contracted with no offloading of pressure to the heels/feet. Three open pressure ulcers were visible on the resident's buttocks and sacrum with no dressings present. The right buttock stage 4 pressure ulcer had declined to 6.5 by 2.4 by 0.2 cm with 40% slough in the wound bed and a macerated periwound. The sacral stage 4 pressure ulcer measured 1.5 by 1.3 by 0.6 cm with 100% slough present and macerated periwound. The left buttock stage 4 measured 8.2 by 5.5 by 0.5 cm with 40% slough with undermining at 10:00 and macerated periwound. Interview and review of the clinical record with RN#3 on 1/17/17 at 1:15 PM failed to provide documentation that the treatment program and/or plan of care had been reviewed / revised to enable healing of the wounds after the pressure ulcers were noted to have declined on 1/13/17. Review of the wound MD progress notes/assessments and orders dated 11/11/16 through 1/16/17 noted that the treatments for the three pressure ulcers remained calcium alginate despite no improvement. The wound MD's assessments done weekly failed to provide any further orders/recommendations for wound healing. 3. Resident #186's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] noted the presence of a deep tissue injury (closed and discolored areas) to the left heel measuring 5.5 by 5 cm and the right heel measuring 1.5 by 3 cm. Physician orders [REDACTED]. The quarterly MDS dated [DATE] identified that the resident was cognitively impaired, displayed no problem behaviors, required extensive assistance from 2 staff members for bed mobility and transfers, was always incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers, and had 2 venous or arterial ulcers. The care plan dated 11/27/16 noted a skin impairment of left heel and 2nd toe vascular wound. Interventions included monitor for deterioration, and follow up with vascular MD as indicated. A vascular surgery consult dated 12/20/16 noted that the left heel was a new pressure ulcer with directions to apply Santyl to the outer edge of the wound twice daily. Review of physician orders [REDACTED]. On 1/5/17 the wound assessment by LPN #4 noted the left heel was 5.2 by 4 cm with eschar (necrotic tissue), continue using skin prep as a treatment and to use off load boots. Observations with NA #9 on 1/10/17 at 11:15 AM noted the resident in bed on his/her right side. The resident's left heel was lacking a dressing and not offloaded. Boots were noted on the table in the resident's room. The left heel was noted with a large blister/necrotic area that was lifting around the edges with the wound edges noted red/pink in color. Interview and review of the clinical record with LPN #3 on 1/18/17 at 2 PM failed to provide documentation that the surgical consult orders had been followed up and/or initiated from 12/20/16 through 1/5/17, and/or that the wound had been re-assessed since 1/5/17 (last documented assessment), and/or that treatment orders had been initiated when the surgeon's orders were discontinued on 1/10/17. LPN#3 was unable to identify why the facility had classified the pressure ulcer as a vascular wound instead of pressure. 4. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #4 was cognitively impaired, totally dependent on staff for bed mobility and transfers, incontinent of bowel with an indwelling urinary catheter, and had a facility acquired stage 4 pressure ulcer. physician's orders [REDACTED]. The care plan dated 12/24/16 identified a stage 4 pressure ulcer on the sacrum which measured 1.4 cm x 0.8 cm x 0.4 cm. Interventions included to provide an alternating pressure mattress, turn and reposition every two hours, and avoid affected areas. The MD pressure wound assessment dated [DATE] identified a stage 3 pressure ulcer that measured 1.3 by 0.8 by 0.4 cm. Continuous observation of Resident #4 from 6:40 AM until 7:40 AM on 1/13/17 identified the resident in bed positioned on his/her back. At 7:40 AM, NA #4 was observed providing incontinent care. The resident was noted to have stool present as well as a dressing loosely hanging from the sacral area with an open area visible on the sacrum. The dressing fell off and it was rolled up in the dirty brief. A new brief was placed on the resident without the benefit of a dressing over his/her wound, and although a pillow was behind the resident's back, the sacral area remained in contact with the mattress. The resident was observed to remain in this position until 11 AM (3 hours and 20 minutes). Interview with LPN #4 on 1/13/17 at 10:50 AM identified that he/she had not been informed that a dressing needed to be done. Interview with LPN #3 on 1/13/17 at 10:55 AM identified that if a dressing falls off during the provision of care, the protocol is to call the treatment nurse to complete a dressing change. At 11 AM, subsequent to surveyor inquiry, LPN# 2 was notified that the dressing had fallen off of Resident #4 during the provision of incontinent care at 7:40 AM. LPN #2 identified that he/she was not aware that the resident's dressing had fallen off but would pre-medicate the resident and call the treatment nurse. LPN#2 identified that he/she should have immediately been informed that the dressing was missing. The resident was pre-medicated at 11 AM to have the dressing changed. Interview with NA#4 on 1/13/17 at 11:10 AM identified that he/she did not report that the resident did not have a dressing on his/her coccyx because he/she forgot. Observation of Resident #4's treatment on 1/13/17 at 11:37 AM identified that the resident had been incontinent of stool and lacking a dressing to protect the area. Interview with LPN#4 on 1/18/17 at 4 PM identified that resident's should be turned and positioned according to the physician's orders [REDACTED]. A subsequent pressure ulcer assessment with the surveyor on 1/19/17 at 11:45 AM noted that the wound had declined to 2.5 by 1.5 by 0.5 cm deep with undermining at 12 and 6 and tunneling at 9:00. The treatment orders had remained calcium alginate with no changes to the plan of care since admission. 5. Resident #152's [DIAGNOSES REDACTED]. The resident had been admitted to the acute care hospital on [DATE] for [MEDICAL CONDITION] and dehydration. Resident #152 was readmitted back to the facility from the acute care hospital on [DATE] with no pressure ulcers present. The care plan (RCP) dated 12/6/16 identified that the resident was at risk for skin breakdown and interventions included pressure ulcer prevention (PUP) protocol and skin surveillance weekly. The MDS dated [DATE] identified that the resident was severely impaired for daily decision making, was totally dependent for all activities for daily living (ADLs), incontinent of bowel and bladder, had no pressure ulcers and was at risk for pressure ulcer development. Nurse's notes dated 1/6/17 and facility documentation dated 1/6/17 identified that the resident was found with an open area on the right buttock that measured 1cm x 0.5 cm., the supervisor was notified and treatment was ordered (however, treatment identified the left buttock). The record failed to reflect the wound description and nursing assessment that included the type, stage of the ulcer, color and/or drainage. Facility pressure ulcer worksheets noted the area as unstageable when first discovered with no further description. Review of the Prediction of Residents at Risk for Development of Pressure Ulcers Policy indicated that the Skin Impairments/pressure ulcers were to be documented upon discovery, with significant change in wound appearance and at least every 7 days. No further wound documentation was noted in the record thereafter. The resident was transferred to the hospital on [DATE]. Review of the Prediction of Residents at Risk for Development of Pressure Ulcers Policy indicated that weekly skin assessments were completed on bath/shower day, documented in the Kardex and any changes were to be noted in nurse's notes and placed on the 24 hour report. Review of the clinical record and interview with LPN #3 on 1/19/17 at 2:00 PM failed to reflect that any weekly skin assessments had been completed in November 2016, December 2016 and January 2017. Additionally, the Policy indicated that the Registered Dietician would review the resident's record who had a change in condition, weight loss or decrease in hydration and make appropriate recommendations. Review of the record and interview with the RD on 1/19/17 at 1:30 PM failed to reflect any dietary evaluations, assessments and or consults. 6. R#115's [DIAGNOSES REDACTED].#115 was severely cognitively impaired, required extensive assistance with all activities of daily living (ADLs), was always incontinent of bowel and bladder, and was at risk for pressure ulcer development. Resident care plan (RCP) dated 10/13/2016 identified an alteration in skin integrity due to bowel and bladder incontinence. Interventions included to provide incontinent care and repositioning every two (2) hours. Continuous observation on 1/11/17 from 10:28 AM through 2:00 PM (3 hours and 30 minutes) noted R#115 seated in a custom wheel chair without the benefit of repositioning and/or incontinent care. Observation of R#115 during NA# 1 and NA#2 provision of incontinent care on 01/11/17 at 02:02 PM noted R#115's buttocks, hips and thighs were noted with deep lines of demarcation impressed into the resident's skin and the brief was noted heavily saturated with urine (blue line completely activated) and feces was smeared between and into the resident's perineal area. With R#115 positioned on his/her back, NA#1 proceeded with a wet disposable paper towel to pull feces from (between the resident's legs/perineal area) and/or from back/anus area through and over the front of the resident's vagina/urethra area. Subsequent to completion of incontinent care and re-placement of a clean brief, the brief was observed to be pulled tight between the resident's legs and at that time surveyor requested that the front of the brief be pulled back and the brief was noted soiled with feces. Interview with NA#1 on 01/11/2017 at 02:19 PM indicated that the last time R#115 received care and was taken out of bed was after 10:00 AM. Although NA#1 was unable to explain why R#115 did not receive care from 10:00 AM to 2:00 PM, NA#2 indicated that they were short staffed and very busy providing care. Interview with the unit charge nurse LPN#1 on 1/11/17 at 2:29 PM noted that although s/he was unable to explain why R#115 had not received care from 10:00 AM, review of the nurse aide care card and the attached pressure ulcer prevention (PUP) policy directed the provision of incontinent care and/or repositioning every two (2) hours and as needed. Interview and review of R#115's record with RN#3 at that time indicated that incontinent care should be provided every two (2) hours and as needed and that when providing incontinent care to always wipe from front to back to prevent infections like a urinary tract infection [MEDICAL CONDITION]. Subsequent to the surveyor's observations and inquiry related to R#115's lack of provision of incontinent/positioning care, corporate nurse #1 provided a revised version of the pressure sore prevention (PUP) plan. S/he indicated that facility staff had received re-training related to the revised pressure ulcer prevention. Upon review of the PUP it was noted that the provision of care and repositioning time frame had been altered/changed from every (2) two hours to every (2) two to (4) four hours and as needed. Corporate nurse #1 indicated that it was the standard in all of his/her other buildings. 7. Resident # 221's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] indicated the resident was in a persistent vegetative state, required total care of all ADL's, was at risk for developing pressure ulcers, and had no pressure ulcers. A resident care plan dated 12/27/16 identified R # 221 was at risk for skin breakdown. Interventions included turn and position, preventative skin care, ulcer care, and pillows for boney prominence. An interview with the DNS on 1/18/17 at 10:56 AM indicated no other care plans prior to 12/27/16 could be found. a. A nurse's note dated 6/23/16 indicated R # 221 returned from the hospital with a deep tissue injury on the right buttock and open area on the right hand. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Treatment to the right hand continued through 8/17/16 although no assessment or description of the area was found. The initial pressure ulcer assessment of the right buttock was not documented until 8/21/16 and was noted as a stage 2 pressure sore. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide an assessment of the deep tissue injury on the right buttock identified on 6/23/16 and/or the open area on the right hand identified on 6/23/16, and/or the open area identified on the physician's orders [REDACTED]. He/she was unable to provide an A & I report. b. A nurse's note dated 7/10/16 indicated a fluid filled blister was noted on R # 221's right foot. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide any record of assessments of the right lateral foot identified on 7/11/16 and/or the open area on the right lateral foot identified on 7/12/16. He/she indicated when a pressure ulcer is identified an accident and incident report is generated to initiate an assessment and/or treatment orders. He/she was unable to provide an A & I report. c. A nurse's note dated 8/22/16 indicated the right great toe was noted with drainage. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The initial assessment was conducted by the wound Physician on 10/6/16 and noted as abrasions on the right dorsal toes .2 cm [MEDICAL CONDITION]. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide any assessments of the to the right medial great toe open area identified on 8/23/16 and/or open area identified on the physician's orders [REDACTED]. He/she was unable to provide an A & I report. d. Review of an Infectious disease consult dated 8/25/16 indicated R # 221 had a bruise on his/her left heel. An interview on 1/18/17 at 10:56 AM with the DNS indicated he/she was unable to provide an assessment of the left heel bruise identified on 8/25/16. He/she indicated when the resident returned from the consult on 8/25/16 the nurse should have read the consult report and assessed the resident's left heel. e. Review of a podiatry consult dated 7/27/16 indicated R # 221's heels needed to be off the resting surface at all times. Review of a physician's orders [REDACTED]. Review of treatment records dated 6/23/16 - 6/30/16, 7/1/16 -7/31/16, 8/1/16 -8/31/16 indicated the preventative ulcer plan (PUP) (repositioning every 2 hours and off-loading heels) had been provided every shift and preventative foot care was provided weekly. Treatment records dated 9/18/16 - 9/30/16, and 10/1/16 - 10/31/16 noted the PUP had only been documented 3 times on 7 AM-3 PM shift and sixteen times on the 3-11 PM shift. Weekly preventative foot care was blank indicating it had not been provided. Review of the treatment records dated 11/1/16 - 11/30/16 noted the PUP was not provided on the 7 AM- 3 PM shift and only fifteen times on the 3 - 11 PM shift. The weekly preventative foot care was blank. 8. Resident #112's [DIAGNOSES REDACTED]. The admission/interim care plan dated 11/18/16 identified bilateral heel pressure ulcers. Interventions included to elevate heels off bed surface and float heels, no pressure on heels, provide off-loading boots, and turn and reposition every two hours. The Admission 5 day MDS assessment dated [DATE] identified the resident was without cognitive impairment, required the extensive assistance of two staff for bed mobility, was totally dependent for transfers, dressing and toileting, and had a suspected deep tissue injury (DTI). physician's orders [REDACTED]. Further orders directed the right heel pressure ulcer to be covered with non-adhesive dressing and dry clean dressing daily for 14 days and off load heels over edge of a pillow. On 12/3/16, physician's orders [REDACTED].U.P. policy. On 12/16/16, treatment orders directed to cleanse the left heel with normal saline, pat dry, skin prep to periwound, xeroform to wound bed followed by dry clean dressing, change every other day for 14 days. On 12/27/16 the treatment was continued. On 12/30/16 the treatment was changed to calcium alginate, with ABD pad and Kerlix wrap and change every day for 14 days. Weekly wound assessments of the right heel by the wound MD identified the following: 11/24/16 - Unstageable. 5 cm x 3.2 cm. Left heel not assessed. 12/1/16 - Stage 2 pressure ulcer. 6.4 cm x 6 cm x 0.2 cm. Left heel was not assessed. 12/8/16 - Deep tissue pressure injury. 6.2 cm x 6 cm and scant amount sero-sanguinous drainage noted, wound bed 51-75% [MEDICATION NAME] 1-25% eschar and was noted to be improving. The left heel was not assessed. 12/15/16 - 4 cm x 5 cm, wound bed 76-100% granulation and the left heel pressure ulcer measured 6 cm x 6 cm, and was a deep tissue pressure injury with scant sero-sanguineous drainage, 1-25% eschar and 51-75% [MEDICATION NAME]. 12/22/16 - 4 cm x 3.4 cm, wound bed 76-100% granulation, wound is improving. Left heel was documented as a deep tissue pressure injury that was 4.5 cm x 4 cm with scant serosanguinous drainage. Wound bed is 51-75% [MEDICATION NAME] 1-25% eschar, wound is improving. An outside hospital podiatry consultation note dated 12/28/16 identified that the resident's wounds were debrided, continue [DEVICE] to the left heel, [MEDICATION NAME] to the right heel, order for off-loading/podus boot for the right foot as the wound has increased in size. Recommendations were for off-loading boot bilaterally at all times, continue with [DEVICE] to the left foot three times per week, and [MEDICATION NAME] to the right heel daily. Observation of Resident #112 on 1/13/17 at 6 AM identified the resident in bed, on his/her back. White, off-loading booties were noted to be on the wheelchair as well as a pillow in the wheelchair. At 6:15 AM, NA#8 provided incontinent care and the resident was noted to have on slipper socks with both of his/her heels resting directly on the mattress and no sign of offloading devices in the bed or on the floor. Following care, the resident was repositioned back onto his/her back with the slipper socks heels resting on the mattress. NA#8 did not offer offloading or application of the booties at that time. The resident had a facial grimace and then verbalized a complaint of heel pain. NA#8 told LPN#6 that the resident was having heel pain. LPN#6 returned at 6:42 AM to inquire about the heel pain level, and the resident replied it was a 10 on a pain scale of 1-10 with 10 being the worst pain. LPN#6 failed to check the resident's heels. Resident #112 then began to cry. The nurse left and returned to administer pain medication, and again, failed to check the resident's heels or provide repositioning. At 6:55 AM, LPN#6 went in to recheck the resident and the resident stated he/she was still in pain. No interventions were initiated. At 7:02 AM, NA#8 went in to check on the resident's pain and the resident identified that he/she still had no relief. The resident continued to be constantly observed until 8:45 AM when a NA went in to deliver the resident's breakfast. The NA was observed to raise the head of the bed, set up the resident's tray and left the room. The resident's heels remained on the bed, the white booties and pillow remained on the wheelchair. The resident remained on his/her back with the white booties and pillow in the wheelchair and heels resting on the bed until 9:40 AM when NA #4 came in to provide AM care. Observation at that time noted the same slipper socks in place and the heels on the bed. Interview with NA#4 on 1/13/17 at 10 AM identified that the resident should have his/her heels on a pillow off of the bed. NA#4 asked Resident #112 if he/she had refused the pillow. Resident #112 replied that he/she had. NA#4 got Resident #112 up to the wheelchair and placed the white off-loading booties on the resident, without any objection from the resident. Interview with Resident #112 on 1/13/17 at 10:10 AM identified that the last time anyone had asked him/her if s/he wanted to off load his/her heels was on the 3-11 shift the previous evening. Resident #112 identified that s/he had never been offered any other measures to maintain off-loading since that time. Interview and review of facility documentation with LPN #3 and LPN #4 on 1/12/17 at 9:25 AM identified that there were no assessments of the resident's wound on admission (11/18/16-the nursing body assessment was blank) through 11/24/16 when the wound MD assessed the resident's right heel and the LPN documented an assessment of the resident left heel. The MD identified the left heel as resolved. LPN# 4 identified that the wound MD did not assess the left heel, at that time, because the hospital MD was responsible for the left heel and, although LPN#4 verbalized that the MD looked at the left heel, LPN#4 was the only one who documented any assessments of the resident's left heel wound on 11/24/16, 12/1/16, 12/8/16, 12/29/16, 1/5/16 and on 1/11/16. LPN#3 identified that he/she is in charge of the wound program and that LPN#4 does all the treatments weekly with the wound MD. Re-interview and clinical record review with LPN#4 on 1/18/17 at 1:20 PM failed to identify that the off-loading boots recommended by the hospital podiatry consult dated 12/28/16 were initiated and LPN #4 noted that they should have been put on the treatment kardex. LPN #4 indicated that although an outside physician consult for the wounds ordered [MEDICATION NAME], the facility did not use his/her orders on 12/28/16 and substituted Calcium Alginate as this was their protocol. The facility was unable to provide a wound treatment formulary. 9. Resident #149's [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] identified that the resident was severely cognitively impaired, displayed no problem behaviors, was totally dependent on 2 staff members for bed mobility and transfers, was incontinent of bowel and bladder, at risk for pressure ulcers and had no current pressure ulcers at that time. Review of physician wound documentation dated 11/3/16 identified a new stage 2 pressure ulcer of the left buttock that measured 1.6 by 1.4 cm. Treatment orders directed calcium alginate to the wound daily. On 11/10/16, physician wound documentation noted the wound was 1.8 by 1.4cm with maceration and no improvement. Treatment orders continued to direct calcium alginate daily. On 11/17/16, the MD wound assessment measured 2.0 x 0.5cm with no description of the wound documented. Treatment orders directed calcium alginate daily. The next MD wound assessment dated [DATE] noted measurement of 1.5 x 1.5. 0.3 cm depth; wound bed with 1-25% slough, The wound is improving. Periwound maceration. Treatment orders were unchanged with no new recommendations. On 12/15/16, the wound depth had increased to 0.5 cm and no treatment plan changes were recommended or initiated. On 12/22/16, the wound MD assessed that the wound had increased in size to 2 x 1.2 x 0.5 cm with no recommendations for changes in treatment. On 12/29/16, the wound MD documented that the wound had declined to a stage 3 pressure ulcer with pain of 4 out of 10 and 26-50%

Based on clinical record review, review of facility documentation and interview, for one of three residents ( Resident #190) reviewed for accidents, the facility failed to implement appropriate interventions and /or failed to provide adequate supervision to prevent an elopement. The findings include: Resident # 190's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The nursing admission assessment dated [DATE] identified the resident was alert and oriented to person and situation. The nurse's note dated 1/31/16 on the 3-11 P.M. shift identified Resident # 190 was observed trying to leave the unit and was redirected by staff with good results. The nurse's notes dated 2/1/16 identified the resident was out of bed and noted wandering during the night and indicated the resident was redirected back to bed without difficulty. The nurse's note dated 2/1/16 on the 3-11 P.M. identified Resident # 190 received Haldol (Anti-psychotic) 2 Milligram ( MG) at 9.25 P.M. for agitation and indicated the results of the medication was pending. The nurse's notes dated 2/2/16 on the 11-7 A.M. noted the resident exhibited behaviors of wandering into other resident's rooms but could be easily redirected. The nurses notes 2/2/16 on 3-11 P.M. shift identified Resident # 190 was noted with agitation, received his/her when needed Haldol with no effect and indicated the resident was placed in a chair in front of the nurses's station where staff could observe for safety. The nurse's note dated 2/3/16 on the 11-7 A.M. shift identified Resident # 190 was placed in bed and at 3:30 A.M. the resident was noted out of bed and heading toward the exit door. Additionally, indicated the resident had a tendency to wander from room to room and was placed in an area where staff could observe the resident for safety. The nurses notes dated 2/3/16 on the 3-11 P.M. shift identified the resident appeared restless and noted combative behavior toward staff. Additionally, indicated the resident was noted wandering from room to room and was not receptive to redirection. The nurses noted dated 2/5/16 on the 11-7 A.M. shift noted the resident was alert, pleasantly confused, and indicated that a Urine Analysis (UA) for Culture and Sensitivity( C&S) had been collected . The nurses note on 2/5/16 on the 3-11 P.M. shift noted the resident was alert and verbally confused, continued to wander on the unit , attempted to leave the unit and indicated Resident # 190 could be redirected. The 2/5/16 nurse's note on the evening shift identified that a (UA) and ( C&S) had been sent to the laboratory and the results were pending. The nurse's note dated 2/6/16 on the 11-7 A.M. shift identified Resident # 190 was up through out the shift , wandering from room to room, and indicated the resident received his/her when needed medication with no ill effect. The nurse's note on the 2/6/16 on 7-3 P.M. shift identified Resident # 190 was agitated, able to be redirected, given when needed Haldol with a positive outcome and that a wander guard was placed on the resident. Additionally, noted Resident # 190 was observed by staff in the dining area through out the shift and was last seen by staff at 3:15 P.M. The nurse's note dated 2/6/16 at 6:00 P.M. identified Resident # 190 left the facility grounds without permission for approximately 10 minutes , the resident was returned to the facility and assessed by the APRN and was noted with no apparent injury. The nurse's note dated 2/6/16 at 6:30 P.M. identified staff received a telephone call from the security desk at 3:45 P.M. that a resident from A wing was at a corner deli. The nurse immediately notified the nursing supervisor who notified the charge nurse she/he had sent a staff to pick up the resident. Additionally, noted the resident was returned to the facility at 4:15 P.M. , vital signs checked, skin intact , assessed for pain and placed on every fifteen minute check and indicated the resident was transferred to the D wing with wanderguard in place . The facility Reportable Event dated 2/6/16 identified Resident # 190 left the facility's grounds without permission for approximately 10 minutes. Additionally, noted the resident sustained [REDACTED]. A review of the National Weather Report dated 2/6/16 noted a temperature of 37 Fahrenheit degrees. The social service note dated 2/8/16 noted Resident # 190 left the building without privileges and was observed by a family walking to the store. Resident # 190 indicated she/he was going to store and was going to come back to the facility. The facilty investigation dated 2/10/16 noted the resident was assessed by an APRN, noted no injuries at the time of the incident, the resident remained at his/her baseline and indicated the resident was treated for [REDACTED]. Security Guard ( # 1) entered the lobby area and heard the alarm sounding and brought the sounding alarm to Security Guard ( # 2)'s attention ( who was responsible for addressing and activating alarms) Security Guard ( # 2) stated I did not hear the alarmand directed Security Guard ( # 1) to address the sounding alarm on 2/6/16. Facility investigation further noted Security Guard # 2 failed to respond to the alarm in accordance to facility protocol which allowed Resident # 190 the opportunity to exit the building without staff redirecting the resident to return to the building immediately. Additionally, the investigation noted a second pipher box ( wireless security system) located at an egress door on the resident unit was checked on 2/5/16( the night before the elopement) was noted to be functioning and working , However , for some unknown reason , the device did not have an audible sound at the time of the incident. On 2/6/16 the device was reset immediately and was noted working. Interview with the Director of Security on 2/26/16 at 4:00 P.M. identified when Security Guard (#1) heard the alarm he/she notified Security Guard (# 2) (who was responsible for responding to the alarm) but instead Security Guard ( # 2) told Security Guard (# 1) to respond. Interview with the DNS on 2/26/16 at 4:30 P.M. identified staff did not respond to the alarm in a timely manner. An Attempt was made to contact Security Guard # 1 but was unsuccessful. A review of the clinical record and a review of facility documentation on 2/26/16 lack documentation and /or evidence the facility implemented intervention to monitor and / or assess the resident for potential elopement prior to 2/6/16 and indicated that Security Guard (# 1) failed to follow facility protocol for responding to an alarm .

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #12) who were reviewed for falls, the facility failed to have a system in place that side rails were checked routinely to ensure the side rails were in safe condition to prevent a fall and/or for one resident room (Resident #26), the facility failed to ensure a safe environment as evidence by an unsafe wall and/or the facility failed to ensure that a Unit closed for remodeling was secured from residents, and/or the facility failed to ensure that staff followed protocol when filling portable oxygen tanks. The findings include: 1. Resident #12's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 had moderate cognitive impairments and required extensive two person assistance with bed mobility. The resident care plan dated 12/26/14 identified that Resident #12 required assistance with activities of daily living related to a [DIAGNOSES REDACTED]. Interventions directed the utilization of two half side rails up as enablers while in bed and assist with incontinent care every two hours and when necessary. The nurse's note dated 2/22/14 identified Resident #12 fell from the bed at 9:00 PM. Resident #12 complained of left arm pain, was assessed and was returned to bed with the assistance of four. Resident #12 complained of left leg pain and was transferred to the hospital for an evaluation. At that time the side rail was noted to be defective and could fall straight down touching the ground. Resident #12 sustained a left femur fracture. Interview with the Director of Maintenance and assistant on 3/24/15 at 12:45 PM identified that after Resident #12's fall although the side rails were not found to be defective new rails were put on Resident #12's bed. He further stated that at times a knob that controls the bed going up and down may get lose and the maintenance staff are requested to tighten it. The Director of Maintenance indicated that prior to the fall, side rails were not routinely checked for function during maintenance rounds. Subsequent to Resident #12's fall, side rails are checked on a regular basis. Interview with the MDS Coordinator on 3/24/15 at 1:15 PM identified that Resident #12 required a two person assist for bed mobility to be pulled up in bed but was an assist of one for incontinent care. Interview with Nurse Aide (NA) #3 on 3/24/15 at 1:50 PM identified that she rolled Resident #12 over on his/her left side, was holding the resident over with one hand and providing incontinent care with her right hand when the rail suddenly went down. Resident #12 landed on the floor. NA #3 stated that the rail was broken and hanging down on the floor. Interview with Resident #12 3/24/15 at 2:10 PM identified that the nurse aide was cleaning him/her up and suddenly the rail went down and he/she ended up on the floor. Resident #12 stated that he/she was told that the rail was loose. Interview with the Assistant Director of Nursing (DON) on 3/25/15 at 2:00 PM and the Director of Nursing on 3/26/15 at 11:30 AM identified that Resident #12's side rails were closely examined the next day and were determined to be defective. 2. Observations during a tour of the 3-D unit on 3/18/15 at 11:36 AM identified Registered Nurse (RN) #1 entered the oxygen filling room, propped the door open with his foot and began to trans fill a portable oxygen tank and three residents were observed in the area. Interview with RN #1 at that time he identified that he did not know the door needed to be closed while filling portable oxygen tanks. Observations at 11:45 AM identified a staff member standing in the doorway of the oxygen room with her foot propping the door open and filling a portable oxygen tank. Interview with the physical therapist at that time she identified she was not aware that the door had to be closed while filling tanks and that she keeps the door open because she is afraid of small spaces. Interview with the DON on 3/18/15 at 12:30 PM identified that it was facility policy to keep the closet door closed while filling oxygen tanks. 3. Resident #26's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that Resident #26 had severe cognitive impairment and was totally dependent on staff for bed mobility. The resident care plan dated 12/26/14 identified the resident required assistance with activities of daily living. Interventions directed to transfer the resident via a mechanical lift and assist with turning and repositioning. Observations on 3/26/15 at 9:40 AM identified Resident #26 lying in bed with the bed up against wall. The resident was observed trying to move him/herself in the bed and the resident's hands were in air. Observations identified the bed was up against the wall and had a long two by four covering the wall. Part of the board (approximately three feet) was noted to be severely marred, rough and splintering. Interview with Licensed Practical Nurse (LPN) #4 at the time of the observation stated she was unaware the wall was in that condition and she would report it to maintenance for repair. Interview with NA #6 on 3/26/15 at 9:45 AM stated that the wall had been that way for months, was caused by the resident's old bed and he had not reported it to anyone. Interview with Maintenance #1 on 3/36/15 at 10:00 AM identified that no one had reported the wall in Resident #26's room to him. He stated that when nursing identifies a problem they are to fill out a form and leave it for maintenance that checks daily for repairs. Maintenance #1 indicated that this could of also been called to the department for repair and he would have done it immediately because the board was a hazard. Subsequent to surveyor inquiry the board was removed. 4. Observations on 3/20/15 at 11:00 AM during a tour of the Eder-1 Unit that was closed for remodeling identified the following: There were open entryways and elevators on to the unit. Several rooms were observed with exposed capped wires from the light fixtures and heating units. Furniture was turned on its sides and around in rooms. The lights were not working in any of the resident rooms. Temperatures throughout the unit including the hallways and resident rooms were noted to be between 52 and 68 degrees. Heating units were pulled away from walls, broken and in disrepair. The resident bathrooms were noted with clogged brown water in them. Furniture was stacked on top of the beds. Screws and blots were lying on the floors. Hand written signs were posted for the residents that indicated the direction to the room for breakfast and where the elevator was located. Interview with the DON at the time of the observations identified that the unit had been shut down and was to be remodeled. The DON stated that she was aware the area was a hazard and that some residents and/or visitors do utilize the elevator to go to the smoking area, the breakfast room and/or the recreation area. The DON stated that although there was a staff member posted at the smoking area during the day and will walk the unit on occasion, there was no staff assigned to monitor the unit. 5. Observations of the Eder-1 Unit on 3/23/15 at 9:30 AM identified security staff at the main desk. The surveyor opened an exit door which then activated an audible alarm. The alarm continued to sound for five minutes and the security staff was not observed on the unit. Interview with Security Staff #1 on 3/23/15 at 9:40 AM identified that he left the nursing unit in order to obtain a key to reset the audible door alarm. Security Staff #1 identified that his responsibility was to remain on nursing unit to ensure the safety of residents who utilize the area to access another portion of the building and he/she should have not left the unit unattended to obtain the key to silence the alarm.

Based on a review of the clinical record, staff interviews and a review of the facility policies and procedures for three of nine residents reviewed for pressure ulcers, Residents #29, #30, and #31, the facility failed to implement interventions to prevent the development and/or worsening of pressure ulcers. The findings included: 1. Resident #29 (R #29) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that R #29 was severely cognitively impaired and required extensive assistance with bed mobility and transfers and had no pressure ulcers. The nursing care plan dated 11/1/12 identified that R #29 was at risk for impairment in skin integrity but lacked documentation of interventions to address the prevention of pressure ulcers to the resident's heels. The Braden scale for predicting pressure sore risk dated 11/21/12 identified that R #29 was at risk for pressure ulcer development. The skin integrity report dated 12/27/12 identified that R #29 had developed a new 1.0 centimeter (cm.) by 1.0 cm. Stage III pressure ulcer to the right heel. The nurse's notes dated 12/27/12 identified that R #29 was assessed by the Advance Practice Registered Nurse (APRN) on 12/27/12 and that physician's orders [REDACTED]. Review of the December 2012 Treatment Administration Record (TAR) lacked documentation to reflect that off-loading of R #29's heels was provided until 12/27/12 after the resident's heel ulcer was identified. 2. Resident #30 (R #30) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Braden scale for predicting pressure sore risk dated 8/27/12 identified that R #30 was at high risk for pressure ulcer development. The MDS dated [DATE] identified that R #30 had impaired short and long term memory, moderate cognitive impairment, and required extensive assistance for bed mobility and transfers, and had no pressure ulcers. The nursing care plan dated 11/23/12 identified R #30 was at risk for impairment in skin integrity but lacked documentation of interventions to address the prevention of pressure ulcers to the resident's heels. Review of the January 2013 TAR lacked documentation to reflect that R #30's heels were off loaded. Review of the clinical record identified a progress note by the APRN dated 1/23/13 that identified R #30 had developed a deep tissue injury on the right heel area that measured 1.5 cm by 1.0 cm. Although recommendations were documented to "float" the resident's heels and to utilize skin prep, review of physician's orders [REDACTED].#30 's right heel wound now measured 2.0 cm. by 0.9 cm. Observation of R #30 on 2/13/13 at 1:00 PM identified that the resident was wearing sneakers while reclining in the wheelchair. The resident's heels were observed to be resting into the foot pad of the reclined chair without the benefit of off loading. Interview with Nursing Assistant #6 (NA #6) on 2/13/13 at 1:05 PM indicated R #30 was wearing sneakers to enable the resident to stand and pivot when transferring out of bed. NA #6 identified she was never directed by the nursing staff to remove the residents sneakers after transfer. Subsequent to the observation, interview with the Director of Nursing identified that she inserviced staff related to removal of sneakers and off loading of heels after a resident at risk for pressure ulcers who requires sneakers to stand and pivot, is transferred. 3. Resident #31 (R #31) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden scale for predicting pressure sore risk dated 8/27/12 identified that R #31 was at high risk for pressure ulcer development. The MDS dated [DATE] identified that R #31 had impaired short term memory, moderate cognitive impairment, required extensive assistance for bed mobility, and had no pressure ulcers. The nursing care plan dated 1/4/13 identified R #31's risk for skin impairment with interventions that included turning and repositioning every two hours, to float the resident's heels, and posey heel lift boots. Although the nursing care plan dated 1/4/13 directed the resident's heels to be floated, the January 2013 TAR lacked documentation to reflect that the residents heels were floated until 1/17/13, after the development of a heel ulcer. Interview with the MDS Director on 2/13/13 at 3:30 PM identified that R #31 had a previously acquired pressure ulcer on his/her heel in the past, therefore the intervention to float the resident's heels was added to the plan of care at that time. The skin integrity report dated 1/17/13 identified a new 3.9 cm. by 3.3 cm. pressure ulcer to the right heel that was staged as a Deep Tissue Injury (DTI). The wound was assessed and physicians orders dated 1/17/13 were obtained that included direction to apply skin prep daily and to off load the resident 's heels. Nurse's notes dated 1/22/13 identified R #31's heel ulcer was assessed by the facility's APRN and that the wound sized measured 3.5 cm. by 4.2 cm. physician's orders [REDACTED]. The orders further directed to float the resident's heels off the bed and chair rests at all times. The MDS Director could not explain the lack of documentation related to the floating of R #31's heels in the TAR prior to the injury on 1/17/13. Interview with the MDS Director on 2/13/13 at 3:30 PM identified the facility does not implement interventions for the prevention of pressure ulcers to a resident's heel until the area is showing signs of redness and/or is "boggy". Subsequent interview with Nurse Manager #1 on 2/13/13 at 2:30 PM identified residents at risk for pressure ulcer development should have interventions that include the prevention of heel ulcers. The facility policy for skin integrity directed in part that residents who are at risk for the development of pressure ulcers would be protected by the utilization of spanko boots and by ensuring the resident's heels are placed off the mattress.

Based on clinical record reviews, review of facility policies, review of facility documentation and interviews for four of seven residents reviewed for falls (Resident #1, #2, #4, & #21), the facility failed to follow the plan of care and/or provide care in accordance with facility policy to prevent injury. The finding includes. 1. Resident #1's [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of nurse's notes dated 12/5/11 on the 7:00-3:00 pm shift identified that the resident was noted to have a swollen right knee after he/she was transferred from the bed into the customized wheelchair. Review of the x-ray report dated 12/5/11 identified that the resident had an acute impacted comminuted fracture to the right distal femur. Review of facility documentation dated 12/5/11 there was a question if the resident had been transferred via a Hoyer lift transfer. A facility investigation dated 12/23/11 identified that the nurse aide assigned to the resident, Nurse Aide # 6 had transferred the resident via a Hoyer lift without assistance of another staff member. Review of facility policy identified that there must be two staff members present during transfer/use of the mechanical lift. Interview with the Director of Nurses on 4/3/12 at 10:00 am identified that the nurse aide involved was terminated for performing an unsafe transfer and that the fracture could have been the result of the unsafe action transferring the resident without assistance. 2. Resident #2's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident had severely impaired cognitive impairment, memory problems and needed extensive assistance with transfers. Review of the physician originally ordered on [DATE] and reordered through 10/20/11 identified that the resident was a Hoyer lift and transferred to a modified custom wheelchair with a Roho cushion, pelvic positioning belt and leg rests. Review of the nursing care plan dated 11/2011 identified that the resident required the assistance of two with all Hoyer lift transfers, feet protected at all times during transfers and was to be inspected prior to and after all transfers for red marks. Review of facility documentation dated 10/16/11 identified that Resident #2 was found with bilateral abrasions on both knees. Review of the nurses' notes dated 10/16/11-10/21/11 identified that the resident had a history of [REDACTED]. On 10/21/11, Resident #2 was complaining of pain in her right knee. Review of the x-ray report dated 10/21/11 identified that the resident had an acute impacted fracture of the right distal femur. Interview with LPN #2 on 4/3/12 at 1:45 pm identified that a nurse aide had reported to him/her that the resident had bilateral abrasions to both knees. Further interview identified that they thought that the resident was dropped due to the knee abrasions but could not prove it. Interview with Radiologist #1 on 4/4/12 at 11:00 am identified that either a fall or trauma to the knee would of caused a femur bone to fracture even with osteopenia present. A subsequent interview on 4/18/12 with Radiologist # 1 identified that from looking at the x-ray, that the resident's osteoporosis would put the resident at greater risk for a fracture, but had this fracture been caused by rolling into a table as was suggested by the facility investigation, it would have been a fracture of the patella, not one that extended through the femur. Radiologist # 1 further identified that the force needed to cause a fracture extending from the patella through the femur would be caused by a fall. 3. Resident #4 had [DIAGNOSES REDACTED]. The plan of care dated 5/19/11 noted that the resident was at risk for falls with an intervention not to leave resident in wheelchair (W/C) alone in room. Nursing narratives and/or facility documentation dated 6/3/11 at 1:00 PM identified that the resident was alone in the room in the W/C, was found on the floor, complained of neck, head and shoulder pain and sustained a scalp laceration. The resident was sent to the emergency department (ED) and returned to the facility following radiological testing and sutures to the scalp. Two scans of the cervical spine dated 6/3/11 noted no obvious fracture yet identified that the exam was limited due to motion and artifact. Nursing narratives indicated that the Resident continued to complain of neck pain and further testing on 7/11/11 identified a fracture of the 2 nd cervical vertebral body. Review of the resident's clinical record and facility documentation with the Director of Nursing on 4/5/12 at 3:10 PM noted that, although the plan of care dated 5/19/11 directed the use of the chair and bed alarms, the alarms were placed after the resident's fall on 6/3/11. The facility care plan policy identified that interventions should reflect what is being done to address the problem, how staff will carry out the interventions and the frequency of the interventions. The nursing assistant (NA) job description noted that the purpose of the NA is to provide for the physical needs and give emotional support to the residents in accordance with their plans of care. Facility staff employeed at the time of the fall were unable to identify how R#4 came to be alone in his/her room. 4. R#21's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the Brief Interview for Mental Status Score of 5 ( 0-7 severe impairment). The care plan dated 12/6/11 identified R#21 as a fall risk related to mild dementia and poor safety awareness with interventions to place call bell within reach, provide clear/well lit paths, provide proper footwear and utilize bed and chair alarms as ordered. Review of the physician orders [REDACTED]. Review of the nurse's notes dated 3/23/12 identified R#21 was found on the floor in front of the bedside chair at 10:45AM. Review of the hospital discharge summary dated 3/28/12 identified that R#21 presented with left frontal superficial ecchymosis and was found to have a minimally displaced left ninth rib fracture. Review of facility Accident and Investigative Report dated 3/23/12 identified R#21 was found on the floor at 10:45AM by the bedside chair without the chair alarm in place. Interview with NA# 8 on 4/20/12 at 10:45AM identified that R#21 was on his/her assignment on 3/23/12 and R#21 was washed and left in bed because he/she wasn't feeling well, amd the bed alarm was in place. Interview with NA#7 on 4/2/0/12 at 11:0AM identified that R#21 was observed trying to get out of bed at approximately 9:30AM. NA#7 was directed by the nurse to get R#21 up out of bed and into a bedside chair. NA#7 was aware that R#21 required a chair alarm from having cared for him/her before and from the care card, but he/she forgot to apply the alarm. Interview and review of the clinical record with the Director of Nursing on 4/20/12 at 11:40 AM identified that NA#7 failed to apply the chair alarm. Review of facility policy identified that all safety devices will be instituted as needed and addressed on the Certified Nurse Aide care card and the care plan.

Based on clinical record review for one (R#6) of three residents reviewed for physician notification and/or for one of two patients who required further testing following an injury (R#4), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being. The findings include: 1. Resident #4 had [DIAGNOSES REDACTED]. The plan of care dated 5/19/11 noted that the resident had potential for pain and interventions included to acknowledge resident's report of pain. Nursing narratives and/or facility documentation dated 6/3/11 identified that the resident fell from the W/C, complained of neck, head and shoulder pain, and sustained a scalp laceration. The resident was sent to the emergency department (ED) and returned to the facility on [DATE] following the performance of head and spine computed tomography (CT) scans and sutures to the scalp. Discharge paperwork from the ED identified that the resident did not have spinal fractures and was to wear a soft cervical collar for continued neck pain. Nursing narratives dated 6/7/11 and/or 6/8/11 indicated that the resident continued to complain of neck pain, stated that s/he had broken bones and needed to go to the hospital. Although the resident was evaluated by the APRN on 6/9/11 and the physician on 6/10/11 the resident required increases in pain and antianxiety medications from 6/9/11 through 6/22/11, the resident's pain continued and the resident requested more assistance to perform activities of daily living. APRN #3's orders directed to obtain the cranial CT report from the hospital dated 6/3/11. The resident's record dated 6/22/11 through 6/29/11 lacked documentation that CT results were obtained. Psychiatric notes by APRN #3 dated 6/29/11 indicated that the resident was injured after a fall (6/3/11), feared that s/he is more severely impaired and, on 7/7/11, ordered that the cervical test report done at the hospital on [DATE] be obtained. The head and spinal CT scans were received by the facility on 7/7/11 and identified that two scans of the cervical spine were performed on 6/3/11, noted no obvious fracture yet identified that the exams were limited due to motion and artifact. The cervical CT scan was repeated on 7/11/11 and identified a [MEDICAL CONDITION] cervical vertebral body with displacement. Review of the resident's record with the DNS on 4/4/12 at 1:45 PM noted that although the resident's plan of care was changed to decrease the resident's pain/anxiety, further testing to ascertain the cause of the resident's continued neck pain was not conducted for over a month after the initial fall. 2. R#6's [DIAGNOSES REDACTED]. In addition, on 12/26/11, R#6 was diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] identified a score of 14 (13-15 cognitively intact), and was totally dependent on two staff members for bed mobility and extensive assist with transfers. A care plan dated 12/23/11 identified R#6's hypertension with interventions to monitor vital signs, assess for headache, and report any changes to the physician. a. Review of the clinical record dated 1/21/12 on the 11-7 shift identified that R#6 vomited 5 times. Although LPN#1 reported R#6's vomiting to the RN Supervisor, the clinical record failed to identify that a physician or APRN was notified of the resident's change in condition. Interview and review of the clinical record with APRN #1 on 4/15/12 at 9:00 AM identified that although he/she was not on call on 1/21/12 on the 11-7 shift, an APRN/MD notification would be expected for any acute changes in a resident, including the vomiting. Review of facility policy identified that a resident's physician must be notified immediately of a change in condition. b. Review of R#6's clinical record dated 1/21/12 at 9:30 AM identified that R#6 experienced an elevated blood pressure of 182/108. APRN #2 was notified and directed to administer [MEDICATION NAME] 2.5mg which resulted in a decrease to 170/100. R#6's blood pressure was not obtained again until 2:30 PM and identified as 183/117. R#6's family member was notified and a call placed to the APRN. At 3:30 PM, APRN #2 was notified of R#6's elevated blood pressure and directed to administer an additional dose of [MEDICATION NAME] 5mg, and to transfer R#6 to an acute care hospital if the blood pressure did not decrease within one hour. At 4:30 PM R#6's blood pressure was 164/110, R#6 complained of a headache for which Tylenol was administered. The clinical record lacked evidence that APRN #2 was notified of R#6's headache and administration of Tylenol. Although plans had been made to send R#6 to an acute care hospital for treatment of [REDACTED].#6's blood pressure was identified as 185/119. On arrival to the acute care hospital, R#6 was diagnosed with [REDACTED]. Interview with APRN #2 on 4/4/12 at 2:30 PM identified that although he/she could not recall specific details, he/she questioned what information staff communicated to him/her on 1/21/12 regarding R#6's condition. APRN #2 stated that clinical practice did not accept a diastolic pressure of 100 or greater. After the administration of the [MEDICATION NAME], he/she would have expected staff to provide close monitoring and a decrease of R#6's blood pressure to a diastolic in the 80s or 90's within the hour. APRN #2 identified that R#6 would have been transferred to the emergency department sooner if he/she was aware that the blood pressure remained above 100 diastolic. Review of facility policy identified that a resident's physician must be notified immediately of a change in condition. According to Rapid Response to Everyday Emergencies, Lippincott Williams and Wilkins, 2006 Hypertensive Crisis refers to the abrupt, acute and marked increase in blood pressure form the patient's baseline and requires rapid assessment and frequent follow-up.

Based on a review of clinical records, facility policy, and interview for one of three residents who were incontinent (R#13) the facility failed to ensure that the resident's plan of care included interventions to manage the resident's incontinence, and for one (R#6) of three residents reviewed for change of condition, the facility failed to assess the resident. The finding included: 1. R#6's [DIAGNOSES REDACTED]. In addition, on 12/26/11, R#6 was diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] identified a score of 14 (13-15 cognitively intact), and was totally dependent on two staff members for bed mobility and extensive assist with transfers. A care plan dated 12/23/11 identified R#6's hypertension with interventions to monitor vital signs, assess for headache, and report any changes to the physician. Review of R#6's clinical record dated 1/21/12 at 9:30 AM identified that R#6 experienced an elevated blood pressure of 182/108. APRN #2 was notified and directed to administer [MEDICATION NAME] 2.5mg which resulted in a decrease to 170/100. R#6's blood pressure was not obtained again until 2:30 PM and identified as 183/117. R#6's family member was notified and a call placed to the APRN. At 3:30 PM, APRN #2 was notified of R#6's elevated blood pressure and directed to administer an additional dose of [MEDICATION NAME] 5mg, and to transfer R#6 to an acute care hospital if the blood pressure did not decrease within one hour. At 4:30 PM R#6's blood pressure was 164/110, R#6 complained of a headache for which Tylenol was administered. The clinical record lacked evidence that APRN #2 was notified of R#6's headache and administration of Tylenol. Although plans had been made to send R#6 to an acute care hospital for treatment of [REDACTED].#6's blood pressure was identified as 185/119. Review of the clinical record from 1/21/12 at 7:30 AM to 5:00 PM failed to demonstrate that an RN assessed/monitored R#6's sustained high blood pressure or headache. On arrival to the acute care hospital, R#6 was diagnosed with [REDACTED]. Interview with APRN #2 on 4/4/12 at 2:30 PM identified that although he/she could not recall specific details, he/she questioned what information staff communicated to him/her on 1/21/12 regarding R#6's condition. APRN #2 stated that clinical practice did not accept a diastolic pressure of 100 or greater. After the administration of the [MEDICATION NAME], he/she would have expected staff to provide close monitoring and a decrease of R#7's blood pressure to a diastolic in the 80s or 90's within the hour. APRN #2 identified that R#7 would have been transferred to the emergency department sooner if he/she was aware that the blood pressure remained above 100 diastolic. Review of facility policy identified that a resident's physician and family must be notified immediately of a change in condition. According to Rapid Response to Everyday Emergencies, Lippincott Williams and Wilkins, 2006 Hypertensive Crisis refers to the abrupt, acute and marked increase in blood pressure form the patient's baseline and requires rapid assessment and frequent follow-up. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified that the resident was confused with limited ability to express needs, was incontinent of bowel and bladder, was dependent on staff for ADL's, had a stage 2 pressure area of the coccyx, and a 3 cm open incision to the right knee. Review of the admission care plan dated 6/3/11 with RN#6 on 4/5/12 at 11:00AM identified that the resident had an open area on his/her coccyx with interventions that included to turn and reposition the resident, utilize pressure relieving devices, monitor skin daily and administer treatment as ordered. A skin assessment dated [DATE] identified that the resident had no bladder control and had an existing skin breakdown. Review of a bowel and bladder retraining record dated 6/4/11 identified that the resident was a poor candidate for a toileting schedule and/or retraining. Review of the resident's ADL Flow Sheets for the period of 6/4/11 through 6/8/11 identified that the resident was incontinent of bowel and bladder daily. A care plan dated 6/8/11 identified that the resident had altered skin integrity and directed to monitor skin daily, notify the physician of any concerns, and administer treatments as ordered. Review of the resident's ADL Flow Sheets for the period of 6/9/11 through 6/13/11 identified that the resident continued to be incontinent daily. Review of a wound note dated 6/13/11 identified that the resident's groin was red with a patchy rash and excoriation. A physician's orders [REDACTED]. Interview with RN#6 on 4/4/12 at 11:00 AM failed to identify that a plan of care to address the resident's bowel and bladder incontinence was developed. Review of the facility's Assessment and Care Planning policies identified that the resident's assessment information will be included in the initial care plan with interventions to address the problem, how staff will carry out the interventions and the frequency of the interventions.

Based on clinical record reviews and interviews with facility personnel for 3 of 4 sampled residents who had a change in condition (Residents (R) #1, R #2, and R#6 and/or for one of one sampled residents who was discharged from the facility due to the resident's attempt to elope, (R#3), the facility failed to ensure that the physician and/or family were notified in a timely manner. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. Review of the nursing care plan dated 12/11 identified that the resident was a Hoyer lift with the assistance of two. Review of nurse's notes dated 12/5/11 on the 7:00 pm - 3:00 pm shift identified that the resident was noted to have a swollen right knee after he/she was transferred from the bed into the custom wheelchair. Review of the x-ray report dated 12/5/11 identified that the resident had an acute impacted comminuted fracture to the right distal femur. Further review failed to identify the family was notified with the change in condition. Review of the nurse's notes dated 12/6/11 at 7:00 am identified that the family was notified when the resident was being sent to the Emergency Department. Review of facility policy identified that the resident's responsible relative must be notified immediately of a change in condition. Interview with the Director of Nurses on 4/3/12 at 10:00 am identified that she would of expected that the charge nurse would of called the family with a change in condtion. 2. Resident #2's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident had severely impaired cognitive impairment, memory problems and needed extensive assistance with transfers. Review of the physician orders [REDACTED]. Review of the nursing care plan dated 11/2011 identified that the resident required the assistance of two with all Hoyer lift transfers, feet protected at all times during transfers and was to be inspected prior to and after all transfers for red marks. Review of facility documentation dated 10/16/11 identified that Resident #2 was found with bilateral abrasions on both knees. Review of the nurses' notes dated 10/16/11-10/19/11 identified that the resident had a history of [REDACTED]. On 10/20/11 on the 3:00 -11:00 pm shift and on 10/21/11 on the 11:00 -7:00 am shift, Resident #2's right knee was reddened, swollen and the resident was crying out when the right leg was moved. Further review failed to identify that the physician was notified. On 10/21/11, on the 7:00 -3:00 pm shift, Resident #2's right knee was swollen and discolored. The Advanced Practice Registered Nurse (APRN) was notified and ordered an x-ray. Review of the x-ray report dated 10/21/11 identified that the resident had an impacted acute [MEDICAL CONDITION] distal femur. Review of facility policy identified that the resident's physician must be notified immediately of a change in condition. Interview with the Director of Nurses on 4/3/12 identified that the staff could of notified the APRN sooner when the resident's knee worsened. 3. Resident #3's [DIAGNOSES REDACTED]. Review of the clinical record dated 7/27/11 identified that the resident required supervision with activities of daily living and was admitted to the facility due to his/her inability to care for himself. Review of the behavioral assessment dated [DATE] identified that the resident was high risk for wandering and an elopement risk. On 7/27/11, Resident #3 had a wanderguard placed. Review of the nurses' notes and social service notes' dated 7/27/11-7/28/11 indicated that the resident had multiple attempts to leave facility, so a decision was made by the Director of Nursing and the Director of Social Services to send the resident back to the hospital due to an inappropriate placement. Resident #3 was sent back to the hospital for a psychiatric evaluation on 7/28/11 with the facility refusing to re-admit the resident back to facility. Further review of the clinical record dated 7/27/11-7/28/11 failed to identify that the physician was notified of the transfer. Review of facility policy identified that the resident has the right to be allowed to stay at facility and may not be discharged from the facility unless the resident's welfare cannot be met by facility. Interview with the Director of Nurses on 4/3/12 at 10:00 am identified that the resident should not of been transferred back to the hospital just because he was trying to elope from the facility. Further interview identified that other interventions could of been implemented to keep resident at facility. 4. R#6's [DIAGNOSES REDACTED]. In addition, on 12/26/11, R#6 was diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] identified a score of 14 (13-15 cognitively intact), and was totally dependent on two staff members for bed mobility and extensive assist with transfers. A care plan dated 12/23/11 identified R#6's hypertension with interventions to monitor vital signs, assess for headache, and report any changes to the physician. a. Review of the clinical record dated 1/21/12 on the 11-7 shift identified that R#6 vomited 5 times. Although LPN#1 reported R#6's vomiting to the RN Supervisor, the clinical record failed to identify that a physician or APRN was notified of the resident's change in condition, and failed to identify that R#6's family was notified. Interview and review of the clinical record with APRN #1 on 4/15/12 at 9:00 AM identified that although he/she was not on call on 1/21/12 on the 11-7 shift, an APRN/MD notification would be expected for any acute changes in a resident, including the vomiting. Review of facility policy identified that a resident's physician must be notified immediately of a change in condition. b. Review of R#6's clinical record dated 1/21/12 at 9:30 AM identified that R#6 experienced an elevated blood pressure of 182/108. APRN #2 was notified and directed to administer [MEDICATION NAME] 2.5mg which resulted in a decrease to 170/100. R#6's blood pressure was not obtained again until 2:30 PM and identified as 183/117. R#6's family member was notified and a call placed to the APRN. At 3:30 PM, APRN #2 was notified of R#6's elevated blood pressure and directed to administer an additional dose of [MEDICATION NAME] 5mg, and to transfer R#6 to an acute care hospital if the blood pressure did not decrease within one hour. At 4:30 PM R#6's blood pressure was 164/110, R#6 complained of a headache for which Tylenol was administered. The clinical record lacked evidence that APRN #2 was notified of R#6's headache and administration of Tylenol. Although plans had been made to send R#6 to an acute care hospital for treatment of [REDACTED].#6's blood pressure was identified as 185/119. On arrival to the acute care hospital, R#6 was diagnosed with [REDACTED]. Interview with APRN #2 on 4/4/12 at 2:30 PM identified that although he/she could not recall specific details, he/she questioned what information staff communicated to him/her on 1/21/12 regarding R#6's condition. APRN #2 stated that clinical practice did not accept a diastolic pressure of 100 or greater. After the administration of the [MEDICATION NAME], he/she would have expected staff to provide close monitoring and a decrease of R#7's blood pressure to a diastolic in the 80s or 90's within the hour. APRN #2 identified that R#7 would have been transferred to the emergency department sooner if he/she was aware that the blood pressure remained above 100 diastolic. Review of facility policy identified that a resident's physician and family must be notified immediately of a change in condition.

Based on a review of clinical records, review of facility documentation and interviews for one of three sample residents identified as totally dependent with transfers ( R # 60) and/or one of three sampled residents identified as an elopement risk ( R# 116) the facility failed to provide the necessary supervision and/or implement new interventions to ensure the safety of the residents and/or the facility failed to ensure that windows properly secured and/or failed to maintain the water temperatures within an acceptable range. The findings include: 1. Resident # 60's [DIAGNOSES REDACTED]. A quarterly assessment ((MDS) dated [DATE] identified the resident had severe cognitive impairment and required total assistance for activities of daily living including transfers. A physician's orders [REDACTED]. A care plan dated 12/16/10 identified an alteration in ability to participate in activities of daily living related to dementia and bilateral hand contractures. Interventions included to transfer out of bed with the assistance of two via mechanical lift. A nurse's note and facility documentation/investigation dated 02/13/11 identified that during a mechanical lift transfer the resident was hit in the head with the mechanical lift bar. The resident sustained [REDACTED]. The resident was transferred to the ER where three sutures were required to close to the lacerated area. Interview with the Assistant Director of Nurses (ADNS) on 03/10/11 at 11:00 AM identified that when attaching the mechanical lift pad to the mechanical lift bars two nurse aides are required to complete the task. One nurse aide controls the lift bar and the other nurse aide operates the mechanical lift controls. Interview with NA#1 on 03/10/11 at 12:30 PM identified that she was aware that she needed the assistance of a second nurse aide to transfer the resident, however she was unaware that a second nurse aide was needed when attaching the pad to the bar. 2. Resident #116 ' s [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident with short and long term memory problems, was moderately cognitively impaired, and independent with bed mobility, transfers and ambulation. An Elopement/Wandering Risk assessment dated [DATE] identified that the resident had a history of [REDACTED]. A care plan dated 12/01/10 identified the resident at risk for alteration in mood and behaviors related to wandering and refusing or removing wanderguard and history of elopement attempts. Interventions included safety checks as ordered and staff to visualize resident as ordered. A nurse's note dated 12/06/10 identified that the resident left the unit unaccompanied on two occasions. A nurse's note dated 12/16/10 identified that a wanderguard was applied and that the resident removed it. A nurse's note dated 2/19/11 and the facility's accident and incident (A&I)report identified that on 02/19/11 at 9:45 AM the nursing supervisor was notified by AMR (American Medical Response) personnel that the resident was found on the street and taken to the emergency room (ER) for evaluation. The documentation identified that the resident was last seen by staff at 9:15 AM. Interview on 03/09/11 at 10:26 AM with the Care Plan Coordinator failed to identify that the resident's care plan was revised to include any additional interventions after the 12/06/10 when the resident left the unit unoccupied on two occasions and again on 12/16/10 when a wanderguard was applied and the resident removed it. Additionally, the facility could not provide any documentation that safety checks were completed/documented to ensure the safety of a resident at risk for elopement. The Care Plan Coordinator indicated the resident was not on any type of safety checks prior to his latest elopement as indicated in the plan of care. Interview on 03/10/11 at 11:30 AM with the ADNS identified that she could not identify the progression of interventions attempted prior to the resident's most recent elopement. 3. a. Observation on 3/07/11 of room 310 at 2:30 PM identified a 5-6 inch gap in the window with a chain attached. Interview with the Director of Maintenance (DM) on 3/07/11 at 3:00 PM identified he was unaware that the window on the third floor had a 5-6 inch gap. Additionally, tour of the facility on 3/10/11 between 10:15 AM and 2:00 PM with the facility's Physical Plant Director and a staff member from the facility's Maintenance Department identified the windows in Room # 230, 212, and 214 on the A-Wing were missing chains to prevent the ability to open the windows greater than 4 inches and ensure the safety of the residents. b. Tour of the facility with the facility's Physical Plant Director on 3/10/11 between 10:15 AM and 2:00 PM identified all the residents bathroom sink temperatures on all units/floors on the second and third floor on the A, B, and S- Wings, as well as common bathing areas throughout the facility were in excess of 123 degrees. Subsequent to surveyor inquiry facility nursing staff were in-serviced on the immediate threat of harm to the residents from bathing, washing, etc. Additionally, the maintenance staff lowered the temperature settings at the mixing valves and began to monitor hot water temperatures throughout the facility until recordings below 120 degrees were obtained. c. Tour of the facility on 3/10/11 between 10:15 AM and 2:00 PM with the facility Physical Plant Director and a staff member from the facility's Maintenance Department identified oxygen concentrators in rooms 376 and 222 had not been serviced in over a year. Interview with the facility's Director of Purchasing at 3:00 PM and review of the facility's equipment log indicated the 2 concentrators had been overlooked on annual inspection by the facility's contracted service provider, and that the concentrators should have been serviced March 2010 in accordance with facility policy.