Every finding on record at Apple Rehab Middletown

Based on clinical record review, policy review, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure an Elopement Risk evaluation was completed on admission to the facility per facility policy. The findings include:Resident #1's diagnoses included dementia with anxiety, mild cognitive impairment, schizoaffective disorder, bipolar type (chronic mental health condition combining symptoms of delusions and hallucination with severe mood swings and episodes of mania), muscle weakness, type II diabetes mellitus and atrial fibrillation (a heart arrhythmia that prevents blood from pumping efficiently and increases the risk of blood clots and stroke).A Nursing admission assessment dated [DATE] failed to identify completion of the required Elopement evaluation. It was not identified whether Resident #1 was or was not at risk for elopement.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and was independent with bed mobility and ambulation without an assistive device.The Resident Care Plan (RCP) dated 2/24/26 identified Resident #1 required staff assistance with Activities of Daily Living (ADLs) and was a fall risk due to multiple risk factors. Interventions included encouraging the resident to ask and wait for staff assistance for transfers and transferring the resident per physician's orders. The RCP identified Resident #1 had cognitive impairment, a positive PASRR level of care due to psychiatric diagnoses, inappropriate behavior and could be resistive to treatment/care. Interventions included discussing implications of not complying with therapeutic regime and eliciting family input for best approaches to the resident.A nurse's note dated 5/8/26 at 10:32 PM by LPN #1 identified Resident #1 returned from a leave of absence (LOA) despite no evidence of a responsible party approval for an LOA on that date. A body audit was completed and no changes were observed, vital signs were stable, blood glucose was 172 and Resident #1 denied pain or discomfort. Resident #1 ate his/her dinner and snack, tolerated all medication with no adverse effects and was sleeping in bed with the call light within reach.The Police Report dated 5/8/26 identified at approximately 6:01 PM officers were dispatched to the facility for reports of a missing person. On arrival, nursing staff reported Resident #1 took off thirty (30) minutes prior and could not be located. Staff identified they last saw Resident #1 outside on the patio, and when they went to administer evening medications, they were unable to locate Resident #1 and were concerned due to his/her altered mental status. The Regional Administrator arrived on scene and reported she spoke with Resident #1's family (Person #2) who identified Resident #1 had been acting suspicious earlier in the evening and they were concerned Resident #1 left with Person #3 who he/she is not permitted to have contact with per the facility, but no protective order was in place. The surveillance cameras were reviewed and identified Resident #1 left the premises at 3:25 PM (over 2.5 hours prior to the police being notified) and spent over an hour pacing the front side walks and talking on his/her phone. At 7:15 PM, officers 'pinged' Resident #1's cell phone, the area was searched and a nearby hotel confirmed Person #3 had been staying at that hotel and offered the room number. Officers were let into the room and Resident #1 was found hiding in the bathroom. The Regional Administrator was notified and drove to the hotel to transport Resident #1 back to the facility.Review of the clinical record from 11/16/25 through 5/8/26 failed to identify an initial Elopement Risk evaluation was completed or that an Elopement Risk evaluation was completed subsequent to the incident.Interview with RN #2 on 6/10/26 at 2:01 PM identified she performed the Nursing admission assessment on 11/15/26 but was unable to explain why the assessment was not completed to indicate if Resident #1 was at risk for elopement. RN #2 identified the assessment should have been completed on admission.Interview with the DON on 6/10/26 at 2:39 PM identified the Elopement evaluation should have been completed on admission to the facility and quarterly, and again after the resident went missing on 5/8/26. She reported she was unaware the evaluations had not been completed. The post-incident evaluation was needed to prevent further elopement incidents and to implement appropriate individualized safeguards.Review of the Elopement Risk policy (undated) directed, in part, all residents are evaluated for risk of elopement on admission and readmission. Every resident admitted to the facility will be evaluated for elopement risk. A care plan will be developed and individualized interventions implemented if the resident is identified to be an elopement risk per the Elopement Risk evaluation.

Based on clinical record review, facility documentation/policies, and interviews, the facility failed to provide adequate supervision and failed to implement required elopement prevention processes for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents. Resident #1 had documented cognitive impairment, required staff assistance for ambulation outside the room, did not have approval for an independent Leave of Absence (LOA), and did not have a completed Elopement Risk evaluation as required by facility policy. The facility permitted Resident #1 to sit outside without supervision, failed to monitor Resident #1's whereabouts, and failed to follow missing resident procedures. As a result, Resident #1 eloped from the facility and was later located by law enforcement at a hotel approximately four (4) miles away. The findings include:Resident #1's diagnoses included dementia with anxiety, mild cognitive impairment, schizoaffective disorder bipolar type, muscle weakness, type II diabetes mellitus, and atrial fibrillation.A Preadmission Screening and Resident Review (PASRR) Level II dated 11/12/25 identified Resident #1 required 24 hour supervision for safety and had an assigned Conservator of Person (Person #6).A Nursing admission assessment dated [DATE] failed to identify completion of an Elopement Risk Evaluation.A physician order dated 11/19/25 directed Resident #1 was independent with ambulation inside the room and required one person assistance with a gait belt for ambulation in the hallways. The order did not authorize independent ambulation outdoors.A physician order dated 11/23/25 directed Resident #1 may go on LOA only with a responsible party.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), required partial assistance for toilet transfers, and was independent with bed mobility and ambulation without an assistive device.The Resident Care Plan (RCP) dated 2/24/26 identified Resident #1 required staff assistance with Activities of Daily Living (ADLs) and was a fall risk due to multiple risk factors. Interventions included encouraging Resident #1 to ask and wait for staff assistance for transfers and to transfer per physician orders. The RCP identified cognitive impairment, a positive PASRR level of care due to psychiatric diagnoses, inappropriate behaviors, and resistance to care. Interventions included discussing implications of not complying with the therapeutic regimen and requesting family input regarding approaches to care.A Capacity to Meet Minimal Basic Needs Interview dated 2/28/26 identified Resident #1 could not meet basic needs in the community.A review of the clinical record from 11/16/25 through 5/8/26 failed to identify a completed Elopement Risk evaluation.A nurse's note by LPN #1 dated 5/8/26 at 10:32 PM identified Resident #1 returned from LOA despite the absence of documentation supporting responsible party approval for an LOA on that date.A review of nurse's notes from 5/1/26 through 5/8/26 failed to identify approval from Person #6 for an LOA on 5/8/26.The Police Report dated 5/8/26 identified at approximately 6:01 PM officers were dispatched to the facility for reports of a missing person. On arrival, nursing staff reported Resident #1 took off thirty (30) minutes prior and could not be located. Staff identified they last saw Resident #1 outside on the patio, and when they went to administer evening medications, they were unable to locate Resident #1 and were concerned due to his/her altered mental status. The Regional Administrator arrived on scene and reported she spoke with Resident #1's family (Person #2) who identified Resident #1 had been acting suspicious earlier in the evening and they were concerned Resident #1 left with Person #3 who he/she is not permitted to have contact with per the facility, but no protective order was in place. The surveillance cameras were reviewed and identified Resident #1 left the premises at 3:25 PM (over 2.5 hours prior to the police being notified) and spent over an hour pacing the front side walks and talking on his/her phone. At 7:15 PM, officers 'pinged' Resident #1's cell phone, the area was searched and a nearby hotel confirmed Person #3 had been staying at that hotel and offered the room number. Officers were let into the room and Resident #1 was found hiding in the bathroom. The Regional Administrator was notified and drove to the hotel to transport Resident #1 back to the facility.A review of the clinical record from 5/8/26 through 6/10/26 failed to identify documentation of Resident #1 leaving the facility, missing resident procedures, a timeline of events consistent with the Police Report, or a completed Elopement Risk evaluation following the incident.An interview with NA #1 on 6/10/26 at 11:27 AM identified that on 5/8/26 she last observed Resident #1 around 3:00 PM sitting in the lobby with a family member. She reported Resident #1 routinely ambulated independently around the facility and sat outside unsupervised. At approximately 4:00 PM, she could not locate Resident #1. LPN #1 informed her that LPN #2 opened the door and allowed Resident #1 to go outside. NA #1 assumed LPN #1 and the Receptionist were supervising Resident #1. At 5:30 PM, LPN #1 informed her Resident #1 could not be found, a missing person code was called, and police were notified.An interview with Resident #1 on 6/10/26 at 11:58 AM identified that since admission to the facility, she/he requested an LOA with Person #3, and was informed that was not permitted. Resident #1 reported asking to sit in the front area on 5/8/26 and leaving without notifying staff. Resident #1 reported walking to a nearby store, being picked up by Person #3 and going to a hotel.An interview with LPN #1 on 6/10/26 at 12:20 PM identified she was receiving report around 3:00 PM on 5/8/26 when Resident #1 requested to go outside. LPN #2 entered the door code and permitted Resident #1 to ambulate to the patio. LPN #1 was unaware of the physician order requiring one person assistance outside the resident's room and did not check on Resident #1. She identified her note incorrectly documented that Resident #1 left on an LOA and reported RN #1 directed her to document that. She identified that if Resident #1 had left on an approved LOA, she would have documented before Resident #1 left the facility.An interview with the Rehab Director on 6/10/26 at 12:40 PM identified Resident #1 had not been evaluated for ambulation on uneven outdoor surfaces due to refusing prior assessments. Nursing should have submitted a screen if Resident #1 desired to ambulate outside independently. Resident #1 was not safe to be unsupervised or ambulate outside independently on 5/8/26.An interview with Person #5 (assistant to Person #6) on 6/10/26 at 1:26 PM identified Resident #1 was not approved for an independent LOA on 5/8/26 and that staff were not to permit contact between Resident #1 and Person #3 due to safety concerns.An interview with the Receptionist on 6/10/26 at 1:52 PM identified she was unaware Resident #1 went outside. She reported Resident #1 often paced outside and returned without issue, and if notified, she would have checked every few minutes. She reported she was not aware Resident #1 was outside until LPN #1 asked her at approximately 5:30 PM.An interview with RN #2 on 6/10/26 at 2:01 PM identified she completed the Nursing admission assessment on 11/15/25 and could not explain why the Elopement Risk evaluation was not completed. She identified LPN #2 should have reviewed orders prior to allowing Resident #1 outside and notified the Receptionist. Resident #1 did not sign out for an LOA. RN #2 initiated the missing person code and notified police.An interview with the Director of Nursing (DON) on 6/10/26 at 2:39 PM identified the Elopement Risk Evaluation should have been completed on admission and quarterly. She identified that staff should verify supervision needs before permitting a resident outside, that LPN #2 should have notified the Receptionist, and that documentation of the missing resident incident was not completed. She identified LPN #1 should not have documented inaccurate information.An interview with the Regional Administrator on 6/10/26 at 3:08 PM identified she reviewed surveillance footage that showed Resident #1 outside at 3:10 PM and leaving the camera view at 3:25 PM. She identified Resident #1 did not sign out on an LOA and was not approved by Person #6 to leave independently. She retrieved Resident #1 from the hotel after police located Resident #1.The facility reported the incident to the State Agency on 6/10/26.Although attempted, interviews with Person #2, Person #3, RN #1, and LPN #2 were unsuccessful.Although requested, documentation pertaining to responsible party approval for an LOA on 5/8/26 was not provided.The Missing Resident, Unauthorized Leave, and Elopement Response policy directed that residents at risk for harm, exploitation, injury, environmental exposure, or inability to meet basic needs were to be treated as high risk missing residents and immediate search and notification procedures should be initiated. The policy identified conditions requiring police notification, documentation requirements, and the need to base the response on assessed risk factors, cognitive status, known habits, and environmental conditions.The Leave of Absence (LOA) policy directed that all LOAs required provider authorization and that an LOA Risk Evaluation process should be used to identify support needs and safety concerns.The Elopement Risk policy directed that all residents be evaluated for elopement risk on admission and readmission and that a care plan be developed if the resident was identified as at risk.

Based on clinical record review, facility documentation, and staff interviews for one (1) of three (3) sampled residents (Resident #1), the facility failed to maintain a clinical record that was complete, accurate, and timely. Specifically, the facility failed to document that Resident #1 was missing from the facility on 5/8/26 and failed to ensure nursing documentation accurately reflected the circumstances of the resident's departure. These failures resulted in a clinical record lacking essential information needed to ensure continuity of care, accurate assessment, and a reliable account of significant events. The findings include:Resident #1's diagnoses included dementia with anxiety, mild cognitive impairment, schizoaffective disorder bipolar type, muscle weakness, type II diabetes mellitus, and atrial fibrillation.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and was independent with bed mobility and ambulation without an assistive device.The Resident Care Plan (RCP) dated 2/24/26 identified Resident #1 required staff assistance with Activities of Daily Living (ADLs) and was a fall risk due to multiple contributing factors. Interventions included encouraging Resident #1 to ask and wait for staff assistance for transfers and transferring per physician orders. The RCP identified cognitive impairment, inappropriate behaviors, and resistance to care. Interventions included discussing implications of not complying with the therapeutic regimen and obtaining family input for approaches to care.A nurse's note by LPN #1 dated 5/8/26 at 10:32 PM identified Resident #1 returned from a Leave of Absence (LOA) despite no evidence of responsible party approval for an LOA that day.The Police Report dated 5/8/26 identified that at approximately 6:01 PM officers were dispatched to the facility for a missing resident. Staff reported Resident #1 left approximately thirty (30) minutes prior and could not be located. Staff identified Resident #1 was last seen on the patio and was not present when evening medications were attempted. Person #2 expressed concern Resident #1 may have gone with Person #3, with whom contact was not permitted. Surveillance footage identified Resident #1 left the premises at 3:25 PM. Police pinged the resident's cell phone and located Resident #1 at a hotel. Resident #1 was found in a bathroom and was retrieved by the Regional Administrator and returned to the facility.A review of the clinical record from 5/8/26 through 6/10/26 failed to identify documentation that Resident #1 was missing from the facility, that missing resident procedures were initiated, that police were notified, or that Resident #1 was returned by the Regional Administrator following police involvement. The clinical record did not include a timeline of the events described in the Police Report or documentation of required notifications.An interview with LPN #1 on 6/10/26 at 12:20 PM identified that on 5/8/26 she was receiving report around 3:00 PM when Resident #1 requested to go outside. LPN #2 opened the door and permitted Resident #1 to ambulate to the patio. LPN #1 did not check on Resident #1 and assumed the Receptionist was monitoring. At approximately 5:30 PM, LPN #1 searched outside, could not locate Resident #1, and notified RN #2. A missing person code was initiated and police were contacted. Resident #1 returned after 8:00 PM and reported leaving to see Person #3. LPN #1 identified her nurse's note incorrectly documented Resident #1 left on an LOA and reported RN #1 instructed her to document the event that way. She identified she would have documented prior to departure if an LOA had been approved.An interview with the Director of Nursing (DON) on 6/10/26 at 2:39 PM identified the missing resident incident should have been documented. The DON identified the nurse's note by LPN #1 contained inaccurate information and that there was no responsible party approval for an LOA on 5/8/26.An interview with the Regional Administrator on 6/10/26 at 3:08 PM identified Resident #1 had not signed out, had not been approved to leave independently, and police were contacted because Resident #1 could not be located. She retrieved Resident #1 from a hotel after police located the resident.The Missing Resident, Unauthorized Leave, and Elopement Response policy (undated) directed that residents at risk for harm, exploitation, injury, environmental exposure, or inability to meet basic needs should be treated as high risk missing residents and immediate search efforts and notifications should be initiated. The policy required documentation including the time the resident was discovered missing, circumstances surrounding the event, resident risk assessment, search efforts, notifications, assessment upon return, physician/provider orders, interventions, incident reporting, care plan updates, and follow up actions.

Based on observations, review of the clinical record, facility policy and interviews for 3 of 6 sampled residents (Resident #'s 8, 18, and 62) reviewed for nutrition, the facility failed to complete nutritional assessments within the required time allotted parameters and additionally, for Resident #18 and Resident #62 failed to prevent a significant weight loss. The findings include: 1. Resident #18's diagnoses included type 2 diabetes, pressure ulcer of sacral region, and muscle weakness. The facility Nursing admission assessment dated [DATE] at 8:55 PM identified Resident #18 weighed 177 pounds, had adequate nutrition and hydration, and was at mild risk for skin breakdown with Moisture Associated Skin Damage (MASD) to the coccyx. A physician's order dated 4/20/26 directed to obtain weekly weights every Friday for 4 weeks and obtain a monthly weight. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 had a Brief Interview of Mental Status score of 8 indicating moderate cognitive impairment and required set up/clean up by staff for eating and was dependent on staff for transfers and dressing. Additionally, Resident #18 had coughing or choking episodes during meals or when swallowing medications, weighed 177 pounds (lbs.) on admission, no significant weight loss was identified (5% or more in the last month or 10% or more in the last 6 months), and was at risk for pressure ulcers. A physician's order dated 5/8/26 directed a carbohydrate-controlled, dysphagia advanced (difficulty swallowing) diet with thin liquids. Review of Resident #18's weights identified the following: 177 lbs. on 4/20/26 (on admission) 176.9 lbs. on 5/1/26 175 lbs. on 5/8/26 The clinical record failed to identify any Nutritional Assessments had been conducted. A nurse's note dated 5/11/26 at 5:58 AM identified Resident #18 was experiencing altered mental status and level of consciousness with a productive cough and diminished lung sounds. Resident #18 presented as pale with pinpoint pupils; an order was obtained from the on-call service to send the resident to the Emergency Department. The hospital history and physical note dated 5/11/26 at 10:56 AM identified Resident #18 was sent to the Emergency Department by the facility with altered mental status, lethargy and was not eating well with poor meal intake and no appetite. The hospital nutrition note dated 5/18/26 at 10:25 AM identified Resident #18 had an admission weight of 147.9 lbs., with muscle wasting to the clavicle, anterior thigh/patella region and fat wasting to buccal (cheek) region, meeting the criteria for malnutrition. Resident #16 required 1:1 feeding assistance and had good meal intakes consuming 75-100% during meals. Nutrition interventions included diabetic restriction, Ensure Plus High Protein daily with meals, adjust insulin per physician, and monition weight, lab work and intake/output. The hospital speech therapy note dated 5/18/26 at 10:30 AM directed to continue a puree diet and thin liquids, 1:1 feeding assistance, medications crushed and one at a time, and to only feed the resident when awake and alert. a. The facility Nursing re-admission assessment dated [DATE] at 3:18 PM identified Resident #18 weighed 160 lbs., needed assistance with eating, had inadequate nutrition but failed to identify a hydration risk (section was left blank). Additionally, the Nursing admission Assessment identified Resident #18 had a Braden Score of 7 indicating a severe risk for skin breakdown. Resident #18 was noted to have a stage 3 pressure ulcer to the sacrum (3.0 cm x 2.0 cm x 0.2 cm), and diabetic foot ulcers to the left heel (2.5 cm x 3.0 cm x 0.0 cm) and right heel (4.2 cm x 2.0 cm x 0.0 cm). The quarterly Minimum Data Set MDS assessment dated [DATE] identified Resident #18 had a Brief Interview of Mental Status of 5 indicating severe cognitive impairment and was dependent on staff for eating, and all activities of daily living. Resident #18 had episodes of coughing or choking during meals or when swallowing medications, weighed 160 lbs., no significant weight loss was identified (5% or more in the last month or 10% or more in the last 6 months), and was at risk for pressure ulcers with 1 stage 3 pressure ulcer present on reentry. The Resident Care Plan dated 6/2/26 identified Resident #18 had the potential for a nutritional decline. Interventions included offering to set up meals, watch for signs and symptoms of trouble with chewing or swallowing and weights as ordered. Review of physician's post readmission orders dated 5/21/26 through 6/4/26 failed to direct facility staff to obtain Resident #18's weights. Review of the meal intakes dated 5/21/26 through 6/7/26 identified that out of 54 meals, Resident #18 consumed 0-25% during 37 meals, 26-50% during 8 meals, 76-100% during 3 meals, had 1 refusal, and 5 meal intakes were left blank. Subsequent to surveyor inquiry after record review, a physician's order dated 6/3/26 directed Resident #18 to be re-weighed. The Assistant Director of Nursing Services (ADNS) and 2 Nurse Aids (NA's) weighed Resident #18 on 6/3/26 at 11:26 AM and a weight of 150.2 lbs. was obtained (readmission weight of 160 a 9.8 lb., 6.13% weight loss in 13 days, and 26.7 lb., 15.09% overall since admission). A subsequent physician's order dated 6/5/26 directed facility staff to obtain weekly weights every Friday for 4 weeks. Review of Resident #18's weights identified the following: 160 lbs. on 5/21/26 on readmission 150.2 lbs. on 6/3/26 148 lbs. 6/5/26 (per physician order to obtain weights on Friday, an additional 1.8 lb. weight loss for a total of 12 lbs., (7.5%) since readmission) Interview and clinical record review with Registered Dietician, (RD) #1, on 6/3/26 at 9:40 AM identified the Weight Policy directed newly admitted /readmitted residents would have a readmission weight and weekly weights for 4 weeks. Additionally, Nutritional Assessments were to be completed on admission/readmission and then annually, quarterly, and for those residents at risk (change in intake, weight fluctuation, change in diet, or abnormal lab work). Review of Resident #18's clinical record failed to identify there was a physician's order to obtain weekly weights after readmission on [DATE] failed to identify a reweight following a significant weight loss noted on readmission or that any Nutritional Assessments had been conducted since Resident #18's original admission on [DATE]. RD #1 indicated that the Nursing Department was responsible for notifying her of weight changes, decreased intakes, or any resident with a pressure ulcer during the at-risk resident meetings. She indicated she had not been notified of Resident #18's decreased meal intakes (on average 0-25% since readmission), not notified of the readmission weight of 160 lbs. on 5/21/26, (down from 177 lbs. on 4/20/26, a 17 lbs., 9.6% weight loss in one month) or that Resident #18 returned with wounds to the coccyx and heels or had additional weight loss of 12 lbs., 7.5% since readmission on [DATE]. Had she been made aware of the resident's wounds, she would have followed the policy to initiate liquid protein, supplements, vitamins (in addition to the prescribed Vitamin D3) and minerals to promote healing. RD #1 indicated that Nutritional Assessments should have been completed on admission, readmission, with significant weight loss, and with a decline in meal intake. Although RD #1 was aware of the policy for Nutritional Assessments she had not seen Resident #18 since his/her original admission on [DATE] because she was only in the facility once a week, no one covered her days off, and even though she notified the Corporate Director of Nutritional Services she was unable to complete her assessments timely, she had not received any coverage or assistance since her hours were cut from 2 days to 1 day in December 2025. Interview with Registered Nurse (RN) Supervisor #1 on 6/3/26 at 9:57 AM identified that the facility's policy was to obtain weights on admission/readmission, then weekly for 4 weeks, then per the physician's order. The facility policy also directed the nurses to notify RD #1 with nutritional concerns, such as weight loss, decreased intake, or loss of appetite. Review of the clinical record identified that Resident #18 had sustained a significant weight loss of 17 lbs. since admission on [DATE], a significant weight loss of 12 lbs. 7.5% since readmission, all meals consumed since readmission on [DATE], averaged 0-25% (last 13 days) and failed to identify that the physician had ordered weights to be obtained weekly on readmission 5/21/26. Although RN #1 was aware of the facility notification and weight loss policy, she could not explain why RD #1 and Advanced Practice Registered Nurse (APRN) #1 had never been notified to assess Resident #18 following each weight loss and decreased intakes, but that notification and assessment should have occurred. Interview and clinical record review with the Assistant Director of Nursing Services (ADNS) on 6/3/26 at 12:30 PM identified that the facility policy directed reweights with any weight discrepancies, and that weight changes were to be reported to RD #1 and the APRN #1. Resident #18's clinical record review identified that the resident's readmission weight on 5/21/26 was 160 lbs., and the weight obtained prior to the hospitalization on 5/8/26 was 176 lbs. (a 16 lbs., a 9.09% weight loss in 13 days, the hospital admission weight on 5/11/26 was noted to be 147.9 lbs.). Additionally, the ADNS identified that a reweight should have been obtained per facility policy, and although she was the one that documented the re-admission weight, she did not request a reweight or notify RD #1 or APRN #1 because she figured they would see the weight change in the electronic health record. Interview with the [NAME] President of Clinical Services on 6/5/26 at 11:24 AM identified he was not aware that there was no coverage for the RD when she was out, and that the expectation was for Nutritional Assessments to be completed within 7 days for residents that have a significant weight loss. Interview and clinical record review with the APRN #1 on 6/3/26 at 10:01 AM identified she was in the facility most days and was familiar with Resident #18's risk for nutritional decline. Review of the clinical record identified the hospital Discharge Summary ordered Ensure Plus (a nutritional supplement) to be given daily with all meals. Review of the physician's orders failed to identify the supplement had been transcribed from the hospital or that any supplemental nutrition had been ordered or given to Resident #18, despite identifying that it was facility practice to follow or discontinue hospital nutritional supplement orders. APRN #1 indicated she believed the resident was receiving supplements. Additionally, APRN #1 identified she had not been made aware of Resident #18's weight loss, decline in meal consumption, or that the resident returned from the hospital with wounds, and if she had been she would have initiated supplements and had RD #1 follow him/her. Interview with the Corporate Director of Nutritional Services on 6/8/26 at 11:22 AM identified there were other RD's available for coverage when any of the registered dieticians were out, however RD #1 did not request coverage for her time off. Additionally, she was not aware that RD #1 was unable to complete her assessments in a timely manner, and it was only brought to her attention on 6/1/26 that admission, quarterly and significant change assessments were not competed or that interventions were not being implemented for residents that presented with weight loss. Furthermore, she identified she oversees staffing and time off requests, and that ultimately the Administrator oversees the RD's work. Interview with the Administrator on 6/8/26 at 1:42 PM identified it was facility practice to complete significant weight loss assessments within 14 days per state regulations, and the facility did not have its own timeframe. b. Interview with the Director of Nurses (DNS) on 6/5/26 at 11:29 AM identified that when a resident was readmitted to the facility or had a significant weight loss, the facility policy directed the completion of a Hydration Assessments and Intake and Output (I & O) tracking to be documented on paper and kept in a binder at the nurse's station. Review of Resident #18's clinical record failed to identify that following readmission on [DATE] and following the subsequent weight loss from readmission to 6/5/26 when a 12 lb./7.5 % significant weight loss was identified that a Hydration Assessment or I & O tracking was initiated. The DNS indicated that she was going to complete the Hydration Assessment and start an I & O record yesterday, 6/4/26, but was unable to do so due to being sidetracked. The DNS could not identify why a Hydration Assessment and subsequent I & O monitoring was not completed following Resident #18's readmission [DATE]). Interview and facility record review with Licensed Practical Nurse (LPN) #5 on 6/5/26 at 11:36 AM identified an I & O binder at the nurse's station for North and South Units (2 of 3 units in the facility), however, there were no sheets to track I & O's in the binder for June 2026, and only one resident from North unit had a I & O tracking sheet for the month of May. 2. Resident #8's diagnoses included Parkinsonism, adult failure to thrive, and palliative care. A physician's order dated 4/16/26 directed to give 6 ounces of house supplement twice a day at lunch and dinner and weigh every evening on the 7th of every month. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 signed onto hospice care and had a Brief Interview for Mental Status score of 0 indicating severe cognitive impairment, required set up assistance with eating, substantial maximum assistance with hygiene, dressing, and was independent with bed mobility, transfers and ambulation. The Resident Care Plan dated 6/4/26 identified a potential for nutritional decline related to recent hospitalization, good intake and appetite, weight was on a downward trend, decreased this quarter, receptive to oral supplements, hospice level of care. Interventions included offering set up for meals, cueing at meals, diet as ordered, provide snacks, providing supplements, and weigh as ordered. Interview and clinical record review with Registered Dietitian (RD) #1 on 6/4/26 at 11:54 AM identified that a Nutrition Assessment was opened for Resident #8 on 5/20/26 and had not been completed. RD #1 indicated that she had 14 days to complete an assessment from admission or the Assessment Reference Date of the Minimum Data Set (MDS) assessment, she was not at the facility yesterday 6/3/26 so the assessment may be a day or 2 late for completion. Further, she indicated that Resident #8 began on Hospice services on 5/1/26. Although a Nutritional Assessment was opened on 5/20/26 it was not completed until 6/4/26, 16 days later, for a significant weight loss of 4% in 30 days and 13% in 180 days. 3. Resident #62 's diagnoses included Alzheimer's disease, prediabetes, severe protein-calorie malnutrition, and possible brain mass. The baseline Resident Care Plan dated 5/4/26 identified a goal to maintain current weight and directed to offer assistance with set up to Resident #62 for meals. The Resident Care Plan failed to include a nutritional risk or intervention for the Resident #62 to maintain his/her weight. An admission nurse's note dated 5/4/26 at 9:19 PM identified Resident #62 had dry oral mucosa (a possible indicator of poor hydration) and poor oral intake. The admission Minimum Data Set assessment dated [DATE] identified Resident #62 had a Brief Interview of Mental status score of 0, indicating severe cognitive impairment, required maximal assistance for eating, and was completely dependent on staff for oral hygiene, personal hygiene, bathroom use and showering/bathing. The admission Minimum Data Set assessment did not identify a significant weight loss or difficulty chewing or swallowing. A physician's order dated 5/5/26 directed to provide a soft texture diet with thin liquids and to provide 6 ounces of house nutritional supplement 4 times a day. (The physician's order failed to direct documentation of the percentage of supplement taken). A Speech Therapy Evaluation dated 5/6/26 identified Resident #62 had dysphagia at the oral phase (difficulty with the voluntary stages of swallowing food and/or liquid) and was at his/her previous level of function, Resident #62 was noted to consume a regular diet, and at baseline had frequent refusals of most food items. A review of the nurse's notes dated 5/4/26, 5/5/26, 5/6/26, and 5/7/26 identified Resident #62 had poor oral intakes. Nurse's notes dated 5/10/26, and 5/11/26 identified Resident #62 continued to have poor oral intakes. A nurse's note dated 5/13/26 at 9:17 AM identified Resident #62 was sent to the emergency room for rapid heart rate, lethargy, and low blood oxygen saturation. A nurse's note dated 5/14/26 at 2:59 AM identified Resident #62 returned from the emergency room with a urinary tract infection. A nurse's note dated 5/14/26 identified Resident #62 had poor oral intake. Advanced Practice Registered Nurse (APRN) #1's note dated 5/15/26 at 9:37 AM identified, in part, Resident #62 had been sent to the emergency room 2 days earlier due to agitation and that a CT scan of the head showed a mass versus a bleed. Resident #62 was treated with an antibiotic for a urinary tract infection. In addition, due to a history of protein-calorie malnutrition, it was recommended that staff feed Resident #62 as he/she had trouble seeing his/her food likely due to the brain mass. The recommendation was to continue the house supplement 4 times daily. Additional nurse's notes dated 5/18/26, and 5/30/26 identified Resident #62 had poor oral intakes. Review of Resident #62's weights identified the following On 5/4/26 a weight of 104.0 lbs. On 5/8/26 a weight of 100.2 pounds. (a 3.8 lb. loss from 5/4/26.) On 5/14/26 a weight of 99 pounds. (a 5 lb. loss from 5/4/26.) On 5/16/26 a weight of 96 pounds. (an 8 lb. 7.69% loss in 12 days) On 5/31/26 a weight of 97 pounds. (a 7 lb. 6.73% weight loss since admission on [DATE].) The revised Resident Care Plan dated 6/1/26 identified a risk for nutritional decline and need for staff assistance with activities of daily living. Interventions directed staff to deliver meals, set up, assist with eating as needed, and to provide diet and supplements as ordered. A review of the clinical record failed to identify that a Nutritional Assessment was completed by Registered Dietitian (RD) #1. An interview with RD #1 on 6/3/26 at 10:45 AM identified that although a Nutritional Assessment was opened on 5/20/26 in clinical record for Resident #62 it was never completed. RD #1 indicated she thought she had 14 days to complete the Nutritional Assessment and could not explain why the Nutritional Assessment was incomplete. Additionally, she indicated that nursing had not notified her of Resident #62's significant weight loss of 7 lbs., 6.73% in a month, but she usually identified weight loss by reviewing weights in the clinical record. Subsequent to surveyor inquiry, Resident #62's Nutritional Assessment was completed on 6/3/26 (33 days after admission) , and the Resident Care Plan was updated to include a Magic Cup (a fortified ice cream-type supplement.) and the house supplement order included a notation to document the amount consumed. Interview and record review with the Director of Nursing (DON) on 6/3/26 at 11:20 AM identified that RD #1 was made aware of Resident #62's weight loss on 5/20/26 during a risk meeting, and the DON showed the meeting attendance sheet with signatures of attendees, including RD #1. The sign-in sheet listed Resident #62 as having a weight concern. An interview with the Advanced Practice Registered Nurse (APRN) #1) on 6/4/26 at 9:15 AM identified that she was never notified of Resident #62's significant weight loss of 6.73 % and further stated if she had been notified that there was a significant weight loss she may have put additional measures in place to prevent further weight loss. Review of the Nutritional Supplementation Program directed, in part, that the facility would use an interdisciplinary approach to identify residents at nutritional risk and to implement appropriate interventions, monitor effectiveness, and adjust the plan of care as needed and that those identified as being at nutritional risk would be referred to the dietitian as appropriate. Review of the Weight Monitoring policy directed, in part, that an initial nutritional assessment would be conducted for all residents by the Registered Dietitian and that nutritional assessments would be made with reference to the Resident's usual body weight to assist in establishing a baseline against which to assess subsequent weight changes.

Based on observations, interviews and review of facility policy for 3 of 3 units, the facility failed to provide a clean and homelike environment by ensuring bathroom fans were clean. The findings include:Observation of 20 out of 29 resident bathrooms on 6/1/26 at 10:15 AM identified ceiling vents exhibited a significant buildup of dust/debris . Observation and interview with the Director of Maintenance 6/2/26 at 11:10 am with the Director of Maintenance, identified a significant buildup of dust on the ceiling vents in 20 out of 29 resident bathrooms. The Director of Maintenance indicated that the bathroom vents are cleaned a couple times per year and that it was his responsibility. He indicated that he last cleaned the vents about six months prior, did not inspect them for cleanliness after he cleaned them and that he should inspect the vents more regularly to ensure accumulation of dust does not occur. Subsequent to surveyor inquiry, the resident bathroom vents were cleaned. Review of the Resident Room Occupied/Discharge Cleaning policy not dated directed in part to provide a clean, sanitary, and attractive environment for residents, visitors, and employees. Additionally, it directed to dust high items using a long-handled duster which included pictures, plaques, mirrors, bulletin boards, tops of partitions, vents, tops of cabinets, coat racks, cabinets and window/door frames.

Based on observation, review of the clinical record, facility policy and interviews during an observation of facility dining, for Resident #69 the facility failed to provide a dignified dining experience for a dependent resident requiring assistance to eat. The findings include: Resident #69's diagnoses included dementia, dysphagia (difficulty swallowing), low back pain, and cancer of the lung.The admission Nursing assessment dated [DATE] identified Resident #69 had difficulty with memory recall and was cognitively impaired.The Baseline Care Plan dated 5/30/26 identified Resident #69 required assistance of 2 people for bed mobility, transferring, and required the assistance of 1 person for bathing, and grooming, and required set-up assistance for eating.A physician's order dated 5/30/26 directed to provide Resident #69 a cholesterol restricted cardiac diet with pureed consistency and thin liquids, and to provide total assistance for eating.The Resident Care Card in effect at the time of the observation identified Resident #69 was receiving a pureed diet and needed assistance.An observation on 6/2/26 at 9:35 AM identified Resident #69 was lying on his/her back, across the middle of the bed, with his/her feet off the side of the bed and not touching the floor. Resident #69 was fully visible from the hallway and when approached stated, I am trying to eat but keep falling back on the bed. Resident #69's meal was observed at bedside, covered, with a diet tag that identified total assistance with eating was required. The call bell was near Resident #69 but out of reach due to his/her body positioning on the bed. An interview with Supervising Registered Nurse (RN) #1 on 6/2/26 at 9:40 AM identified she was assigned as an extra set of hands for the shift. RN #1 further stated she was not familiar with Resident #69 because he/she was recently admitted , and because of this was unable to assist him/her.An interview with Licensed Practical Nurse (LPN) #2 on 6/2/26 at 9:44 AM identified breakfast had been delivered at 8:30 AM (1 hour and 15 minutes earlier). LPN #2 also stated she was aware Resident #69 needed help with eating and that she was trying to find someone to assist him/her.A follow-up observation on 6/2/26 at 9:55 AM identified Nursing Assistant (NA) #2 was offering assistance to Resident #69 with the breakfast meal. Resident was positioned appropriately in bed; however, NA #2 was standing over Resident #69 and was not at eye level.An interview with DNS on 6/2/26 at 10:00 AM identified that she did not believe it was appropriate or dignified for Resident #69 to wait over an hour for assistance. The DNS indicated she was not aware of a policy regarding caregivers standing over a resident while assisting a resident to eat a meal. Review of the Feeding Assistance policy directed, in part, Residents will be offered nutritionally balanced meals and appropriate assistance with feeding according to their needs, preferences, diet orders, and plan of care. In addition, the policy directed assisting residents to an appropriate upright position during meals and interacting respectfully with the Resident and promoting dignity during meals.

Based on observations, interviews, clinical record review, and facility policy for 1 of 2 sampled residents (Resident #1) reviewed for skin conditions and 2 of 6 sampled residents (Resident#18 and Resident #62) reviewed for nutrition, the facility failed to notify the provider and dietitian of a significant weight loss and change in condition. The findings include: 1. Resident #1's diagnoses included lymphedema, cellulitis, and morbid obesity. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status of 15 indicating intact cognition, required partial/moderate assistance with lower body dressing, and supervision/touch assistance with upper body dressing, personal hygiene and transfers. The Resident Care Plan dated 4/21/26 identified Resident #1 was at risk for skin breakdown due to decreased mobility, incontinence, a diagnosis of lymphedema and a lymphatic wound (identified 2/27/26, resolved 4/13/26). Interventions included a consultation with the wound specialist, continuing treatment for protection as ordered for the resolved right lower leg wound and to keep skin clean, and dry. Observation and Interview with Resident #1 on 6/1/26 at 1:39 PM identified bilateral lower extremity swelling and a white sock on the right leg that was pulled up to mid calf, with the top section of the sock appearing similar to gauze material covering the right lower leg. Resident #1 reported being hospitalized in March for a leg infection and stated that he/she had lymphedema and that the sock was pulled up due to the right leg weeping. Resident #1 further reported that the leg used to get wrapped, but it has not been wrapped for some time, even though staff was aware of both the swelling and weeping. Interview with Registered Nurse Supervisor (RN) #8 on 6/5/26 at 8:49 AM identified care for lymphedema was resident specific, but it was facility protocol to start with a visit to the lymphedema clinic. In cases where the residents could not be seen due to wounds or weeping, they were seen by the in-house APRN and provided with in-house interventions such as wraps. Additionally, RN #8 identified Resident #1 reported weeping to his/her legs yesterday (6/4/26), but she had not yet updated the APRN #1. Interview and clinical record review with APRN #1 on 6/8/26 at 8:21 AM identified she was not updated to Resident #1's legs weeping on 6/4/26, and if she was, she would have referred him/her to be seen by the wound team. Interview with RN #8 on 6/8/26 at 8:35 AM identified she updated APRN #1 last week, however a review of the nurse progress notes a as well as a review of the APRN book titled Critical Concern for the Practitioner binder failed to reflect APRN #1 was ever updated. 2. Resident #18's diagnoses included type 2 diabetes, pressure ulcer of sacral region, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #18 had a Brief Interview of Mental Status of 5 indicating severe cognitive impairment and was dependent on staff for eating, and all activities of daily living. Additionally, the MDS identified Resident #18 weighed 160 lbs., had no significant weight loss identified (5% or more in the last month or 10% or more in the last 6 months), and was at risk for pressure ulcers with one stage 3 pressure ulcer present on reentry. The Resident Care Plan dated 6/2/26 identified Resident #18 had the potential for a nutritional decline. Interventions included offering to set up meals, watch for signs and symptoms of trouble with chewing or swallowing and weights as ordered. Interview and clinical record review with Registered Dietician, (RD) #1 on 6/3/26 at 9:40 AM identified Nutritional Assessments were to be completed annually, quarterly, and on readmission and for those residents that experienced weight loss or decreased meal intake. Further, at risk residents were those that had a change in intake, weight fluctuation, change in diet or abnormal lab work. She identified that although the Nursing Department usually let her know about at risk residents, she was not updated on Resident #18's decreased meal intake (on average 0-25% since readmission), the readmission weight of 160 lbs. on 5/21/26, (down from 177 lbs. on 4/20/26, a 17 lbs., 9.6% weight loss in one month), that Resident #18 was readmitted on [DATE] with wounds to the coccyx and heels and had additional weight loss from 5/21/26 to 6/5/26 of 12 lb.s/7.5%. Had she been aware of the Resident's wounds, she would have followed facility policy to initiate liquid protein, supplements, vitamins (in addition to the prescribed Vitamin D3) and minerals to promote healing. Interview with Registered Nurse (RN) Supervisor #1 on 6/3/26 at 9:57 AM identified that the facility's policy directed the nurses to notify the Dietician with nutritional concerns, such as weight loss, decreased intake, or loss of appetite. Review of the clinical record identified that Resident #18 had sustained a significant weight loss of 17 lbs. since admission on [DATE] and an additional weight loss following readmission on [DATE] of 12 lbs., 7.5%. Although RN #1 was aware of the facility notification and weight loss policy, she could not explain why the RD #1 and Advanced Practice Registered Nurse (APRN) #1 had never been notified to assess Resident #18, but that notification and assessment should have occurred. Interview and clinical record review with the ADNS on 6/3/26 at 12:30 PM identified that the facility policy directed reweights with any weight discrepancies, and that weight changes were to be reported to the RD and APRN. Resident #18's clinical record review identified that the resident's readmission weight on 5/21/26 was 160 lbs., and the weight obtained prior to the hospitalization on 5/8/26 was 176 lbs. (a 16 lbs., a 9.09% weight loss in 13 days, the hospital admission weight on 5/11/26 was noted to be 147.9 lbs.). Additionally, the ADNS identified that a reweight should have been obtained according to the facility policy, and although she was the one that documented the re-admission weight, she did not request a reweight or notify RD #1 or APRN #1 because she figured they would see the weight change in the electronic health record. Interview and clinical record review with APRN #1 on 6/3/26 at 10:01 AM identified she was in the facility most days and was familiar with Resident #18's risk for nutritional decline. Additionally, APRN #1 identified she had not been made aware of Resident #18's significant weight loss, decline in meal consumption, or that the resident returned from the hospital with wounds, and if she had been she would have initiated supplements and had RD #1 follow him/her. 3. Resident #62 's diagnoses included Alzheimer's disease, prediabetes, severe protein-calorie malnutrition, and possible brain mass. The baseline Resident Care Plan dated 5/4/26 identified a goal to maintain current weight and directed to offer assistance with set up to Resident #62 for meals. The Resident Care Plan failed to include a nutritional risk or intervention for the Resident #62 to maintain his/her weight. An admission nurse's note dated 5/4/26 at 9:19 PM identified Resident #62 had dry oral mucosa (a possible indicator of poor hydration) and poor oral intake. The admission Minimum Data Set assessment dated [DATE] identified Resident #62 had a Brief Interview of Mental status score of 0, indicating severe cognitive impairment, required maximal assistance for eating, and was completely dependent on staff for oral hygiene, personal hygiene, bathroom use and showering/bathing. The admission Minimum Data Set assessment did not identify a weight loss or difficulty chewing or swallowing. A physician's order dated 5/5/26 directed to provide a soft texture diet with thin liquids and to provide 6 ounces of house nutritional supplement 4 times a day. (The physician's order failed to direct documentation of the percentage of supplement taken). A Speech Therapy Evaluation dated 5/6/26 identified Resident #62 had dysphagia at the oral phase (difficulty with the voluntary stages of swallowing food and/or liquid). Additionally, at his/her previous level of function, Resident #62 was noted to consume a regular diet, and at baseline had frequent refusals of most food items. A review of the nurse's notes dated 5/4/26, 5/5/26, 5/6/26, and 5/7/26 identified Resident #62 had poor oral intakes. Nurse's notes dated 5/10/26, and 5/11/26 identified Resident #62 continued to have poor oral intakes. A nurse's note dated 5/13/26 at 9:17 AM identified Resident #62 was sent to the emergency room for rapid heart rate, lethargy, and low blood oxygen saturation. A nurse's note dated 5/14/26 at 2:59 AM identified Resident #62 returned from the emergency room with a urinary tract infection. A nurse's note dated 5/14/26 identified Resident #62 had poor oral intake. Advanced Practice Registered Nurse (APRN) #1's note dated 5/15/26 at 9:37 AM identified, in part, Resident #62 had been sent to the emergency room 2 days earlier due to agitation and that a CT scan of the head showed a mass versus a bleed. Resident #62 was treated with an antibiotic for a urinary tract infection. In addition, due to a history of protein-calorie malnutrition, it was recommended that staff feed Resident #62 as he/she had trouble seeing his/her food likely due to the brain mass. The recommendation was to continue the house supplement 4 times daily. Additional nurse's notes dated 5/18/26, and 5/30/26 identified Resident #62 had poor oral intakes. Review of Resident #62's weights identified the following On 5/4/26 a weight of 104.0 lbs. On 5/8/26 a weight of 100.2 pounds. (a 3.8 pound loss from 5/4/26.) On 5/14/26 a weight of 99 pounds. (a 5 pound loss from 5/4/26.) On 5/16/26 a weight of 96 pounds. (an 8 pound 7.69% loss in 12 days) On 5/31/26 a weight of 97 pounds. (a 7-pound 6.73% weight loss since admission on [DATE].) An interview with the APRN #1 on 6/4/26 at 9:15 AM identified she was not notified that Resident #62 had a significant weight loss of 6.73 % from the date of admission on [DATE] to 5/31/26 and further stated if she had been notified that there was a significant weight loss she may have put additional measures in place to prevent further loss. An interview and record review with the Director of Nursing (DNS) on 6/4/26 at 12:55 PM identified that APRN #1 or physician should have been notified by a nurse of the 6.73% significant weight loss. Review of the clinical record failed to identify the licensed provider had been notified but should have been per the policy and was unable to indicate why provider notification had not occurred. Review of the Change in Resident Condition and Notification policy directed, in part, that significant changes in a resident's physical, mental, emotional, or clinical condition would be assessed promptly and communication to the provider as appropriate. Additionally, the notification and physician orders, interventions, and resident responses would be documented in the medical record. Review of the Nutritional Supplementation policy directed, in part, that the physician or provider would be notified of significant changes in nutritional status including response to supplementation or recommendations for changes to the nutritional plan of care. Review of the Weight Monitoring policy identified, in part, that the purpose of the policy was to effectively monitor and communicate weight changes. Additionally, the charge nurse would compare weights to determine a 5% weight change in 30 days or a 10% change in 180 days, and that a significant weight change would be reported to the physician/APRN. Review of the Nursing Documentation Policy directed in part to ensure accurate, timely and complete electronic documentation that meets high-quality resident care and meets regulatory and legal requirements. Additionally directing documentation should be completed as soon as possible, reflect resident's current condition, and change in resident's condition, new symptoms or reactions to treatment including actions takes such as physician notification.

Based on observation, interviews, clinical record review, and facility policy for 1 of 2 sampled residents (Resident #1) reviewed for skin conditions, the facility failed to provide appropriate care and service for weight and intake and output monitoring, dietary recommendations, and scheduling appointments for a resident with a diagnosis of lymphedema (abnormal buildup of lymph fluid in soft tissue) and for 23 of 58 sampled residents (Resident #1, Resident #3, Resident #4, Resident #8. Resident #9, Resident #15, Resident #17, Resident #22, Resident #25, Resident #27, Resident #37, Resident #39, Resident #42, Resident #43, Resident #45, Resident #46, Resident #49, Resident #52, Resident #53, Resident #54, Resident #55, Resident #57, and Resident #60 reviewed for quarterly nursing risk assessments, (Braden pressure ulcer, fall, elopement, dehydration, pain, siderail, swallowing, and bladder/bowel risk assessments) the facility failed to ensure nursing risk assessments had been completed quarterly, every 3 months, per the facility policy. The findings include:1. Resident #1 diagnoses included lymphedema, cellulitis, and morbid obesity. The hospital Discharge summary dated [DATE] at 10:58 AM identified Resident #1 had severe chronic bilateral lower extremity edema with overlying skin changes including skin thickening, pigment changes and cobblestone appearance. Additionally, erythema (redness) to the right lower extremity slightly improved since admission and was stable. Hospital orders directed for a 2 gram no added salt, strict intake and output (I & O) monitoring, and orders to obtain daily weights to rule out Congestive Heart Failure (CHF). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status of 15 indicating intact cognition, required partial/moderate assistance with lower body dressing, and supervision/touch assistance with upper body dressing, personal hygiene and transfers. Additionally, the MDS identified Resident #1 did not have any rejection of care and had open lesions other than ulcers, rashes, or cuts with applications of non-surgical dressings and ointments/medications. The Resident Care Plan dated 4/21/26 identified Resident #1 was at risk for skin breakdown due to decreased mobility, incontinence, a diagnosis of lymphedema and a lymphatic wound (identified 2/27/26, resolved 4/13/26). Interventions included a consultation with the wound specialist, continuing treatment for protection as ordered for the resolved right lower leg wound and to keep skin clean, and dry. The Nutritional assessment dated [DATE] at 9:41 AM identified Resident #1 had a weight of 397.8 lbs., with no significant changes over the past quarter, had a history of weight fluctuations related to bilateral lower extremity edema and that the right lower leg lymphatic non-pressure ulcer was resolved. Although the hospital Discharge summary dated [DATE] directed daily weights, a 2 gram no added salt, heart healthy diet, and strict I & O monitoring, physician's orders dated 4/1/26 through 6/1/26 directed monthly weights to be obtained, a carbohydrate controlled, cholesterol restricted, fat-controlled diet, and failed to direct any I&O monitoring. Further, there were no physician orders directing to discontinue of any of the hospital Discharge Summary directives. Observation and Interview with Resident #1 on 6/1/26 at 1:39 PM identified bilateral lower extremity swelling and a white sock on the right leg that was pulled up to mid calf, with the top section of the sock appearing similar to gauze material covering the right lower leg. Resident #1 reported being hospitalized in March for a leg infection, that he/she had lymphedema, and that the sock was pulled up due to the right leg weeping (severe tissue swelling forcing excess fluid to seep through the skin). Resident #1 further reported that the leg used to get wrapped, but it has not been wrapped for some time, even though staff was aware of both the swelling and weeping. A. A review of the facility wound report dated 6/5/26 identified that Resident #1's right lower lymphatic leg wound that was acquired 3/12/25 resolved on 4/13/26. Interview with Supervising Registered Nurse (RN) #8 on 6/5/26 at 8:49 AM identified care for lymphedema was resident specific, but facility protocol was to start with a visit to the lymphedema clinic. In cases where the residents could not be seen due to wounds or weeping, they were seen by the in-house Advanced Practice Registered Nurse (APRN) and provided with in-house interventions such as ACE Bandage wraps. Additionally, RN #8 identified Resident #1 reported weeping to his/her legs on 6/4/26, but she had not yet updated APRN #1. Interview with the APRN #1 on 6/5/26 at 9:09 AM identified it was facility practice to send a resident with lymphedema to a lymphedema clinic, conduct vascular studies to treat the underlying perfusion, and obtain lab work. APRN #1 identified she saw Resident #1 earlier in the week on 6/2/26 for cellulitis and prescribed antibiotics. The lymphedema clinic would not see the resident, nor would they come out to treat the resident due infection, therefore, the appointments to the lymphedema clinic were cancelled in the past. Additionally, she identified the facility had tried everything already but there was nothing more that could be done for Resident #1's weeping, edema, and weight gain. B. The Nutritional assessment dated [DATE] at 9:41 AM identified Resident #1 had a weight of 397.8 lbs., with no significant changes over the past quarter, had a history of weight fluctuations related to bilateral lower extremity edema, and had increased intake and non-compliance to diet. A review of the meal ticket dated 6/3/26 and the Diet Roster dated 6/4/26 directed dietary staff to provide Resident #1 with a cholesterol restricted, fat-controlled diet. Review of Resident #1's weights identified the following (failing to obtain a weight in May): 397.8 lbs. on 4/6/26 436.4 lbs. on 6/1/26 441.6lbs. on 6/3/26 Interview and clinical record review with the Director of Nurses (DNS) on 6/5/26 at 11:51 PM identified it was facility policy to send residents with lymphedema to the lymphedema clinic, but Resident #1 had recurring wounds, so the facility was waiting for the wounds to heal. Review of Resident #1's clinical record with the DNS identified a Report of Consultation to Lymphedema Therapy dated 7/9/25 but failed to identify the name of a clinic or contact information, with recommendations to hold therapy at the clinic until a Circaid Reduction Kit (an inelastic bandaging system for late-stage edema) was received. A request was initiated for a Circaid reduction kit that was approved by APRN #1 on 8/1/25 and received but could not be utilized due to the resident's active wounds, so Ace Bandage wraps were initiated. A review of the wound report dated 6/5/26 identified Resident #1's wounds had healed on 4/13/26. A review of nurse's notes failed to identify any consultations or attempts to schedule a lymphedema clinic appointment since the directive to cancel appointment per the consultation report 7/9/25 or following 4/23/26 when the wounds were healed. The DNS added that RN #8 was in charge of scheduling appointments but was unable to obtain one due to Resident #1's legs weeping almost immediately after the wounds healed, however, she would have expected Resident #1 to have orders for at least Ace Bandage wraps. Additionally, a review of the hospital Discharge summary dated [DATE] and physician's orders since readmission on [DATE] failed to identify a physician's order for daily weights, I & O monitoring, a 2 gram no added sodium diet, the Circaid wraps, Ace Bandage wraps or compression stockings, or that the directives from the hospital Discharge Summary had been discontinued or addressed by any facility practitioners. Interview with RN #8 and the DNS on 6/5/26 at 1:41 PM identified she was responsible for setting up appointments for residents, including the lymphedema clinic, however, the clinic prohibited residents with weeping areas or wounds to be seen. RN #8 stated that although Resident #1's wound had healed on 4/13/25 and right lower extremity had not started weeping until 6/4/26 she had not made any attempts to contact the lymphedema clinic to schedule an appointment. Further, RN #8 stated she failed to update the APRN of Resident #1's current weeping skin status and failed to request that the APRN assess the resident for reimplementation of ACE Bandage wraps. The DNS identified that the facility should have followed up with the lymphedema clinic to schedule an appointment or at the least reached out to APRN #1 to assess if ACE Bandage wraps were still appropriate, as well as should have notified APRN #1 when Resident #1's weeping skin started on 6/4/26. Interview and documentation review with the Corporate Director of Nutritional Services on 6/5/26 at 1:10 PM identified diet orders were communicated to the Dietary Department by nursing or the dietician on the diet roster and meal ticket. Review of Resident #1's diet identified he/she was on a cholesterol restricted and fat-controlled diet, not a low sodium diet (the facility equivalent to a 2 gram no added sodium diet). Interview and clinical record review with APRN #1 on 6/5/26 at 1:58 PM identified she felt that Resident #1's edema and weight gain were strictly due to lymphedema and not due to underlying cardiac issues (such as potential CHF per the hospital Discharge Summary). Additionally, APRN #1 identified that she was not aware the resident's wounds had healed on 4/13/26 and had not been notified that Resident #1's leg had begun weeping on 6/4/26. Had she been notified, she would have referred the resident to the wound team. Although she made recommendations it was up to the Nursing Department to schedule follow up appointments, and she was told no lymphedema clinic appointments were available. Additionally, a review of Resident #1's hospital Discharge summary dated [DATE] at 10:58 AM identified directives for a 2-gram sodium no added sodium heart healthy diet, daily weights and strict intake and output monitoring. APRN #1 indicated the orders were never addressed but should have been, due to the residents' underlying issues of lymphedema, edema and significant weight gain. A request was made to the DNS on 6/8/26 at 10:35 AM for the lymphedema clinic phone number. The DNS stated, I hope we can figure out the name of the clinic. Interview with the Director of Rehabilitation on 6/8/26 at 10:47 AM identified residents with lymphedema were sent out to an outside clinic because there was no trained specialist in house. A call to Person #2 on 6/8/26 at 10:55 AM at the lymphedema clinic phone number provided by the DNS identified they only provided outpatient physical therapy services that did not include lymphedema clinic services. Subsequent to surveyor inquiry, a physician's order dated 6/8/26 directed to obtain a daily weight in the morning for weight gain and cellulitis x 10 days, obtain vital signs every shift for cellulitis for 5 days and obtain lab work CBS with diff, CMP, ESR CRP for cellulitis on 6/9/26. Review of the Admission/readmission policy directed to the provider to verify all admitting orders, including medications, treatments and therapies, then transcribe the orders in the electronic health record. Review of the Intake and Output Policy directed in part that intake and output (I &O) will be initiated only when clinically indicated based on the result of the hydration risk screening, completed as part of the nursing admission assessment. Additionally, I & O Monitoring may also be initiated or continued per physician order and significant changes I weight or labs suggesting fluid imbalance. Review of the Nursing Documentation Policy directed in part to ensure accurate, timely and complete electronic documentation that meets high quality resident care and meets regulatory and legal requirements. Additionally directing documentation should be completed as soon as possible, reflect resident's current condition, and change in resident's condition, new symptoms or reactions to treatment including actions takes such as physician notification. Review of the Weight Monitoring policy directed in part that accurate and timely measurement of weight changes in all residents is an important tool in assessing their nutritional status. Residents will be weighed weekly for 4 weeks on admission and remission then monthly unless otherwise indicated by the MD order or recommended by the RD. Weights will be taken and recorded, and if there is a 5 lbs. weight discrepancy a reweight should be obtained. The charge nurse should then review the weight and compare this to the previous weights to determine a 5% weight change in 30 days or 10% change in 180 days. 1. Resident #1's diagnoses included sepsis, lymphedema and chronic ulcers of the right lower leg. Resident #1's last nursing risk assessment was completed upon admission on [DATE], 5 months ago. 2. Resident #3's diagnosis included progressive multifocal leukoencephalopathy, immunodeficiency and post-traumatic stress disorder. Resident #3's last nursing risk assessment was completed on 1/19/26, 5 months ago. 3. Resident #4's diagnosis included chronic kidney disease, anxiety disorder and obstructive and reflux uropathy. Resident #4's last nursing risk assessment was completed on 11/4/25, 7 months ago. 4. Resident #8's diagnosis included Parkinsonism, adult failure to thrive and palliative care. Resident #8's last nursing risk assessment was completed on 12/9/25, 6 months ago. 5. Resident #9's diagnosis included hemiplegia affecting the right dominant side following a stroke, peripheral vascular disease and diabetes. Resident #9's last nursing risk assessment was completed 12/18/25, 6 months ago. 6. Resident #15's diagnosis included malignant neoplasm of the parathyroid gland and tongue, chronic obstructive pulmonary disease and gastrostomy. Resident #15's last nursing risk assessment was completed on 12/22/25, 6 months ago. 7. Resident #17's diagnosis included malignant neoplasm of the lung, Parkinson's disease and dysphagia (swallowing difficulty). Resident #17's last nursing risk assessment was completed upon admission on [DATE], 4 months ago. 8. Resident #22's diagnosis included pneumonia, sepsis and acute respiratory failure. Resident #22s last nursing risk assessment was completed on 2/3/26, 4 months ago. 9. Resident #25's diagnosis included diabetes, lymphedema and dementia with behaviors. Resident #25's last nursing risk assessment was completed 2/23/26, 4 months ago. 10. Resident #27's diagnosis included dementia with psychotic disturbance, adult failure to thrive and major depressive disorder. Resident #27's last nursing risk assessment was completed on 11/19/25, 7 months ago. 11. Resident #37's diagnosis included dementia with psychotic disorder, depressive disorder and dysphagia. Resident #37's last nursing risk assessment was completed on 1/10/26, 5 months ago. 12. Resident #39's diagnosis included diabetes, adult failure to thrive and dementia with anxiety. Resident #39's last nursing risk assessment was completed on 11/15/25, 7 months ago. 13. Resident #42's diagnosis included Alzheimer's disease, diabetes and peripheral vascular disease. Resident #42's last nursing risk assessment was completed on 2/8/26, 4 months ago. 14. Resident #43's diagnosis included post-traumatic stress disorder, epilepsy and bipolar disorder. Resident #43's last nursing risk assessment was completed on 2/27/26, 4 months ago. 15. Resident #45's diagnosis included dementia with psychotic disturbance, mood disturbance and anxiety, epilepsy and dysphagia. Resident #45's last nursing risk assessment was completed on 1/12/25, 17 months ago. 16. Resident #46's diagnosis included autistic disorder, schizophrenia and heart failure. Resident #46's last nursing risk assessment was completed on 6/3/26 subsequent to surveyor inquiry. The prior completed nursing risk assessment was completed on 7/18/24, 22 months ago. 17. Resident #49's diagnosis included nontraumatic intracerebral hemorrhage, urinary tract infection, obstructive and reflux uropathy. Resident #49's last nursing risk assessment was completed on 2/4/25, 16 months ago. 18. Resident #52's diagnosis included dementia, diabetes and chronic kidney disease. Resident #52's last nursing risk assessment was completed on 9/30/23, 33 months ago. 19. Resident #53's diagnosis included diabetes, morbid obesity and cardiac pacemaker. Resident #53's last nursing risk assessment was completed on 12/10/25, 6 months ago. 20. Resident #54's diagnosis included chronic obstructive pulmonary disease, heart attack and ventricular tachycardia. Resident #54's last nursing risk assessment was completed on 8/16/25, 10 months ago. 21. Resident #55's diagnosis included diabetes, schizophrenia and anemia. Resident #55's last nursing risk assessment was completed on 10/29/25, 8 months ago. 22. Resident #57's diagnosis included dementia, major depressive disorder and peripheral vascular disease. Resident #57's last nursing risk assessment was completed on 1/10/26, 5 months ago. 23. Resident #60's diagnosis included chronic ulcer of the right lower leg, cellulitis of the right and left lower leg and traumatic brain injury. Resident #60's last nursing risk assessment was completed on 9/4/25, 9 months ago. Interview and record review with Director of Nursing (DON) and Registered Nurse (RN) #3 on 6/3/26 at 1:05 PM identified fall risk assessments were completed upon admission, quarterly and annually. The admission nurse and others are responsible to complete the risk assessments. The Minimum Data Set (MDS) Coordinator sets the schedule for the assessments to be completed. A review of Resident #46's risk assessments identified that the last fall risk assessment was completed on 7/18/24. The clinical record failed to reflect documentation of any subsequent risk assessment. The DON further indicated that risk assessments were utilized to complete the MDS assessments on a quarterly basis. Although the DON indicated that she should have been notified if the risk assessments were not being she had not been. An interview and clinical record review with the MDS Coordinator, Licensed Practical Nurse (LPN) #3 on 6/3/26 at 1:39 PM, identified that the quarterly nursing risk assessments were opened by the MDS Coordinator per the MDS schedule. Review of Resident #46's clinical record identified the last risk assessment done was on 7/18/24 and the clinical record failed to reflect documentation of any subsequent risk assessments. The MDS coordinator indicated that she had been giving nursing a calendar, and the DON had been opening the risk assessments but now the MDS Coordinator was responsible to open the assessment, conduct the MDS assessments, and complete the Resident Care Plan review per the MDS schedule. Additionally, the MDS Coordinator indicated she was pretty sure the risk assessments were completed but if they were not completed, she would notify the DON. The MDS Coordinator indicated she did not know why the risk assessments were not completed. A review of Resident #4's clinical record identified that the last risk assessment was completed on 11/4/25 and that the MDS Coordinator had opened the MDS assessment but could not recall why the risk assessments were not scheduled or completed. Additionally, the MDS assessment dated [DATE] was completed but no risk assessments were noted. The MDS Coordinator was unsure why the risk assessments had not been scheduled. Although requested, a facility policy for quarterly nursing risk assessments was not provided. A review of the Falls policy, directed in part that all residents would be assessed for fall risk upon admission, quarterly, and annually. A review of the Intake and Output Monitoring policy, directed in part that the hydration risk screening would be completed as part of the nursing admission assessment and may also be completed independently of admission/re-admission when clinically indicated. A review of the Nursing Documentation policy, directed in part that documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs. A review of the Pain Assessment and Management policy, directed in part that each resident would be assessed for pain upon admission, readmission, quarterly, annually, significant change in condition, and as otherwise clinically indicated. The Resident Assessment Instrument (RAI) Manual dated October 2025 directed The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. MDS 3.0 is part of that assessment process and is required by CMS. State Operation Manual Appendix PP directed to 483.20(c) Quarterly Review Assessment: A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. INTENT 483.20(c) To assure each resident is assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 sampled residents (Resident #28) reviewed for medication administration and for 1 of 10 sampled residents, (Resident #40) reviewed during initial screening, the facility failed to store medications securely, and for 1 of 2 sampled medication carts reviewed for medication storage, for Resident #53 , the facility failed to ensure expired medication was appropriately discarded after the expiration date and for Resident #68, failed to ensure medications were stored per the manufacturer's recommendations. The findings include: 1. Resident #28 's diagnoses included diabetes, chronic congestive heart failure and chronic peripheral insufficiency. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #28 had a Brief Interview for Mental Status score of 15 indicating intact cognition and was independent with eating, dressing, bed mobility, transfers and ambulation and required set up assistance with personal hygiene. The Resident Care Plan dated [DATE] failed to identify self-administration of medications. A physician's orders in effect on [DATE] directed to administer multivitamin with minerals 1 tablet orally in the morning for supplements. The physician's order failed to direct self-administration of medications. An observation on [DATE] at 9:57 AM identified an orange pill in a medicine cup at Resident #28's bedside, no staff were present. Interview and observation with LPN #1 on [DATE] at 9:57AM identified that the orange pill at the bedside in a medicine cup was a multivitamin with minerals. LPN #1 indication she thought Resident #28 took the medication but apparently did not. LPN #1 discarded the medication in the garbage. Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM identified that a self-administration assessment was done for residents wanting to self-administer medications and that a physician's order for Resident #28 was not obtained for self-administration of medications. The DON indicated that Resident #28 did not have a self-administration assessment, and the nurse passing the medications was responsible for ensuring that no medication was left at the bedside. 2. Resident #40's diagnoses included Parkinson's disease, atopic dermatitis, and primary open-angle glaucoma of the right and left eyes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #40 had a Brief Interview of Mental Status score of 15 indicating normal cognitive function and was independent for eating, oral hygiene, walking, and transfers. The Resident Care Plan (RCP) dated [DATE] identified Resident #40 had visual impairment related to glaucoma. Interventions included providing eye medication as ordered. Additionally, the RCP identified he/she was at risk for skin breakdown. Interventions included to provide lotions/creams as ordered. Physician orders in effect from [DATE] through [DATE] directed to administer Systane Complete Ophthalmic Solution, one (1) drop in both eyes every eight (8) hours as needed and Clobetasol Propionate External Cream 0.05 percent (%), apply to hands and posterior neck topically as needed for flare up related to atopic dermatitis. Observation on [DATE] at 9:51 AM in Resident #40's room identified an Artificial Tears Ophthalmic Solution 1/2 full 15 milliliter (ml) bottle and Systane ultra-high performing dry eye relief 1/4 full 10 ml bottle in Resident #40's room on his/her dresser. Resident #40 indicated he/she used them regularly for his/her dry eyes and had them in his/her possession for a couple months. No staff were noted to be present. Observation, interview and clinical record review with the Licensed Practical Nurse (LPN) #4 and Resident #40 on [DATE] at 10:18 AM identified a 1/2 full bottle of Artificial Tears, 1/4 full bottle of Systane dry eye relief on the dresser, and a 1/2 full medicine cup with a white cream substance that Resident #40 identified as his/her medication s/he received from the facility and had it on hand for about 10 days. LPN #4 indicated that during medication administration it was the nurse's responsibility to observe the resident taking their medication and that if they didn't, the medication should have been removed from the room and never left without the nurse present. LPN #4 indicated that residents could be assessed to self-medicate, but that the medications would still be locked up to prevent the resident from not taking the medication as prescribed. LPN #4 stated that she did not know the eye drop solutions were present in the room, she did not administer the cream during her shift, and that medications should not be stored in the room without staff present. LPN #4 confirmed the medication cart had Resident #40's prescribed eye medication and discarded the medications found on Resident #40's dresser. LPN #4 could not identify how long the medications had been present in their room. Review of Resident #40's medication administration record (MAR) identified that Clobetasol Propionate External Cream 0.05 percent (%) had last been administered on [DATE] at 6:07 AM. Interview with the Director of Nursing (DON) on [DATE] at 1:20 PM identified that medications should not be left at the resident's bedside and that it was the responsibility of the nurse to observe the resident during medication administration to make sure all medications were taken. The DON indicated that if a resident wanted to self-administer medication, then an assessment would need to be completed and if the resident was assessed as able to self-administer, the medications would still have to be appropriately secured. Review of Medication Administration policy undated directed, in part, that all medications would be stored securely and accessed only by authorized personnel. Additionally, it directed to administer medications according to physician/provider orders and accepted standards of practice. Review of the Medication Storage in the Facility policy not dated directed in part that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the Self-Administration of Medications policy not dated directed in part that residents may self-administer medications if it was determined to be safe and appropriate based on an individual assessment conducted by a licensed nurse. Residents approved for self-administration must store medications securely as directed by facility policies to prevent misuse or accidental exposure. 3. Resident #53's diagnoses included diabetes and diabetic retinopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he/she was cognitively intact and was completely dependent on staff for personal hygiene, bathing, and upper and lower body dressing. A physician's order dated [DATE] directed to administer Lantus Solostar (insulin glargine) subcutaneous Solution Pen-Injector 100 Unit/ML: Inject 30 unit subcutaneously one time a day for diabetes mellitus. An observation of the Center Unit medication cart on [DATE] at 3:05 PM and interview with the Infection Control Nurse/Assistant Director of Nursing (ICN/ADON) identified Resident #53 had an opened insulin glargine pen with a label dated [DATE], indicating the date it was opened. The ICN/ADON stated the pen was good for 28 days and that after 28 days the pen should have been discarded on [DATE]. Subsequent to Surveyor inquiry, the ICN/ADON discarded the insulin glargine pen and stated she would order a new one for Resident #53. 4. Resident #68 's diagnoses included stroke, low blood pressure, and type 2 diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he/she was cognitively intact and required extensive hands-on assistance in the bathroom for personal hygiene after using the toilet. A physician's order in effect on [DATE] directed to inject Insulin Lispro 100 UNITS/ML on a sliding scale, based on the result of fingerstick blood glucose (blood sugar) testing before meals. An observation of the Center Unit medication cart on [DATE] at 3:05 PM with the Infection Control Nurse/Assistant Director of Nursing (ICN/ADON) identified 2 unopened Insulin lispro pens for resident #68 dated [DATE] and labeled with a sticker instructing to refrigerate until opened. The ICN/ADON stated that the 2 unopened Insulin Lispro pens should have been stored under refrigeration in the medication room until they were opened. Subsequent to surveyor inquiry, the ICN/ADON removed the 2 unopened Insulin Lispro pens from the cart and reordered them from the pharmacy. Interview with Pharmacist #1 on [DATE] at 1:45 PM identified that Resident # 53's insulin glargine was to be discarded after 28 days per the manufacturer's recommendation to ensure product sterility and stability and that since the pen was dated [DATE], it should have been removed and discarded on [DATE]. The pharmacist could not identify any significant risk if a resident received it after 28 days of use and restated that it should have been discarded per manufacturer's recommendations. Pharmacist #1 indicated that Resident #68's Insulin Lispro pen should have been refrigerated until opened per the manufacturer's recommendations, and that once opened, it was to be discarded after 28 days. If the medication was left out of refrigeration it could still have been used for 28 days, minus any days left out of refrigeration. A review of the Medication Storage in the Facility policy date 1/2026 directed, in part, that medications would be stored following manufacturers' recommendations and those requiring refrigeration would be stored between 36 degrees Fahrenheit and 46 degrees in a refrigerator with a thermometer to monitor the temperature. Additionally, outdated, contaminated or deteriorated medications are disposed of according to the procedures for mediation destruction.

Based on observation, clinical record review, facility documentation, facility policy, and interviews, the facility failed to administer its resources effectively and to ensure timely and effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings included:The facility administration failed to:Ensure a nutritional assessment was completed timely for a resident with a significant weight loss.Ensure oversite of the facility narcotic record keeping of controlled substances.Please cross reference F692 and F761Interview with the Administrator on 6/8/26 at 10:45 AM indicated that the Administrator was aware of the requirement for the Director of Nursing to conduct bimonthly audits of the narcotics. The Administrator was unaware that the Director of Nursing was observed by a surveyor falsifying the May 2026 bimonthly audits but was made aware by corporate leadership that this had happened. The Administrator further indicated that if he was aware this had occurred, he would have referred the matter to corporate for follow-up.Interview with Corporate Director of Nutritional Services on 6/8/26 at 11:22AM indicated that when the Dietitian was absent and needed coverage, there was coverage available. The Corporate Director of Nutritional Services had not been aware the Dietitian needed coverage and the dietitian had not requested coverage. Additionally, the Corporate Director of Nutritional Services was unaware the Dietitian was unable to complete her assignment, assessments or interventions for residents. The Administrator was ultimately responsible for oversight of the dietitian.Interview with the Administrator on 6/8/26 at 11:52 AM indicated that corporate compliance issues were reported to the corporate compliance phone number or email and then to the facility leadership. When issues were identified, corporate leadership would come to the facility and inform the facility leadership of the investigation and follow up. The Administrator further indicated that he did oversee the Dietitian. The Administrator was unaware the Dietitian was unable to complete the resident assessments or that coverage was needed for her absences. If the dietitian needed coverage, she would tell the corporate nutritional oversite staff and coverage would be provided.The facility failed to utilize resources effectively to attain/maintain the residents' well-being and failed to provide oversight of the staff.A review of the Administrator job description directed the responsibility of the administrator was to plan, organize, develop and direct the overall operations of the facility in accordance with current federal, state and local standards and regulations. Ensured the highest quality care was given at all times in a safe and secure facility. Strived to achieve the highest degrees of employee satisfaction through the integration of Quality Improvement concepts at all levels of the organization to attain the facilities and corporation's mission statements. Leads by example and addresses all observed areas of concern or concerns brought by others. Oversee the development and overall training of personnel to ensure maintenance and consistency of quality services in compliance with corporate policies and regulations.A review of the Employee Code of Ethics aimed at ensuring all documents or records which you prepare contain only accurate and truthful information. Always speak truthfully to all persons with whom you have contact in the course of your duties, including residents, visitors, other staff members, government officials and other care givers. Report any suspected violations of this Code of Conduct or state or federal law in accordance with our Corporate Compliance policy.A review of the Corporate Compliance Hotine identified confidential reporting of serious concerns relating to known or suspected violations of laws or regulations. All calls will be handled and investigated as necessary by the Corporate Compliance Officer in a confidential manner. If you suspect any of the following: Inaccurate or falsified billing practices and/or documentation, call the Corporate Compliance Hotline number, toll free, anonymous, available 24 hours, 7 days a week.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 6 sampled residents (Resident#18) reviewed for nutrition the facility failed to follow infection control precautions with a wound infection, for 1 of 2 sampled residents (Resident #68) reviewed for Infection Control practices, the facility failed to properly dispose of soiled incontinence briefs according to facility policy, and during an inspection of the facility's only medication room reviewed for medication storage, the facility failed to properly dispose of biohazardous waste. The findings include: 1. Resident #18's diagnoses included type 2 diabetes, pressure ulcer of sacral region, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #18 had a Brief Interview of Mental Status of 5 indicating severe cognitive impairment and was dependent on staff for all activities of daily living. The Resident Care Plan dated 6/1/26 identified Resident #18 was on Enhanced Barrier Precautions (EBP) for a MRSA infection. Interventions included a sign outside the door, directing all providers and staff to wear gloves and a gown for high contact activities such as dressing, transferring, changing linens, changing briefs, device care and wound care. A physician's order dated 6/1/26 directed for contact precautions for a wound infection every shift x 15 days. Observation and interviews with Nurse Aide (NA) #1 and NA #2 on 6/2/26 at 10:06 AM identified Resident #18's door closed with a Contact Precautions sign posted outside the door and a personal protective equipment (PPE) cart positioned beneath the sign. NA #1 was observed opening the door while wearing gloves but without a gown, asking if the nurse was available to perform a treatment. Upon entering the room, both NA #1 and NA #2 were observed providing care to Resident #18 while wearing gloves but not gowns. During interview, NA #1 stated she was not wearing a gown because she believed the precaution sign was left over from a previous resident and NA #2 stated he understood the precaution sign to apply only when bodily fluids were involved, both NAs identifying they believed gowns were not required, even though they were performing peri care that included changing a used brief, and dressing Resident #18. Interview with Registered Nurse (RN) #1 on 6/2/26 at 10:11 AM identified it was the facility's policy that gowns and gloves were worn by staff when providing care to residents who were on contact precautions. RN #1 further identified Resident #18 had a wound to the coccyx, and gowns and gloves should be worn when providing care to the resident. Interview and signage review with the Director of Nurses on 6/2/26 at 10:40 AM identified it was the facility's policy for staff providing care to a resident on contact precautions to wear gloves and a gown when providing personal care, further specifying that the NA's that were providing care to Resident #18 should have been wearing gowns and gloves. Review of the Transmission Based Precautions Policy directed in part that transmission-based precautions are utilized to minimize the risk of transmission of infectious agents within a healthcare setting. Additionally, transmission-based precautions will be instituted for known or suspected infections for which route of transmission/prevention are known (droplet and contact). 2. Resident #68 's diagnoses included stroke, low blood pressure, and type 2 diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he/she was cognitively intact and required extensive hands-on assistance in the bathroom for personal hygiene after using the toilet. The Resident Care Plan dated 6/1/26 identified Resident #68 required assistance with activities of daily living. Interventions including offering assistance in the bathroom if he/she was unable to complete personal care on his/her own. A physician's order in effect on 6/1/26 directed staff to assist Resident #68 with transfers (moving from one surface to another) and ambulation. Observations on 6/1/26 at 10:00 AM and again on 6/2/26 at 9:10 AM identified an open bag with soiled items containing visible feces stored on the floor of Resident #68's bathroom. Feces were also noted on the raised toilet seat in the same bathroom. An interview and observation on 6/2/26 at 9:25 AM with Licensed Practical Nurse (LPN) #2 identified that a Nursing Assistant (NA) should have disposed of the items and that they should not have been left on the floor. Additionally, LPN #2 stated housekeeping staff should have cleaned the bathroom. LPN #2 could not explain the lack of adherence to infection control practices. On 6/2/26 at 10:30 AM, subsequent to Surveyor inquiry, the soiled items were removed and the bathroom was cleaned. A review of the Incontinent Care policy directed, in part, that incontinent care would be provided by nursing staff for residents who were incontinent and that appropriate infection control practices would be followed, including disposing of soiled materials appropriately. A review of the Resident Room Occupied/Discharge, Clean policy identified, in part, to provide a clean, sanitary, and attractive environment for residents that reduces the possibility of cross contamination. 3. During an inspection of the facility's only medication room reviewed for medication storage on 6/2/26 2:45 PM observation and interview with the Infection Control Nurse/Assistant Director of Nursing (ICN/ADON) identified a biohazardous red bag in a cabinet under the medication room sink. The cabinet was unlocked, and the cabinet door did not have a biohazardous waste label to indicate that biohazardous waste material was being stored inside. The ICN/ADON opened the bag and noted 2 used drainage containers for a drainage catheter collection system. The ICN/ADON identified that biohazardous waste was not supposed to be stored in the medication room or under a sink. ICN/ADON also stated the person who required the drainage containers was no longer at the facility, and she was unable to identify who left the biohazardous waste under the sink or why it was left there. An interview with the Maintenance Director on 6/4/26 at 9:00 AM identified that all biohazardous/red-bagged waste was supposed to be stored in a locked area in the basement and that biohazardous waste was supposed to be taken directly to that area. He stated that the RN Supervisors had a key to the biohazardous waste storage area. Additionally, an inspection of soiled utility areas identified there were no receptacles for storage of biohazardous waste. A review of the policy, Medication Storage in the Facility, directed in part, that medications and biologicals would be stored safely and securely, and that the room would be kept clean and free of clutter. Additionally, potentially harmful substances would be clearly identified and stored in a locked area separate from medications.

Based on interviews, facility documentation review, and facility policy for 2 of 24 sampled residents (Resident #2 and Resident #18) reviewed for advance directives the facility failed to obtain and transcribe physician's orders to the electronic clinical record. The findings include:1. Resident #2's diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure and obesity.Review of the Medical Interventions Consent form dated [DATE] located in Resident #2's chart identified signed advance directives for a full code (resuscitate if unresponsive).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status of 15 indicating intact cognition, required set up with eating, and was dependent on all other Activities of Daily Living (ADL's). Additionally, the MDS identified Resident #2's most recent entry into the facility was on [DATE].Review of the Resident Care Plan dated [DATE] and in place on [DATE] identified Resident #2 needed staff assistance with ADLs. Interventions included advance directives per physician's order.Review of the physician's orders dated [DATE] through [DATE] failed to identify an order for code status.Review of the Advance Directives banner in the electronic health record failed to identify a code status.2. Resident #18's diagnoses included type 2 diabetes, pressure ulcer of the sacral region, and muscle weakness.Review of the Medical Interventions Consent form dated [DATE] in Resident #18's chart had a signed advance directive for a code status of Do Not Resuscitate/Do Not Intubate (DNR/DNI).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 had a Brief Interview of Mental Status of 5 indicating severe cognitive impairment and was dependent on staff for eating, and all Activities of Daily Living (ADL's). Additionally, the MDS identified Resident #18's most recent entry into the facility was on [DATE].Review of the Resident Care Plan dated [DATE] identified Resident #18 needed staff assistance with ADLs. Interventions included advance directives per physician's order.Review of the physician's orders dated [DATE] through [DATE] failed to identify an order for code status.Review of the Advance Directives banner in the electronic health record failed to identify a code status.Interview and clinical record review with Licensed Practical Nurse (LPN) #2 on [DATE] at 3:00 PM identified the facility's policy required both a signed advance directive in the chart and a corresponding physician's order specifying the resident's code status. LPN #2 stated that all nurses were responsible for ensuring both components were in place, however, a review of Resident #2 and Resident #18's electronic clinical records failed to identify physician's orders specifying a code status. Although Resident #2 had a signed advance directive dated [DATE] and Resident #18 had a signed advance directive dated [DATE] in the physical chart, LPN #2 stated these were not obtained during the residents' most recent readmissions. LPN #2 further stated that physician's orders should have been entered, as staff rely on those orders to determine code status during an emergency requiring Cardiopulmonary Resuscitation (CPR). In the absence of the orders, the nurse would have to take the time to refer to the physical chart for advance directives status.Subsequent to surveyor inquiry LPN #2 entered physician's orders dated [DATE] to reflect advance directives for Resident #2 and Resident #18.Interview with Registered Nurse Supervisor (RN) #1 on [DATE] at 9:06 AM identified that the facility's policy requires completion of the Medical Interventions consent on admission or readmission, followed by entering a physician's order reflecting the resident's code status. RN #1 stated that in an emergency, the nurse would have to refer to the physician's order or the Advance Directives banner displayed at the top of the electronic health record screen. RN #1 also stated that although a physician's order should always be present, if it were missing, the nurse would need to check the physical chart for the resident's directives.Review of the Advance Directives Policy directed in part that advance directives will be reviewed with the resident or appropriate decision maker, documented in the medical record and supported by physician orders.

Based on observation, facility documentation, facility policy and interviews for storage and reconciliation of narcotic medications, the facility failed to maintain bi-monthly reconciliation of narcotic medications and failed to accurately document the destruction of house-stock narcotic medications to prevent misappropriation of narcotic medications. The findings include:An observation and interview with the Director of Nursing (DON) on 6/2/26 at 2:30 PM in her office, identified a Narcotic Destruction Form in plain view on a cabinet with 3 house-stock narcotics documented as destroyed.A review of the Narcotic Destruction Form identified 3 corresponding Controlled Substance Disposition Records attached. The narcotics included:House Stock Morphine Sulfate 100mg/ml with quantity destroyed listed as 23.25House Stock Morphine Sulfate 100mg/5 ml with quantity destroyed listed as 8.50House Stock Lorazepam 2 mg/ml with quantity destroyed listed as 29.50The Controlled Substance Disposition Records failed to document the date of receipt by the DON, or that the amount taken into custody was verified as correct. The Narcotic Destruction Form additionally failed to identify the date of the drug destruction, the signature, date, and title of the witness of the destruction, or the signature and title of the person destroying the drug. The DON identified that the she thought the drugs were destroyed at some time in the middle of the previous month and she thought they were destroyed with the Assistant Director of Nursing Services (ADON). The DON could not explain why the form was not completed at the time of the drug destruction. Additionally, the DON stated narcotics were held for destruction in a double-locked safe until they are destroyed, and the destruction was required to be witnessed. An interview with the Director of Nursing (DON) on 6/2/26 at 2:45 PM at the nurse's station identified that she conducted bimonthly audits of narcotic medications stored in the medication carts and that bimonthly narcotic audit records were stored in the DON office. An observation of the DON upon entering her office and interview on 6/2/26 at 2:50 PM identified her filling out a Bimonthly Narcotic Audit form dated 5/5/26 and although there was an area to fill out a second audit, the form was blank for the second audit date indicating incomplete bimonthly audits for May 2026. The DON stated she had forgotten to fill out the May narcotic form at the time of the audit and had planned to complete the form on 6/1/26 but was unable to because of the start of survey. The DON was unable to explain why no second audit for the month of May 2026 had been completed; however, she was aware of the requirement to audit narcotics twice a month.An interview with the Administrator on 6/8/26 at 10:45 AM identified he was aware of the requirement for conducting bi-monthly narcotic audits. He had also heard from corporate that the DON was observed creating the May 2026 bimonthly narcotic audits and if he had been aware of it happening prior to the Surveyor observation, he would have referred corporate to follow-up. The Administrator also stated he did not routinely participate as a witness to narcotic destruction.A review of the PCU072 Drug Destruction policy dated 1/26 identified, in part, the facility would adhere to the rules and regulations of its specific state as well as any other regulatory bodies, including but not limited to Drug Enforcement Administration (DEA), State Board of Pharmacy, and OSHA, regarding drug destruction.

Based on clinical record review, facility documentation review, facility policy review, and interviews for three of four residents (Resident #2, #3 and #6) reviewed for medication errors, the facility failed to ensure the physician/APRN was notified timely when medications were not administered timely in accordance with physician orders. The findings include: Resident #2's diagnoses included diabetes and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment. The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 had diabetes, risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and risk for seasonal allergies. Interventions directed to administer meds as ordered and check blood sugar via fingerstick as ordered. Physician orders dated 3/25/2026 directed the following:fingerstick for blood sugar level four (4) times a day for diabetesKlor-Con 10 Oral Tablet Extended Release 10 MEQ (milliequivalent) give three (3) tablets by mouth one time a day for hypokalemia (low potassium)Guaifenesin Oral Tablet 400 mg give one (1) tablet by mouth two (2) times per day for congestion. Physician order dated 4/13/2026 directed Insulin Lispro Injection Solution 100 unit/ml (milliliter) inject 6 units subcutaneously with meals for diabetes. Review of MAR dated 4/15/2026 identified the medications were scheduled to be administered at 8 AM, and Resident #2 did not receive the above listed medications. Additional review identified the flowing:The finger stick was signed and coded as #2 to indicated refused.Klor-Con 10 Oral was signed/coded as 12 (medication unavailable).Guaifenesin Oral Tablet was signed/coded as 12 (medication unavailable).Insulin Lispro 6 units was signed/coded as 3 to identify the medication was held and see nursing notes. Review of the nursing note dated 4/15/2026 failed to identify the fingerstick was not obtained and/or refused, and failed to identify the Klor-Con, Guaifenesin and Lispro insulin were not administered as ordered. Interview and record review with the DNS on 5/13/2026 at 11:17 identified Resident #2 was followed by APRN #2. Although the DNS stated she had notified APRN that some of the medications were not administered, however she was unable to provide documentation that APRN #2 was notified the finger stick was obtained, the Lispro insulin, Klor-Con 10 Oral and Guaifenesin were administered as ordered. Interview on 5/12/2026 at 11:20 AM APRN #2 identified she was not notified of the missed medications. Interview on 5/12/2026 at 11:43 AM interview with APRN #3 identified she was covering for APRN #2 on 4/4/15/2026 and she was not notified of the missed medications, and if they were not administered, or the resident refused, she would have wanted to be notified. APRN #3 stated she should have been notified especially since Resident #2's blood sugar was elevated at 12 noon (313) and she was concerned that the Klor-Con was missed. 2. Resident #3's diagnoses included diabetes, dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of seven out of ten, indicative of moderate cognitive impairment. The RCP dated 4/9/2026 identified Resident #3 had diabetes, was at was at risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and potential for alteration in mood. Intervetnions directed to administer meds as ordered and, check blood sugar via fingerstick as ordered. Physician orders dated 4/8/2026 directed to administer the following at 8 AM:fingerstick for blood glucose level two (2) times a day for diabetesInsulin Lispro Injection Solution, inject six (6) units subcutaneously with meals for diabetes for diabetes,Aripiprazole (Abilify) Oral Tablet 10 mg, give 10 mg by mouth one (1) time a day for schizophreniaLiquid Protein two (2) times a day 30 milliliters (ml) liquid protein. Review of the electronic MAR notes identified the fingerstick, Lispro insulin, and liquid protein were coded at 12:42 PM as #3 that indicated hold, see nursing notes; Abilify was coded at 12:42 PM as #12 medication unavailable. Review of nursing notes dated 4/15/2026 failed to identify the physician/APRN was notified that fingerstick, insulin and medications that were not administered as ordered. On 5/13/2026 at 11:17 AM interview and record review with DNS identified RN #1 should have notified APRN #1. Although the DNS stated she notified APRN #1 the medications were not administered and the fingerstick was not obtained, she was unable to provide documentation the APRN was notified. On 512/2026 at 11:21 AM interview with APRN #1 identified that she was not notified the medications were not administered and the fingerstick was not obtained, and stated she would have wanted to be notified. 3. Resident #6's diagnoses included non-pressure chronic ulcer of right lower leg, cellulitis and chronic pain. The quarterly MDS assessment dated [DATE] identified Resident #6 had a BIMS score of twelve out of fifteen, indicative of no cognitive impairment. The RCP dated 3/11/2026 identified Resident #6 had cellulitis, interventions directed pain management as ordered. Physician orders dated 3/25/2026 directed Xtampza ER Oral Capsule (extended-release capsule containing oxycodone for pain) 12-hour abuse-deterrent 9 mg, give one (1) capsule by mouth every 12 hours related to other chronic pain. Additional order directed Oxycodone HCL 5 mg every four (4) hours as needed for pain. Review of Medication Administration Report dated 4/15/2026 identified Resident #6 did not receive the 9 AM Xtampza ER 9 mg scheduled at 9 AM, and it was signed with a code #2 to indicate the medication was refused. Review of nursing progress note dated 4/15/2026 failed to identify the physician/APRN was notified the Xtampza was not administered as ordered. Interview and record review on 5/7/2026 at 11:24 AM with RN #1 identified she did not administer the Xtampza, and she did not notify the DNS, ADNS or the APRN. Interview and record review with RN #3 on 5/12/2026 at 9:20 AM identified she was the supervisor on 4/15/2026 and she was working on a unit passing morning medications for residents on her unit. RN #3 stated she did not recall that RN #1 was late that day, and she was not aware medications were administered late or omitted. On 5/13/2026 at 11:17 AM interview and record review with DNS identified Resident #6 had no history of medication refusals, and the medication was coded as refused on 4/15/2026. The DNS stated the physician/APRN should have been notified. The DNS further stated she thought she may have notified the APRN and if she did she would have written a nursing note, but was unable to provide documentation that she had notified the ARPN. Interview on 5/12/2026 at 11:20 AM APRN #2 indicated she was not working on 4/15/2026 (she was not notified the Xtampza was not given) and APRN #3 was covering. Interview on 5/12/2026 at 11:43 AM interview with APRN #3 identified she was not notified by the nurse or the DNS that the Xtampza was not administered as ordered, and stated she would want to have been notified. Subsequent to surveyor inquiry the DNS wrote a nursing note dated 5/7/2026 that identified on 4/15/2026 medication administration was delayed and APRN #2 was updated. Interview and record review on 5/7/2026 at 11:24 AM with RN #1 identified she did not administer the medications listed above for Residents #2, #3 and #6 and she did not notify the DNS, the ADNS, the physician or any APRN. Interview failed to identify why she did not notify. Interview and record review with MD #1 on 5/12/2026 at 12:16 PM with MD #1 identified he was not notified on 4/15/2026 that the medications were not administered as ordered for Residents #2, #3 and #6. MD #1 stated he was notified by the DNS last week (the week of 5/4/2026) that the medications were not administered as ordered. Review of facility Medication Administration policy directed in part; to administer medications one (1) hour before or after the ordered time. Review of facility Change in Condition/Family/MD Notification Policy directed in part; to make resident's physician and family aware of any significant change in condition, all significant changes in residents' condition will be reported to physician and family, the nurse will document in the nurse's notes that the physician and family or responsible party have been notified of a change in condition.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of four residents (Resident #1, #2, #3 and #6) reviewed for medication errors, the facility failed to ensure licensed staff covered a unit to administer medications timely and failed to ensure the residents were free from neglect when medications were not administered timely in accordance with physician orders and facility policy. The findings include: Resident #1's diagnoses included diabetes, arthritis, atrial fibrillation and morbid obesity. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment, required assistance with ADLs (activities of daily living), and received anticoagulant (medication to prevent blood clots, diuretics, and hypoglycemic medication (to control blood sugar). The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 had diabetes, a risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and pain risk. Interventions directed to administer medications as ordered, and assess pain. Physician orders dated 4/16/2026 directed to administer the following:Jardiance Oral Tablet (used to control blood sugar) 25 milligrams (mg) give one (1) tablet by mouth one (1) time a day for diabetes type 2.Vitamin D3 Tablet 4000 units by mouth once a day for supplement.Ammonium Lactate External Cream 12 % (moisturizer), apple to bilateral thighs topically two (2) times a day. Review of April MAR dated 4/15/2026 identified Resident #1's fingerstick on 4/15/2026 at 9 AM was 227. Review of Medication Administration Record (MAR) dated 4/15/2026 identified the following medications were scheduled to be administered at 9 AM and were not signed to indicate they were administered at 9 AM: Jardiance Oral Tablet (used to control blood sugar) 25 milligrams (mg) give one (1) tablet by mouth one (1) time a day for diabetes type 2.Vitamin D3 Tablet 4000 units by mouth once a day for supplement.Ammonium Lactate External Cream 12 % (moisturizer), apple to bilateral thighs topically two (2) times a day. Review of the electronic MAR notes identified the Jardiance was signed with a code 12 at 1:11 PM, the Vitamin D was coded at 1:12 PM with a #12, and the Ammonium Lactate was coded at 1:04 PM, and were all signed/coded as #12. Additional review identified a code 12 indicated the medication was unavailable. 2. Resident #2's diagnoses included diabetes and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment. The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 had diabetes, risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and risk for seasonal allergies. Interventions directed to administer meds as ordered and check blood sugar via fingerstick as ordered. Physician orders dated 3/25/2026 directed the following:fingerstick for blood sugar level four (4) times a day for diabetes.Klor-Con 10 Oral Tablet Extended Release 10 MEQ (milliequivalent) give three (3) tablets by mouth one time a day for hypokalemia (low potassium).Guaifenesin Oral Tablet 400 mg give one (1) tablet by mouth two (2) times per day for congestion. Physician order dated 4/13/2026 directed Insulin Lispro Injection Solution 100 unit/ml (milliliter) inject 6 units subcutaneously with meals for diabetes. Review of the MAR dated 4/15/2026 identified the medications were scheduled to be administered at 9 AM, and Resident #2 did not receive the above listed medications. Additional review identified the following:The finger stick was signed and coded as #2 to indicated refused.Klor-Con 10 Oral was signed/coded as 12 (medication unavailable).Guaifenesin Oral Tablet was signed/coded as 12 (medication unavailable).Insulin Lispro 6 units was signed/coded as 3 to identify the medication was held and see nursing notes. Review of the nursing note dated 4/15/2026 failed to identify the fingerstick was not obtained and/or refused, and failed to identify the Klor-Con, Guaifenesin and Lispro insulin were not administered as ordered. 3. Resident #3's diagnoses included diabetes, dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of seven out of ten, indicative of moderate cognitive impairment. The RCP dated 4/9/2026 identified Resident #3 had diabetes, was at was at risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and potential for alteration in mood. Interventions directed to administer meds as ordered and, check blood sugar via fingerstick as ordered. Physician orders dated 4/8/2026 directed to administer the following at 8 AM:fingerstick for blood glucose level two (2) times a day for diabetesInsulin Lispro Injection Solution, inject six (6) units subcutaneously with meals for diabetes for diabetes,Aripiprazole (Abilify) Oral Tablet 10 mg, give 10 mg by mouth one (1) time a day for schizophreniaLiquid Protein two (2) times a day 30 milliliters (ml) liquid protein. Review of the electronic MAR notes identified the fingerstick, Lispro insulin, and liquid protein were coded at 12:42 PM as #3 that indicated hold, see nursing notes; Abilify was coded at 12:42 PM as #12 medication unavailable. 4. Resident #6's diagnoses included non-pressure chronic ulcer of right lower leg, cellulitis and chronic pain. The quarterly MDS assessment dated [DATE] identified Resident #6 had a BIMS score of twelve out of fifteen, indicative of no cognitive impairment. The RCP dated 3/11/2026 identified Resident #6 had cellulitis, interventions directed pain management as ordered. Physician orders dated 3/25/2026 directed Xtampza ER Oral Capsule (extended-release capsule containing oxycodone for pain) 12-hour abuse-deterrent 9 mg, give one (1) capsule by mouth every 12 hours related to other chronic pain. Additional order directed Oxycodone HCL 5 mg every four (4) hours as needed for pain. Review of Medication Administration Report dated 4/15/2026 identified Resident #6 did not receive the 9 AM Xtampza ER 9 mg scheduled at 9 AM, and it was signed with a code #2 to indicate the medication was refused. Interview and record review on 5/7/2026 at 11:24 AM with RN #1 identified she did not administer the Xtampza, and she did not notify the DNS, ADNS or nursing supervisor. Interview and record review with RN #3 on 5/12/2026 at 9:20 AM identified she was the supervisor on 4/15/2026 and she was working on a unit passing morning medications for residents on her unit. RN #3 stated she did not recall that RN #1 was late that day, and she was not aware medications were administered late or omitted. Interview and record review with RN #1 on 5/7/2026 at 11:24 AM identified she was the charge nurse on the 7 AM to 3 PM shift on 4/15/2026. RN #1 stated she had only worked at the facility for about one (1) month and worked the evening shift (3 to 11 PM) on a different unit. She was working in different facility during the night shift, ending at 7 AM on 4/15/2026 and when this facility asked her to work the 7 AM to 3 PM she had advised the facility that while she could work for them, she would be arriving about 9 AM due to the time required for travel from the other location to this facility, and the DNS and ADNS were both aware that she would be arriving late for her shift. RN #1 stated she was told the medication pass would be started prior to her arrival. When she arrived, she received help from another charge nurse to complete blood sugar testing upon arrival and administered insulin. RN #1 stated she documented held medications/orders on the MAR, did not administer breakfast insulin if it was missed but gave the lunch dose of insulin, and she documented Resident #1's unavailable medications on the MAR but did not write a nursing note. RN #1 stated she did not check the automated medication machine (emergency medication supply) for missing medications because she was behind on her medication pass, and informed the next shift at 3 PM of medications that were not administered. RN #1 did not notify the DNS or ADNS. RN #1 stated she should have asked for help to ensure medications were administered timely. On 5/13/2026 at 11:17 AM interview and record review with the DNS identified RN #1 was scheduled to work as the charge nurse on 4/15/2026, and she was aware RN #1 was not in the building at the start of the shift, and stated she could not have been passing medications to residents. The DNS stated she was enroute to the facility when she was notified RN #1 was going to be late and she did not assign another nurse to start the medication pass, do fingersticks or administer insulin. Although the DNS stated RN #1 punched in at 9:06 AM, the DNS failed to identify how the facility supported RN #1's medication pass after her late arrival, and failed to identify how the facility ensured fingersticks were obtained and medications and insulin were administered timely when the facility was aware RN #1 was arriving late. Interview failed to identify the facility had a plan to manage staffing to ensure resident medications were administered timely when the nurse was expected to be one (1) and a half hours late to start the shift and medication pass. Facility documentation review identified RN #1 punched into work on 4/15/2026 at 9:06 AM (one hour and a 36 minutes after the shift started). Review of facility Abuse Policy directed in part, neglect was the failure to provide goods or services necessary for physical, mental or psychosocial well-being.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of four residents (Resident #1, #2, #3 and #6) reviewed for medication errors, the facility failed to ensure medications were administered timely and failed to ensure staff searched for medications that were unavailable in the unit medication cart. The findings include: Resident #1's diagnoses included diabetes, arthritis, atrial fibrillation and morbid obesity. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment, required assistance with ADLs (activities of daily living), and received an anticoagulant (medication to prevent blood clots), diuretics, and hypoglycemic medication (to control blood sugar). The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 had diabetes, a risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and pain risk. Interventions directed to administer medications as ordered, and assess pain. Physician orders dated 4/16/2026 directed to administer the following:Jardiance Oral Tablet (used to control blood sugar) 25 milligrams (mg) give one (1) tablet by mouth one (1) time a day for diabetes type 2.Vitamin D3 Tablet 4000 units by mouth once a day for supplement.Ammonium Lactate External Cream 12 % (moisturizer), apple to bilateral thighs topically two (2) times a day. Review of April MAR dated 4/15/2026 identified Resident #1's fingerstick on 4/15/2026 at 9 AM was 227. Review of Medication Administration Record (MAR) dated 4/15/2026 identified the following medications were scheduled to be administered at 9 AM and were not signed to indicate they were administered at 9 AM:Jardiance Oral Tablet (used to control blood sugar) 25 milligrams (mg) give one (1) tablet by mouth one (1) time a day for diabetes type 2.Vitamin D3 Tablet 4000 units by mouth once a day for supplement.Ammonium Lactate External Cream 12 % (moisturizer), apple to bilateral thighs topically two (2) times a day. Review of the electronic MAR notes identified the Jardiance was signed with a code 12 at 1:11 PM, the Vitamin D was coded at 1:12 PM with a #12, and the Ammonium Lactate was coded at 1:04 PM, and were all signed/coded as #12. Additional review identified code 12 indicated the medication was unavailable. 2. Resident #2's diagnoses included diabetes and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment. The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 had diabetes, risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and risk for seasonal allergies. Interventions directed to administer meds as ordered and check blood sugar via fingerstick as ordered. Physician orders dated 3/25/2026 directed the following:fingerstick for blood sugar level four (4) times a day for diabetes.Klor-Con 10 Oral Tablet Extended Release 10 MEQ (milliequivalent) give three (3) tablets by mouth one time a day for hypokalemia (low potassium).Guaifenesin Oral Tablet 400 mg give one (1) tablet by mouth two (2) times per day for congestion. Physician order dated 4/13/2026 directed Insulin Lispro Injection Solution 100 unit/ml (milliliter) inject 6 units subcutaneously with meals for diabetes. Review of the MAR dated 4/15/2026 identified the medications were scheduled to be administered at 9 AM, and Resident #2 did not receive the above listed medications. Additional review identified the following:The finger stick was signed and coded as #2 to indicated refused.Klor-Con 10 Oral was signed/coded as 12 (medication unavailable).Guaifenesin Oral Tablet was signed/coded as 12 (medication unavailable).Insulin Lispro 6 units was signed/coded as 3 to identify the medication was held and see nursing notes. 3. Resident #3's diagnoses included diabetes, dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of seven out of ten, indicative of moderate cognitive impairment. The RCP dated 4/9/2026 identified Resident #3 had diabetes, was at was at risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and potential for alteration in mood. Interventions directed to administer meds as ordered and, check blood sugar via fingerstick as ordered. Physician orders dated 4/8/2026 directed to administer the following at 8 AM:fingerstick for blood glucose level two (2) times a day for diabetesInsulin Lispro Injection Solution, inject six (6) units subcutaneously with meals for diabetes for diabetes,Aripiprazole (Abilify) Oral Tablet 10 mg, give 10 mg by mouth one (1) time a day for schizophreniaLiquid Protein two (2) times a day 30 milliliters (ml) liquid protein. Review of the electronic MAR notes identified the fingerstick, Lispro insulin, and liquid protein were coded at 12:42 PM as #3 that indicated hold, see nursing notes; Abilify was coded at 12:42 PM as #12 medication unavailable. 4. Resident #6's diagnoses included non-pressure chronic ulcer of right lower leg, cellulitis and chronic pain. The quarterly MDS assessment dated [DATE] identified Resident #6 had a BIMS score of twelve out of fifteen, indicative of no cognitive impairment. The RCP dated 3/11/2026 identified Resident #6 had cellulitis, interventions directed pain management as ordered. Physician orders dated 3/25/2026 directed Xtampza ER Oral Capsule (extended-release capsule containing oxycodone for pain) 12-hour abuse-deterrent 9 mg, give one (1) capsule by mouth every 12 hours related to other chronic pain. Additional order directed Oxycodone HCL 5 mg every four (4) hours as needed for pain. Review of Medication Administration Report dated 4/15/2026 identified Resident #6 did not receive the 9 AM Xtampza ER 9 mg scheduled at 9 AM, and it was signed with a code #2 to indicate the medication was refused. Interview and record review on 5/7/2026 at 11:24 AM with RN #1 identified she did not administer the Xtampza on 4/15/2026, and she did not notify the DNS, ADNS or nursing supervisor. Interview failed to identify why the Xtampza was not administered and why the MAR was signed with a code 2 to indicate the medication was refused. Interview and record review with RN #3 on 5/12/2026 at 9:20 AM identified she was the supervisor on 4/15/2026 and she was working on a unit passing morning medications for residents on her unit. RN #3 stated she did not recall that RN #1 was late that day, and she was not aware medications were administered late or omitted. RN #3 stated RN #1 notified her when RN #1 arrived in the facility and she was not initially concerned about medication administration timing as she believed it remained within the medication pass window of one (1) hour before or after the scheduled time. Interview failed to identify they time RN #1 arrived. RN #3 stated she was aware RN #1 usually worked the 3 to 11 PM shift and that the unit assigned had heavier care needs. RN #3 stated if she had known RN #1 would arrive at 9 AM, she would have completed the unit's fingersticks and insulin administrations before RN #1 arrived. Interview and record review with RN #1 on 5/7/2026 at 11:24 AM identified she was the charge nurse on the 7 AM to 3 PM shift on 4/15/2026. RN #1 stated she had only worked at the facility for about one (1) month and worked the evening shift (3 to 11 PM) on a different unit. She was working in different facility during the night shift, ending at 7 AM on 4/15/2026 and when this facility asked her to work the 7 AM to 3 PM she had advised the facility that while she could work for them, she would be arriving about 9 AM due to the time required for travel from the other location to this facility, and the DNS and ADNS were both aware that she would be arriving late for her shift. RN #1 stated she was told the medication pass would be started prior to her arrival. When she arrived, she received help from another charge nurse to complete blood sugar testing upon arrival and administered insulin. RN #1 stated she documented held medications/orders on the MAR, did not administer breakfast insulin if it was missed, but gave the lunch dose of insulin, and she documented Resident #1's unavailable medications on the MAR. RN #1 stated she did not search the medication room for additional supplies of medications, she did not check the automated medication machine (emergency medication supply) for missing medications and she did not contact the supervisor or DON to obtain additional medication supplies because she was behind on her medication pass. RN #1 stated she informed the next shift at 3 PM of medications that were not administered. RN #1 did not notify the DNS or ADNS. RN #1 stated she should have asked for help to ensure medications were administered timely. Facility documentation review identified RN #1 punched into work on 4/15/2026 at 9:06 AM (one hour and a 36 minutes after the shift started). Additional attempts to interview RN #1 during the survey regarding Resident #2, #3 and 6's medication administration on 4/15/2026 were unsuccessful. Interview and record review with the DNS on 5/13/2026 at 11:17 AM identified RN #1 was scheduled to work as the charge nurse on 4/15/2026, and she was aware RN #1 was not in the building at the start of the shift, and could not have been passing medications to residents. The DNS stated she was enroute to the facility when she was notified RN #1 was going to be late and she did not assign another nurse to start the medication pass, do fingersticks or administer insulin. Although the DNS stated RN #1 punched in at 9:06 AM, the DNS stated she did not assign another nurse to the unit at 7:30 AM to begin the medication pass to ensure resident medications were administered timely. Although the DNS stated during the shift she asked RN #1 how things were going she did not identify medications were not administered timely and was not aware prior to surveyor inquiry. The DNS stated the fingersticks, insulin and medications that were not administered should have been administered by another nurse assigned to cover when RN #1 was identified to be arriving late for her shift. Review of facility Medication Administration policy directed in part, that all medications will be administered in accordance with physician orders, one (1) hour before or after the scheduled time.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for activities of daily living, the facility failed to ensure staff acted timely on therapy recommendations for alternative lifts for transfers. The findings include: Resident #1's diagnoses included arthritis, abnormal posture and morbid obesity. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment, required assistance with ADLs (activities of daily living). The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 required assistance with ADLs. Interventions directed to assist with ADLs and transfers as indicated, physical therapy and occupational therapy as ordered, and offer out of bed Monday, Wednesday and Friday after breakfast and back to bed before end of first shift. Observation and interview on 5/7/2026 at 9:54 AM with Resident #1 identified he/she had a collapsible oversized wheelchair in his/her room and got out of bed to the wheelchair on Mondays, Wednesdays, and Fridays, with assistance of two (2) aides and a mechanical lift. Resident #1 stated he/she would like to get out of bed more often and could only tolerate sitting in the wheelchair for limited periods due to discomfort on his/her bottom and back, and Resident #1 was willing to get up to a recliner chair. Resident #1 further identified the facility had attempted to obtain a wheelchair that he/she could exit the room with, however, he/she was told it was too wide for the doorway. Observation and interview on 5/12/2026 at 2:05 PM with Resident #1 while Resident #1 was in bed, he/she would like to get out of bed to a recliner, and he/she was currently getting up to a standard wheelchair. Resident #1 stated when in the (bariatric) wheelchair, he/she filled the wheelchair side-to-side. Review of a typed piece of paper provided by PT #1, labeled Occupational Therapy Screen dated 11/6/2025 with OT #'s name typed at the bottom of the page identified Reason: seating options: family request. The paper indicated an extensive investigation for optional out of bed seating options and inquiry for a customized wheelchair (CWC) was completed in the past. Pursuit of CWC in the past, (Sept and [DATE]) with vendors unable to make a chair to the resident's specification and needs. Pursuit of the facility bariatric power recliner chair (reference documentation 6/5/2025) found chair incompatibility with facility mechanical lift as the lift does not fit around the recliner chair as recliner seat width is 29 inches and the chair base width is 36 inches. Resident #1 currently using a 28-inch-wide wheelchair seat width, but measurements taken today reveal his/her current seat width hips/buttocks is 34 inches. The facility mechanical lift will not go around the 36-inch seat width in order to position and place him/her in the power recliner chair. OT #1 contacted community CWC vendors to inquire about potential changes and new options. New wide CWCs can accommodate up to 600 lbs with the maximal seat base width of 30 inches and the overall chair width 42 inches due (to) requirements and safety anti-tippers, wheels, casters, wheel push rims, and arm rest supports. The chair is rigid and unable to be folded. Door with into room is 39 inches therefore the chair will not be able to fit thought the doorway. In addition, the facility mechanical lift will not fit around a CWC. Unfortunately this therapist has exhausted all seating options with the only recommendation to pursue potential options for alternative lifts. This information was communicated to the rehab director and will be communicated with the facility administrator and the interdisciplinary team which will include the director of nursing and the social worker. The team will decide how best to share this information with the resident and/or family who on 11/5/2025 was inquiring about a CWC. Interview on 5/12/2025 at 11:58 AM with PT #1 (Rehab Director) identified Resident #1 was evaluated on 3/13/2026 (61 days prior to interview) and therapy had recommended a bariatric recliner, however the facility's current mechanical lift could not accommodate the recliner. PT #1 stated the information was relayed to nursing and maintenance, as therapy does not place orders for the mechanical lifts. Interview and record review on 5/12/2026 at 1:12 PM with OT #1 identified in November 2025 the findings of the Occupational Therapy Screen were shared during morning report with the rehab director, the Administrator, social worker and the DNS. The team was informed the facility bariatric recliner would work for Resident #1, the DNS had NAs assess if the mechanical lift would work with the chair and it was determined the lift could not accommodate the bariatric chair. The decision was that the facility was going to see if the company had another lift that would work. OT #1 stated it was her understanding that the DNS and the interdisciplinary team, who were aware of the situation, would determine how and who would be responsible for obtaining a different lift that would fit the bariatric chair needed for Resident #1. Interview failed to identify why a mechanical lift was not obtained that would fit with the resident's chair since November 2025 (6 months prior). Interview with Corporate RN #4 on 5/12/2026 at 2:15 PM identified Resident #1's room had sufficient space to accommodate a large recliner and space to operate a mechanical lift that would accommodate Resident #1's needs. RN #4 was unable to explain why the facility had not pursued a mechanical lift that would work with the bariatric chair that the facility already had, that had been identified by therapy as an option for Resident #1. Interview failed to identify why a mechanical lift was not obtained that would fit with the resident's chair since November 2025 (6 months prior). Review of facility Resident Rights Policy directed in part, to provide quality care and services with reasonable accommodation of your individual needs and preferences.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure the physician orders were reviewed and renewed at least every 60 days. The findings included: Resident #1's diagnoses included diabetes, arthritis, atrial fibrillation and morbid obesity. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment and required assistance with ADLs (activities of daily living). The Resident Care Plan (RCP) dated 3/13/2026 identified Resident #1 had diabetes, a risk for hyperglycemia (high blood sugar) and/or hypoglycemia (low blood sugar), and pain risk. Interventions directed to administer medications as ordered, and assess pain. Record review identified Resident #1 was on a 60-day schedule for review and renewal of physician orders. Record review failed to identify when the physician orders were last signed by the physician or APRN on either the paper record or the electronic medical record (EMR). Interview on 5/7/2026 at 2:10 PM with the DNS and Corporate RN #2 identified all resident physician orders should be signed every 30-days or every 60-days. Further, some resident orders were signed on paper, and some were electronic EMR orders. Interview identified all newly admitted resident orders are signed in the EMR, and any long-term resident orders that originated prior to the current EMR (example three (3) years ago) display in the EMR monthly report without any physician signatures and indicate the orders are signed as wet ink (indicated that means the physician/APRN sign on paper). The DNS and RN #2 were unable to provide any documentation that Resident #1's physician orders were reviewed and signed, and were unable to provide documentation as to the last time the orders were signed. In addition, the DNS and RN #2 were unable to provide any physician/APRN progress notes that indicated the monthly orders were reviewed and renewed. Subsequent to surveyor inquiry, Corporate RN #4 provided documentation that the monthly orders were signed by MD #1 on 4/16/2026, however RN #4 was unable to provide documentation of orders signed every sixty (60) days prior to 4/16/2026. RN #4 indicated the order should be signed at least every sixty (60) days. The facility did not provide a facility policy related to physician visit frequency, or physician order (paper or electronic) frequency of review and signatures.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure Resident #1 was treated with dignity and respect. The findings include: Resident #1's diagnoses included atrial fibrillation, weakness, and arthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory deficits, was alert and oriented to person, place, and time, and was dependent on staff for personal hygiene, transferring, and repositioning. The Resident Care Plan dated 9/25/24/24 identified Resident #1 had behaviors characterized by ineffective coping. Interventions directed to offer social services support and not to invade the resident's personal space. The Facility Reported Incident form dated 11/14/24 at 12:30 PM identified Resident #1 alleged on 11/13/24 a nurse aide, Nurse Aide (NA) #1, called him/her a pain in the ass. The investigation identified the incident was witnessed by two (2) other staff members and NA #1 told Resident #1 to stop being a pain in the butt. The social service note dated 11/15/24 (a late entry) identified Resident #1 reported a nurse aide, NA #1, had used inappropriate language and made Resident #1 feel uncomfortable. The social service note dated 11/18/24 identified the social worker met with Resident #1 after NA #1 returned to work pending the conclusion of the investigation and Resident #1 indicated everything was fine between him/her and NA #1. Interview with the Social Worker (SW) #1, on 12/11/24 at 8:30 AM identified Resident #1 called her to his/her room to discuss an inappropriate remark made by NA #1. SW #1 indicated Resident #1 explained he/she became upset yelling when the arm of the wheelchair, which was removed for safe transfer, was not placed where Resident #1 wanted it placed. SW #1 identified NA #1 proceeded to tell Resident #1 he/she was a pain in the butt. SW #1 stated she reported this to the Administrator and Director of Nursing. In an interview on 12/11/24 at 9:55 AM NA #1 identified Resident #1 began yelling at another nurse aide and she told Resident #1 to stop being a pain in the butt. Interview with the Administrator on 12/11/24 at 10:12 AM identified SW #1 reported Resident #1 stated NA #1 made an inappropriate remark that caused him/her to feel bad. The Administrator indicated NA #1 was removed from the schedule and an investigation was conducted. At the conclusion of the investigation NA #1 returned to work. Interview with Resident #1 on 12/11/24 at 10:20 AM he/she identified NA #1 stated he/she had been a pain in the butt when Resident #1 asked the wheelchair arm to be removed from the top of the chair. Resident #1 identified although he/she had a bantering repour with NA #1, this incident made him/her feel disrespected. Review of the Residents Rights Policy identified the Residents Right to be treated with consideration, respect and full recognition of dignity and individuality.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to report the allegation to the Administrator and/or his/her designee immediately and to the state agency within two (2) hours after the allegation of verbal abuse. The findings include: Resident #1's diagnoses included anxiety, schizoaffective disorder, and asthma. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented and exhibited behavioral symptoms directed towards others, such as verbal threatening, screaming at others, and cursing at others. The Resident Care Plan dated 10/17/24 identified Resident #1 was impulsive and not always able to control behavior and at risk for changes in mood state due to anxiety. Interventions directed to avoid verbal triggers, approach resident at a later date, offer a different staff member, assist resident to another area, to be aware of changes in mood, mental state, and offer to discuss feelings and options to channel feelings. The nurse's note dated 10/20/24 at 4:01 PM identified Resident #1 was heard yelling at a nurse aide while self-propelling back to their room screaming obscenities and racial slurs at the nurse aide and Resident #1 stated did not like the way the nurse aide had spoken to him/her. The Facility Reported Incident dated 10/21/24 at 9:45 AM identified the Administrator and Director of Nursing were reviewing the seventy-two (72) hour report and found that there had been a verbal incident with a staff member and resident. The report indicated that the 10/20/24 incident was reported to the state agency on 10/21/24 at 9:45 AM. In an interview on 11/13/24 at 11:33 AM Resident #1 identified he/she had a verbal exchange with a nurse aide, Nurse Aide (NA) #1, at the nurse's station on 10/20/24. An interview on 11/13/24 at 12:00 PM with the Administrator and Director of Nursing (DON) identified on 10/21/24 during morning shift report, a nurse's note dated 10/20/24 at 4:01 PM indicated a verbal altercation had occurred at the shift change, 7AM-3PM to 3-11PM, between Resident #1 and NA #1. The Administrator stated NA #1 was removed from the schedule and suspended until an investigation was conducted. The DON stated she did not know why the Nursing Supervisor, Registered Nurse (RN) #1, did not call anyone or initiate an investigation into the allegation. In an interview on 11/13/24 at 12:37 PM RN #1 identified she heard yelling coming from the hallway, she went to the nurse's station where she identified Resident #1 was yelling at NA #1. RN #1 identified she assisted the resident back to his/her room, NA #1's shift was completed, and he was leaving the building. RN #1 indicated although she wrote a nurse's note in Resident #1's record and the change of shift report, she did not inform the DON or begin an investigation because she was not aware of a verbal interaction maybe indicative of abuse. Review of the abuse policy directed: The Administrator/DNS or designee will immediately conduct an investigation upon submission of a report to FLIS within 2 hours of notification of alleged allegation of abuse.

Based on clinical record reviews, review of facility documentation and policy review and interviews for one of three sampled residents (Resident #4) who was a high risk for falls, the facility failed to ensure the environment was free of hazardous objects to prevent a fall and/or for Resident #4 who required staff assistance with mobility in the wheelchair, the facility failed to ensure the lower extremities were positioned during transport of the resident to prevent a fall. The findings include: Resident #4's diagnoses included dementia with behavioral disturbance, arthritis, muscle weakness, unsteadiness on the feet, and [CONDITION(S)]. The admission Minimum Data Set assessment dated [DATE] identified Resident #4 had severe cognitive impairments, required extensive two (2) person assistance with transfers in and/or out of the bed and chair, extensive one (1) person assistance with movement on the unit, utilized a wheelchair for mobility on and/or off the unit, the resident's balance during transitions when moving from seated to standing and/or moving from bed to chair was unsteady and the resident was only able to stabilize with staff assistance, and a history of one (1) fall in the past six (6) months. The admission Resident Care Plan dated 5/26/19 identified Resident #4 was at risk for falls related to decreased coordination, impaired balance, impaired safety awareness. Interventions directed to encourage the resident to ask and wait for staff assistance for transfers and/or toileting, encourage the resident to transfer and change positions slowly, and offer toileting before supper. The care plan revision dated 5/30/19 directed for the call bell to be within reach when in the bed and/or bedside chair, encourage the resident to use the handrails or assistive devices properly, to wear proper and non-slip footwear, and to ensure the environment is free of clutter. a. The nurse's note dated 6/9/19 at 10:52 PM indicated a charge nurse was in the hallway and heard a loud noise and upon entering Resident #4's room, the resident was lying on the floor in front of the roommate's bed with blood coming from his/her forehead, left upper arm, left elbow, and right thumb. The note identified the Nursing Supervisor was immediately notified, assessed the resident and Resident #4 was transferred to the hospital at 10:50 PM. The nurse's note date 6/9/19 at 10:57 PM identified upon entering the room, the Nursing Supervisor found Resident #4 lying on his/her side with the air pump cord from the roommate's bed near the resident's feet. The Reportable Event Form dated 6/9/19 identified at 10:40 PM, the resident was observed lying on his/her side with blood noted to forehead and arms. After the investigation was concluded, the air mattress pump to the roommate's bed was secured with zip ties. The nurse's note dated 6/10/19 at 3:53 AM identified Resident #4 returned to the facility at 3:15 AM. The note indicated per the hospital discharge summary Resident #4 sustained a four (4) centimeter (cm) long and two (2) millimeter (mm) deep laceration to the right anterior parietal scalp which was repaired with five (5) sutures, dressed with antibiotic ointment and a non-adherent dressing. The resident also sustained skin tears to the right elbow, right hand and the left hand that were repaired with glue. Review of the nursing to therapy communication form dated 6/10/19 identified Resident #4 with frequent falls and that he/she tripped over an air mattress cord on 6/9/19. In an interview with the Staff Development Nurse, Registered Nurse (RN) #2, on 8/21/19 at 11:45AM she indicated on the evening of 6/9/19 that Resident #4 was observed lying on the floor at the foot of the roommate's bed with his/her head against the wall. RN #2 stated Resident #4 roommate's bed had an air mattress and when the bed was in the low position, the cords from the mattress to the pump were loose and hanging and Resident #4 tripped over the cords. RN #2 identified after the 6/9/19 incident, the [NAME] for the roommate's air mattress was secured with a zip ties to ensure the room was free of hazardous objects. b. The nurse's note dated 8/6/19 at 10:54 PM indicated around 10:00 PM while Resident #4 was being wheeled by a nurse aide to his/her room, Resident #4's right foot went under the pedal and the resident fell forward to the ground hitting the right side of the head causing a gash with a moderate amount of blood. The nurse's note also indicated Resident #4 complained of pain to the right arm and was transported to an acute care hospital for an evaluation. The hospital discharge summary dated 8/6/19 identified Resident #4 sustained a small hematoma with a laceration in the right frontal scalp. The discharge summary identified the six (6) sutures were applied followed by a skin adhesive to reinforce the area. The Reportable Event Form dated 8/6/19 indicated Resident #4's right foot got caught under the foot pedal of the wheelchair while being wheeled by a nurse aide, causing the resident to fall forward on the floor hitting the right side of his/her head and sustain a large gash. Review of the care plan revision dated 8/7/19 directed calf supports to the wheelchair leg rests during transport as tolerated. In an interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 8/21/19 at 2:45 PM, she indicated that Resident #4 fell from the wheelchair and was transferred to an acute care hospital for an evaluation secondary to a large gash on the forehead. RN #1 stated the nurse aide should have ensured Resident #4's feet were secure while transporting the resident. During an interview with the 3-11PM nurse aide, Nurse Aide (NA) #2, on 8/21/19 at 3:45 PM she indicated that on the evening of 8/6/19 Resident #4 was seated in a wheelchair, she came up behind the resident's wheelchair and while wheeling the resident from the nursing station to his/her room, Resident #4's feet got stuck under the foot pedal. NA #2 stated that she could not see Resident #4's feet while pushing the wheelchair and she did not realize that Resident #4's feet were not secure on the foot pedals. NA #2 stated that prior to 8/6/19 Resident #4's did not utilize foot rests on his/her wheelchair and she did not check prior to pushing the wheelchair that foot rests had been applied. The policy also indicate that residents who are at risk shall have a care plan that addresses interdisciplinary measures to prevent falls and any environmental/equipment recommendations to prevent injuries.

Based on a review of the clinical record, a review of facility documentation, staff interviews and a review of the facility policy for one sampled resident (Resident #36), reviewed for restraints, the facility failed to ensure the resident was free from physical restraints which resulted in a fall with an injury. The findings include: Resident # 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes dated 6/18/19 identified APRN #1 indicated Resident #36 had advanced dementia, was very confused with chronic [MEDICAL CONDITION], needed assistance with activities of daily living, was able to ambulate with assistance of one using a rolling walker, was dependent upon staff for toileting, hygiene and grooming. Additionally, the resident's plan of care included fall precautions interventions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, frequently incontinent of bowel and bladder, extensive assistance with bed mobility, toilet use, and limited assistance with locomotion on and off the unit in a wheelchair (the resident self propelled). The care plan dated 7/5/19 identified Resident #36 was a fall risk. Interventions included to keep the call bell in reach, encourage the resident to ask and wait for staff assistance for transfers and/or toileting. Additionally, the care plan identified Resident #36 self propelled in the wheelchair but at times required assistance for long distances. The plan of care also identified Resident #36 had cognition issues and frequently attempted to self transfer and ambulate. Interventions included allowing the resident time to respond when speaking, offering support and reassurance, and to offer gentle reminders. Review of the facility documentation dated 7/22/19 identified Resident #36 had an unwitnessed fall from a wheelchair on 7/22/19 at 4:20 PM (20 minutes after incontinent care was provided). Staff described the resident as being agitated before the fall. The report indicated Resident #36 had received incontinent care at 4:00 PM, was sitting alone and unattended in his/her room prior to the fall. Further review of the facility documentation identified NA #1 indicated Resident #36 was antsy, restless, and agitated and did not sit still. NA #1 placed the resident in the wheelchair and when he/she returned to the resident's room, 20 minutes later, Resident #36 was found face down on the floor and sustained a laceration to his/her right temple. Resident #36 was transferred to the emergency department for evaluation and treatment. Review of the hospital documentation dated 7/23/19 indicated Resident #36 sustained a left temple laceration that required sutures. Fractures to the left orbit were identified as well. The injury resulted in a severely swollen left eye with bruising. The discharge instructions included to monitor the resident's vision in the left eye and to avoid anticoagulation therapy. Interview with NA #1 on 8/14/19 at 10:11 AM identified she was assigned to care for Resident #36 on 7/22/19. NA #1 indicated Resident # 36 was confused, did not follow commands, was difficult to redirect, had a history of [REDACTED]. NA #1 identified Resident #36 was not capable of using the call bell for assistance, was not easily directed, and sometimes tried to self ambulate or self transfer. NA #1 indicated on 7/22/19 he/she provided incontinent care to Resident #36 at which time the resident was agitated and fidgety. NA #1 put a clean brief on Resident #36 and transferred him/her from the bed into a locked wheelchair, and then left the resident in the room alone. NA #1 identified when she returned to Resident #36's room, 20 minutes later, the resident was on the floor, face down with blood by his/her head. Interview and review of the clinical record with the Director of Nursing (DON) on 8/14/19 at 11:28 AM identified Resident #36 was cognitively impaired, combative, noncompliant with transfers, self propelled in a wheelchair, attempted to get out of bed independently, had a history of [REDACTED]. The DON indicated Resident #36 self propelled in his/her wheelchair therefore, the chair should have been unlocked so the resident would be free from physical restraints. Furthermore, the DON identified Resident #36 should not have been left unsupervised for twenty minutes, and should have been in common area for supervision. The DON indicated leaving an agitated, cognitively impaired resident alone in a locked wheelchair, who self propelled was not a safe practice, it prohibited movement, and was a restraint.

Based on clinical record review, and staff interview for 1 of 3 sampled residents reviewed for hydration (Resident # 4) the facility failed to ensure the resident's fluid intake was monitored and/or the resident assessed for dehydration and/or the physician was notified. The findings include: Resident # 4's [DIAGNOSES REDACTED]. Review of a hospital report dated 5/26/17 identified the resident's BUN was 33mg/dL (7-20 considered normal) and the Creatinine was 1.0mg/dL (0.5-1.1 considered normal). A dehydration evaluation dated 7/7/17 identified the resident's fluid intake was between 840cc to 1140cc for three days, and the resident had no symptoms of dehydration. A dietary progress note dated 9/14/17 identified fluctuating weight (76lbs), decrease in food/fluid intake, and refusing meals at times. The note recommended weekly weights for better/closer monitoring and that Resident #4 required to be fed. Physician orders [REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, extensive assistance of one person for eating, and on a mechanically altered and therapeutic diet. The RCP dated 12/22/17 identified potential for nutritional decline. Interventions included provide diet as ordered, verbal cues, weights as ordered, and record intake and output as ordered. Review of the Nutritional Assessments dated 12/3/17 and 3/4/18 identified the resident's estimated fluid needs as 1400-1680 cc per day and monitor weights as ordered. Interview and review of Resident # 4's clinical record with the DON on 6/18/18 at 12:00PM identified the weights and vital signs summary for Resident # 4 identified that from 11/2/17 thru 3/6/18 the resident was being weighed monthly and weekly weights were not completed, that intake and output was not monitored from 9/14/17 thru 3/23/18, the resident's meal consumption sheets from 9/14/17 thru 3/23/18 identified that the resident frequently refused meals and/ or ate 0-50% of meals and that the resident was not assessed for dehydration. Nurse's notes dated 3/23/18 at 12:15PM identified that when RN #1 woke Resident #4 to administer medications, the resident was noted to be short of breath, pulse was weak to palpate, temperature of 94.3, was unable to get a pulse ox reading and oxygen at 2 liters was placed on the resident, rhonchi was heard in the lungs, a faint blood pressure, the resident appeared with generalized weakness, was pale and malnourished. The physician was notified and the resident was transferred to the hospital. The note further identified that the resident refused breakfast and the NA reported the resident had been eating poorly over the past few days. Interview with RN # 1 on 6/15/18 at 1:47PM stated that when she went to administer Resident #4's medications in the morning the resident was pale. RN # 1 stated she tried to obtain a pulse ox but was unable, the blood pressure was low and Resident # 4 was short of breath. RN # 1 stated she placed oxygen on the resident notified the Supervisor and notified the physician who directed to send the resident to the hospital for an evaluation. RN # 1 further stated that NA # 1 reported to her that the resident did not eat that morning and had been eating poorly for days before this. RN # 1 further stated that she had not been told the resident wasn't eating well while receiving report from the other shifts. Review of the clinical record with the DON on 6/18/18 at 12:00PM identified that there were no nursing notes or assessments of the resident from 3/5/18 until the change in condition on 3/23/18. Review of the hospital report dated 3/23/18 identified the resident presented with altered mental status changes, shortness of breath, low grade temp, rhonchi in the lungs, and an oxygen saturation of 78%. The report identified lab work was completed and noted the BUN at 106mg/dL, Creatinine at 2.5mg/dL and Sodium at 159 (135-145 considered normal). Additionally the note identified the resident received 1800cc of Normal saline, admitted to critical care with [DIAGNOSES REDACTED]. Interview with MD # 1 on 6/18/18 at 9:45AM stated that Resident #4 had a general decline related to his/her [DIAGNOSES REDACTED]. MD# 1 stated that if the resident was not eating well he would expect nursing to assess the resident and notified him of their assessment. MD # 1 further stated that he would have spoken with the family to determine a plan to put into place to meet the residents needs. MD# 1 further stated that he would want staff to assess and monitor if the resident was not eating or drinking well. Interview with NA # 1 on 6/18/18 at 2:00PM stated that Resident # 4 didn't eat much but lately had been eating less and did report this to the charge nurse. NA # 1 stated that the nurses she reported this to said ok but didn't direct her to try anything different. NA # 1 further stated that she did not know if the resident was on intake and output. The policy for intake and output identified to ensure that a properly dated I&) record is in place, all nursing personnel are responsible for recording I&O, and it is the nurse's respnsibility to review the I&O at the end of each shift. The policy for change in condition identified to make a resident's physician and family aware of any significant change in condition.

Based on observations, clinical record review, and interviews for one of six residents (Resident #136) reviewed for pressure ulcer, the facility failed to provide care and services to prevent the development of a pressure ulcer. The findings include: Resident #136's was admitted on [DATE] to the facility with an admitting [DIAGNOSES REDACTED]. The resident's additional [DIAGNOSES REDACTED]. Resident #136's admission MDS dated [DATE] identified that the resident scored a 15/15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The resident care plan dated 2/20/17 identified that Resident #136 was a risk for skin breakdown due to altered mobility and the presence of an [DEVICE] device. Interventions included a pressure redistribution mattress and to off load pressure to the resident's heels with a pillow. The physician progress notes [REDACTED]. The resident returned to the facility on [DATE] with orders to administer oral antibiotics and a follow-up appointment with an infectious disease physician. physician's orders [REDACTED]. In addition, the physician's orders [REDACTED]. The physician's progress note dated 3/23/17 identified Resident #136 returned from the Acute Care Facility on 3/22/17 after removal of the external fixation pins, but was not able to remove the internal hardware due to the need for substantial debridement, down to the exposed metal. The wound on the anteromedial aspect of the distal leg measured approximately 11 centimeters long and 1-1/2 centimeters deep (which had a [DEVICE] placed). A skin/wound tracking record dated 4/17/17 identified a left heel unstageable pressure ulcer measuring 5.5 cm x 7.7 cm. Intervention was to off-load the heel with foam within the splint. A physician's progress note dated 4/18/17 identified that Resident #136 had been identified with a deep tissue injury with about 2 centimeters of central black tissue with surrounding dusky tissue on the left heel. Some serosanguinous drainage was noted on the lateral aspect of the heel and nursing had noted necrotic tissue on the resident's heel. Resident #136 was wearing a splint to keep the lower extremity somewhat immobilized. The progress note further identified that MD #1 ordered to free float the left heel at all times, remove the splint, and skin prep twice daily and as needed to the area. Interview and observation with Resident #136 on 5/17/18 at 8:00 AM indicated that upon return from the hospital for the removal of the [DEVICE], his/her left lower extremity was immobilized with a hard splint that was wrapped in bandages to keep it in place. Resident #136 indicated that his/her left heel would rest on the splint 24 hours a day with no off-loading to the left heel. Observation during the interview identified the splint in the resident's room. The splint was an L-shaped, white splint that was hard to the touch. A brownish, circular stain was noted where the heel would rest if the foot was placed in the splint. Resident #136 indicated that the stain was from the drainage from the left heel. After the pressure ulcer on the left heel was identified, a new soft brace was put on the left lower extremity that had a circular opening at the heel for the pressure ulcer to be free from any pressure or touching the splint. The green and black colored, foam-like soft splint, was in place during the interview and various observations of the resident. Interview with the Director of Therapy on 5/18/17 at 11:30 AM indicated Resident #136 had the splint on that was in the room and was the same splint the resident wore when the [DEVICE] was removed. The Director of Therapy indicated that when he/she saw the resident in the splint, it was wrapped in ACE bandages to keep it in place. Interview with MD #1 on 5/18/17 at 11:45 AM identified the splint was the reason the resident developed the pressure ulcer on the left heel. Interview with Corporate Nurse #1 on 5/18/17 1:00 PM indicated that Resident #136's left heel was off-loaded with foam per the progress note after the identification of the unstageable pressure ulcer on 4/17/17. Although all pressure ulcer care plans were requested, the facility and Corporate Nurse #1 could not provide a care plan that included the left heel unstageable pressure ulcer identified on 4/17/17.

Based on clinical record review, review of facility documentation and staff interviews for one three residents (Resident #157) reviewed for accidents, the facility failed to ensure treatment was provided in accordance with the physician recommendation to prevent an injury. The findings included: Resident #157 ' s [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified cognitive impairment and total dependence from staff for personal hygiene. The care plan dated 11/28/15 identified the resident had a behavior of chewing his/her right index finger. The care plan also had an intervention that directed staff to apply a Band-Aid to the resident's right index finger. The nurse's note dated 11/29/15 indicated Resident #157's right index finger remained red, swollen, and warm to touch and the physician was updated. The nurse's note dated 11/30/15 identified Resident #157 was seen by the physician and the physician directed staff to cover the resident's right hand with a sock to protect the resident ' s hand and prevent Resident #157 from biting and chewing his/her finger. Review of the reportable event dated 12/16/15 indicated Resident #157 was found with the right index finger in his/her mouth and blood was all over his/her face. The reportable event further identified Resident # 157 chewed the flesh of the proximal phalanx right index finger and indicated flesh had been removed from the top and the bottom of the resident's finger and that the top of the wound showed bone exposure. The nurse ' s note dated 12/16/15 recorded at 7:38 A.M. identified Resident # 157 ' s right index finger was macerated to the bone and the finger was noted with a 2.0 CM by 1.0 CM open area to the top and a 3.0 CM by 1.0 CM redden area on the underside with a small distal area at the end of the resident ' s finger. The physician was notified and directed to apply Clindamycin 300 MG (antibiotic) twice a day for 7 days. The physician further directed to cleanse the right finger with Normal Saline, apply an AGB, wrap with Kerlix and then apply a sock. Review of the clinical record on 6/14/16 identified only one occasion (12/3/15) where the facility implemented the physician ' s directive on 11/30/15 to apply a sock to the resident ' s right hand to prevent the resident from chewing and/or biting his/her finger. A review of TAR for December 2015 noted the physician ' s directive to apply a sock to the resident ' s right hand was not placed on the TAR until 12/19/16 on the 11-7 A.M. shift. Interview with Nurse Aide (NA) #1 on 6/14/16 at 11:40 A.M indicated on 12/16/15 during last rounds the resident was observed with his/her right index finger in his/her mouth. NA#1 indicated the resident had geri-sleeves on the right hand; however, the resident did not have a sock on the right hand. NA#1 indicated he/she was not aware Resident # 157 needed to have a sock on the right hand. Interview with Licensed Practical Nurse (LPN) #1 on 6/14/16 at 12:10 P.M. indicated on 12/16/15 at 4:30.A.M, Resident #157 was observed with his/her right index finger in his/her mouth and blood was noted around the resident's mouth. LPN#1 further indicated Resident #157 ' s hands were contracted and the resident often kept his/her hands close to his/her face. LPN #1 also indicated Resident #157 utilized geri-sleeves at the time of the incident but did not have anything on to protect his/her fingers. Interview with LPN #2 on 6/14/16 at 12:25 P.M. indicated Resident #157 hands were clenched and the resident kept his/her hands in close proximity to his/her face. LPN #2 further indicated the resident started biting the fingers about a month or two before the 12/16/15 incident. LPN #2 indicated Resident #157 utilized a geri-sleeve, however, the sleeve did not cover the resident's fingers. LPN #2 indicated socks were not used to prevent the resident from biting and/or chewing his/her hands at the time of the incident. Interview with MD #1 on 6/14/16 at 3:10 P.M. indicated Resident # 157 was seen on 11/30/15 after an incident of biting his/her right index finger. MD #1 indicated LPN # 3 was directed to place a sock over the resident ' s right hand to protect the resident from biting and/or chewing his /her finger. Interview with the DNS on 6/15/16 at 12:35 P.M. indicated a physician's order [REDACTED].# 157's hands to prevent the resident from chewing and biting. Interview with LPN#3 on 6/16/16 at 12:49 P.M. indicated the physician directed him/her to apply a sock to the resident's hands on 11/30/15, however, he/she forgot to write the physician's order [REDACTED]. The facility physician's orders [REDACTED].

Based on review of clinical records, facility documentation, facility policies, acute care hospital records, and interviews for one of six residents reviewed for advanced directives (Resident #158), the facility failed to ensure the resident's right to choose whether or not to formulate an advanced directive was maintained and/or that the resident's code status based on the physician order [REDACTED]. The findings include: 1. Resident #158 (R #158) had [DIAGNOSES REDACTED]. R #158 was admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE] identified that R #158 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for most ADLs though required limited assistance for eating. Review of the admission physician's orders [REDACTED].#158's code status was "Full Code." Review of the clinical record identified that the demographic records listed Persons #2 and #3 as conservators of estate and person for Resident #158 although the legal documents naming the two persons as conservators were not available upon initial review of the clinical record. Subsequent to surveyor inquiry, the legal documents for R #158 were obtained and identified that Persons #2 and #3 were actually named as standby Plenary Guardians of the Person and not conservators. Review of documentation from Person #1 alleged that Person #2 reported that upon R #158's admission to the facility, a form was presented to Person #2 to authorize a directive for Do Not Resuscitate (DNR). The documentation identified that Person #2 reported to Person #1 there was a brief discussion about the topic and agreed without being provided any foundation or explanation to a DNR status for R # 158. Person #1's documentation further identified that no members of R #158's interdisciplinary team at the resident's group home were notified of the alleged change in status and they were subsequently unable to provide additional guidance. Review of the DNR consent form signed by Person #2 on [DATE] identified the form was incomplete. The DNR consent form lacked documentation to reflect the date of the discussion of the DNR decision and further lacked documentation of the name and title of the health care agent who discussed the risks and benefits of the decision with Person #2. On [DATE], R #158's morning fingerstick (testing for glucose) was 101 (Normal ,[DATE]). Review of R #158's food intake documentation on [DATE] identified that R #158 had eaten 50% of breakfast and 25% of his/her lunch on [DATE]. Review of the nurse's notes dated [DATE] at 3:45 PM identified R #158 was found unarousable, pale, diaphoretic, staff was unable to obtain a blood pressure, but the resident was breathing. A fingerstick was done with a result of 33. Glucose gel was given by mouth and a repeat test of R #158's fingerstick was documented as 48. A second tube of glucose gel was administered at 4:00 pm with no change in fingerstick results as the level remained at 48. The documentation identified that the physician was notified, directed staff to transfer the resident to the Emergency Department (ED), and the charge nurse called 911. Review of the interagency referral form dated [DATE], used to provide the accepting facility (Acute Care Hospital #1) with documentation of the resident's current status and medical information, identified that the words "Full Code" were initially entered onto the "CODE STATUS" portion of the form but were crossed off, the word "error" was written, and the words "DNR/DNI" were entered. Interview with RN #2 on [DATE] at 2:45 PM identified that he/she completed the interagency referral form on [DATE] in preparation for R #158's transfer to the hospital. RN #2 stated that although the preprinted interagency referral form was partially completed and had R #158's code status documented as "Full Code," he/she looked under the advanced directives section of the resident's clinical record, saw the DNR consent form, and crossed off Full Code and added DNR/DNI. RN #2 stated that he/she assumed that the resident's status had been changed since the interagency referral form was created but that he/she did not check the physician orders. Review of the clinical record including physician progress notes [REDACTED]. R #158 was transferred to the ED with a DNR transfer form to Acute Care Hospital #1 at 4:30 PM. Review of R #158's clinical record from Acute Care Hospital #1 identified that R #158 arrived at the ED via ambulance at 4:34 PM on [DATE]. Review of ED record identified that upon arrival, R #158's blood sugar was 70 and that the resident was breathing, though cyanotic, and hypotensive. The ED physician documented that the resident had an in effect DNR/DNI (based on information supplied by the facility) and that he/she anticipated that it was "just a matter of moments before (he/she) arrests." The documentation identified that R #158 was made comfortable with suctioning and positioning and that R #158 expired at 5:09 PM in the ED. Interview with MD #1 on [DATE] at 11:15 AM identified that he/she was aware that he/she could not write an order for [REDACTED].#1 stated that a staff member in the facility had approached him/her a few days to a week prior to R #158's hospital transfer requesting a DNR/DNI order be written and that he/she told them that it could not be done based on state regulations that protected residents such as R #158 by requiring specific interventions before a DNR could be considered. MD #1 could not recall the name of the staff member that had approached him/her. Interview with the DNS on [DATE] at 10:00 AM identified that a blank DNR consent form is included in all admission packets and that facility practice was that the charge nurse obtain consent from the resident or responsible party to address the advance directive issue. The DNS was unable to explain how the charge nurse would know if the person asked to sign the DNR consent form as a "responsible party" for a newly admitted resident, actually had the authority to do so based on legal documentation or other circumstances. In addition, the DNS was unable to provide documentation of education for licensed staff for presentation of advance directive information. The DNS stated that after R #158's transfer to the hospital and subsequent death, the facility became aware that R #158 should not have had a DNR/DNI consent form and that although education was provided to RN #2, he/she was unable to provide documentation of education provided to other licensed staff at the facility. The DNS stated that he/she was not aware of the conflicting physician order [REDACTED]." The facility had three nursing units. All three licensed staff members/charge nurses were interviewed regarding how they would determine a resident's code status. Interview with LPN #2 on [DATE] at 9:42 AM identified that if he/she needed to determine a resident's code status in an emergent situation, he/she would go to the MAR for documentation of the resident's code status. Interview with LPN #4 on [DATE] at 9:45 AM identified that if he/she needed to determine a resident's code status in an emergent situation, he/she would go to the advance directive section of the resident's chart and look for a signed consent form. Interview with RN #3 on [DATE] at 9:50 AM identified that if he/she needed to determine a resident's code status in an emergent situation, he/she would look in the record for a physician order. Upon review of an expanded sample of residents for potential conflict of DNR consent and physician orders [REDACTED].#9 was identified to have a signed DNR/DNI consent order dated [DATE] under the advance directive section and a physician order [REDACTED]. The current facility policy directed in part that licensed staff or the resident's attending physician would review advance directives with the resident or responsible party. The policy directed that the resident's code status would be documented on the advance directive consent form, physician orders, and in the care plan which would be reviewed quarterly for any changes. Upon request by the state agency on [DATE] at 1:00 PM, the facility provided an immediate action plan to ensure the rights of residents to decide whether or not they choose to formulate an advance directive and to be fully informed in order to make knowledgeable choices regarding health status and treatment options. The action plan included an immediate review of all current residents' records to ensure DNR/DNI consent forms were not in conflict with physician orders. In addition, the facility implemented a system whereby residents who did not enter the facility with a formulated advance directive would be considered Full Code status until the facility determined the capability of the resident to sign his/her own DNR consent and /or that the facility can confirm the responsible party had to authority to sign for the resident. In addition, staff education was started and will be ongoing to ensure licensed staff is aware of the revised practice and how to quickly and efficiently identify a resident's code status in an emergency situation.

Based on clinical record reviews, review of facility documents , review of facility policy and procedures and interviews for three of five sampled at risk for pressure ulcer development (Residents # 112, # 90 , #49), the facility failed to ensure that the resident did develop a pressure and / or that the pressure ulcer did not deteriorate and / or for two of five sampled residents (Residents # 63 and # 32), the facility failed to follow the resident's plan of care and / or follow facility's policy procedures for pressure ulcer development . The findings included: 1. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified decision making was reasonable and consistent, independence with activities of daily living and intact skin. A Braden Scale skin assessment dated [DATE] indicated the resident was not at risk for skin breakdown. The plan of care dated 12/24/13 noted a decline in the resident's ability to move independently and the risk for skin breakdown. Interventions included weekly body audits, and to check skin for reddened areas. The nurse's note dated 2/8/14 indicated the resident had complained of bilateral heel pain and stated "I need something because there is going to be a break down " . At that time skin assessment reflected the areas were intact. Interventions included application of daily skin prep to the areas. The physician's orders [REDACTED]. The nurse's note dated 3/17/14 noted the resident had a pressure area on the coccyx. The note identified that a dressing was applied to the area. The Skin/Wound Tracking Record identified that on 3/17/14, Resident #112 was noted to have a stage 2 pressure ulcer on the coccyx that measured 2.5 CM X 0.3 CM that was yellow in color. The physician's orders [REDACTED]. The weekly wound documentation dated 3/26/14 indicated the wound was still a stage 2 and measured 2.5 CM X 0.5 CM with visible yellow (tissue). On 4/1/14 the Resident's pressure ulcer on the coccyx was a stage 2 and measured 3 CM X 1 CM with no depth. Intermittent observations on 4/2/14 between 9:30 A.M. and 2 P.M. identified that the resident was lying in bed on her /his back. Observation on 4/3/14 at 10:45 A.M. identified that Resident #112 had a pressure area on the coccyx that was completely covered with yellow slough. Interview with LPN #7 on 4/2/14 at 3:47 P.M. identified that she/he completed wound training through the facility's corporations wound program. LPN #7 noted that "a stage 2 pressure ulcer can have slough " . Interview with the DNS on 4/2/14 at 2:45 P.M. indicated that she/he had cosigned the weekly facility pressure documentation without visualizing the wound and or thoroughly assessing them due to assigned duties. Interview with the ADNS on 4/3/14 at 10:50 A.M. indicated the wound was unstageable because the wound bed was completely covered. The interview also identified that the ADNS had measured the wound on 4/2/14 during wound rounds and it was restaged to unstageable. 2. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden Skin assessment dated [DATE] identified that the resident was at risk for skin breakdown. The interventions on the Interim plan of care included off-loading the heels in bed, pressure reducing mattress and chair cushion, and to turn and re-position according to facility policy. The nurse's note dated 2/5/14 identified that Resident #90 complained of pain to the toes and heels. Interventions included skin prep applied to the heels and off -loading by suspension with a wedge. Further review of facility documentation identified that an alternating pressure mattress (APM) mattress was implemented on 2/6/14. The nurse's note dated 2/7/14 identified that Resident # 90's heels were being off loaded with a blanket. A nurse's note dated 2/12/14 identified that the legs were elevated while he/she utilized a recliner due to lower extremity [MEDICAL CONDITION]. The nurse's note dated 2/16/14 identified a 1 CM by 1 CM opened area on Resident #90's right buttocks. Interventions included skin prep and Allevyn to the area. On 2/17/14, the nurse's note identified that there were two opened areas on the resident's coccyx that measured 2.2 CM by 1.2 CM and 2.0 CM by 1.0 CM, and a " non stageable " area that measured 5 CM by 5 CM was also noted on Resident # 90's left heel. The note further indicated that Allevyn dressing was used to treat all the opened areas. Review of the TAR for 2/1/14 to 2/18/14 identified that documentation of the resident's heels being off loaded started on 2/18/14, after the resident's skin was compromised. The weekly skin assessment dated [DATE] through 2/26/14 identified bilateral [MEDICAL CONDITION] and on 2/19/14 a left heel pressure area. Observation on 4/2/14 at 6; 25 A.M. noted that the heel elevator was not in place and the resident stated " I do not want it on and I am not putting it on " . Also the heels were noted on the mattress and left foot eschar was visible. Clinical record review and interview with the DNS on 4/2/14/at 9:40 A.M., identified that the resident was compliant with the utilization of the heel floater; and documentation regarding the use of the heel floater was initiated on 2/18/14 after the left heel was noted to be blackened. Interview and record review with RN #3 on 4/2/14 at 3:10 P.M. failed to provide documentation that the resident's heels were consistently off loaded after [MEDICAL CONDITION]. RN #3 noted that she/he did not think that she/he had to initiate a kardex to reflect that staff was off loading the resident's heels. The interview further identified that RN#3 had worked in the acute care setting and that would have been duplication of care and documentation. Interview with LPN#7 on 4/2/14 at 3:47 P.M. indicated that she/he completed wound training through the facility's corporation wound program. LPN #7 verbalized that she/ he believed that a " stage 2 pressure ulcer can have slough in there". 3. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing Admission assessment dated [DATE] identified the resident had a knee immobilizer on the right leg and skin was intact. Braden Scale Pressure Sore Risk assessment dated [DATE] identified the resident was a high risk for pressure ulcer development. The admission care plan dated 12/21/13 identified the resident was at risk for pressure sore development. Interventions included off load heels in bed, turning and repositioning per facility policy. The admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance from one person for bed mobility, was at risk for pressure ulcers and had no pressure ulcers on admission. The RCP updated 1/6/14 identified to elevate heels while in bed and weekly body audits The December treatment Kardex for 12/21/13 through 12/31/13 failed to document that the resident's heels were off loaded. The January 2014 treatment kardex failed to document that the right heel was off loaded as per care plan. The facility's Skin/Wound Tracking Record dated 1/26/14 identified that Resident #49 had developed a stage 2 area on the right Achilles that measured 1 CM by 1.5 CM with no depth. A physician's progress note dated 1/26/14 identified a 1 CM x 2 CM shallow, second degree skin ulcer where the resident's splint ended. Further documentation identified the skin ulcer was from pressure and the licensed staff was directed to discontinue the immobilizer and use ace wraps. The physician's orders [REDACTED]. Nursing notes dated 1/26/14 identified the resident complained of pain in the lower right leg, sock removed and open wound stage 2 pressure sore 1CM x 0.75 CM on the right Achilles was documented. Skin Wound tracking record dated 1/26/14 identified on the right distal leg/ right Achilles 1CM x 1.5 CM red with yellow color (Stage 2). Review of Weekly Body Audits identified 1/20/14 body audit was not completed prior to skin breakdown on 1/26/14. Nurse's notes dated 2/26/14 identified a new 1.5 CM x 3 CM purple area noted on the left heel. Although the left lower extremity was elevated on a pillow, no off-loading of the heel was documented as being done. Review of weekly body audits dated 2/17/14 and 2/24/14 failed to be completed because the resident was already out of bed in the wheelchair and dressed. Skin Wound tracking Record dated 2/26/14 identified a left heel deep tissue injury which measured 1.5 CM x 3 CM purple in color with comments off load heels. physician's orders [REDACTED]. Interview and review of the clinical record and the TAR, with the DNS on 4/3/14 at 11:45 A.M. failed provide documentation that the resident's heels were off loaded prior to the development of the pressure sore. Further interview identified that the facility was aware there was a problem with prevention and not offloading of heels. According to facility wound prevention in part identified to use pillows to elevate heels while in bed and or other pressure reducing devices for feet in bed, weekly skin audits should be completed on bath/ shower day. Interview with MD #1 4/3/14 identified that the pressure ulcers on the heels were caused by not off-loading the heels. 4. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No open areas/stage 2 pressure sores were noted. The hospital documentation dated 3/15/14 identified that Resident #32 had a Deep Tissue Injury (DTI) on the right coccyx that measured 2 CM by 0.5 CM with no depth and noted a stage 2 area on the coccyx that measured 0.3 CM by 0.1 CM with no depth. physician's orders [REDACTED]. The initial physician order [REDACTED]. A Skin/Wound Tracking record dated 3/15/14 identified a stage II pressure ulcer on the right coccyx/right buttock that measured 1.0 CM by 0.5 CM and an opened DTI that measured 0.5 CM by 0.5 CM. The initial RCP dated 3/15/14 directed staff to complete treatment ordered, turn and reposition every two hours, off load heels, pressure redistribution mattress/chair cushion, body audit weekly and alternating pressure mattress. The Skin/Wound tracking/assessment record dated 3/15/14, 3/18/14 and 3/26/14 identified that the wound measurements were completed by LPN #5 without the benefit of an RN assessment and / or signature. Interview with RN #1 on 4/2/14 at 12:10 P.M. identified that an RN should sign the pressure ulcer assessment either on the tracking sheet or somewhere in the narrative nursing notes. Interview with the DNS on 4/3/14 at 11:00 A.M. identified that although she/he is responsible for overseeing the wound care program in the facility, she/he does not see every wound every week. The DNS stated that the facility continued to stage the right coccyx area as a DTI because that is how the hospital staged it on admission. Review of the policies with the DNS noted that the facility wound protocol failed to direct RN oversight of wounds. Additionally, although the documentation of the resident's wound on 3/15/14 identified an " open DTI " , the facility protocols direct that a DTI is a purple or maroon localized area of discolored, intact skin or blood filled blisters due to damage of underlying soft tissue from pressure and/or sheer. b. Observation on 4/2/14 with LPN #3 of the resident's buttock identified an Allevyn on Resident # 32's coccyx dated 3/31/14. The April 1, 2014 through April 3, 2014 Treatment Administration Record (TAR) failed to direct any treatments including Allevyn be applied to the resident's coccyx and/or right buttock. The treatment orders for Resident #32's pressure areas were not transcribed onto the April 2014 TAR. Interview and clinical record review with LPN#3 (the treatment nurse) on 4/2/14 at 11:15 A.M., noted he/she was unaware that Resident #32 had an open area on the coccyx and LPN#3 could not find any treatments listed on the TAR. Interview with LPN#4 on 4/2/14 at 11:40 A.M. identified that on 4/1/14 he/she removed the Allevyn from Resident #32's buttock, cleansed the area with Saline, measured the area, applied skin prep and reapplied the soiled Allevyn dated 3/31/14 because it was not due to be changed. Interview with DNS on 4/2/14 at 11:45 A. M. identified that LPN #4 should have discarded the soiled dressing and reapplied a new dressing. 5. .Resident # 63's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with ADLs, noted limited assistance for eating, was unable to ambulate, continent of bowel and bladder, had one stage 2 pressure ulcer and one unstageable pressure ulcer. Braden scale dated 3/6/14 identified a score of 16. ( Total Score of 12 or less represents high Risk). A nursing admission note dated 3/6/14 identified the resident had a 3 CM x 3 CM eschar area to right heel and a 0.5 CM x 1 CM stage 2 pressure ulcer to the left buttock/coccyx area. The facility's Skin/Wound Tracking record dated 3/19/14 and 3/26/14 identified the resident's right heel wound as a black intact Deep Tissue Injury (DTI) measuring 3 CM x 3 CM with interventions to offload heels and utilize multipodus boots. A Pressure Ulcer Tracking sheet dated 3/6/14 identified a stage 2 coccyx area measuring 2.5 CM x 0.1 CM. A second Pressure ulcer tracking sheet dated 3/6/14 (same date as above with conflicting measurements) identified a stage 2 coccyx wound measuring 0.5 CM x 0.5 CM with interventions to utilize Allevyn and reposition every 2 hours. A skin/wound tracking record dated 3/19/14 identified the left buttock/ coccyx area as a superficial pink with yellow stage 2 measuring 0.5 CM X 0.5 CM excoriated area with interventions to utilize Alleyvn. A skin wound tracking record dated 4/2/14 identied the coccyx wound as a stage 2 measuring 0.3 CM x 0.8 CM excoriated pink area with yellow skin. A physician's orders [REDACTED]. Observation of Resident # 63's coccyx wound on 4/3/14 identified a reddened area containing three areas of excoriation with a moderate amount of yellow drainage on the dressing ( question if yellow drainage was [MEDICATION NAME]) The wound was cleansed with Normal Saline, [MEDICATION NAME] and Allevyn was applied. Interview with the DNS on 4/3/14 at 10:10 A.M. identified that the wound description of pink with yellow was interpreted as a superficial wound with slough. He/She further identified that wound descriptions and measurements were not consistently accurately described. Interview with Assistant Director of Nursing ( ADNS) on 4/3/14 at 12:10 A.M. identified that there was a total of three small excoriated wounds that contained slough. :

Based on review of the clinical record, review of facility documentation and interview for one of four sampled resident's reviewed for accidents (Resident #172), the facility failed to ensure a safe transfer resulting in a fall. The findings include: Resident #172's [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE] identified the resident was disoriented to person, place and time, and required the assistance of two persons for transfers and ambulation. A Fall Risk assessment dated [DATE] identified the resident was at risk for falling. The Admission Care Plan dated 6/18/13 and the Nurse's Aide Care Card directed the staff to provide the assistance of two with a walker for transfers and ambulation. Nurse's Notes dated 6/23/13 identified that at 9:45 A.M. while NA#1 was transferring the resident from a recliner to a standing position, the resident lost his/her balance and fell to the floor landing on his/her buttocks. The resident then tipped backwards, rolled on his/her left shoulder, hitting his/her head on the bed frame. The resident complained of severe pain in the left shoulder and was unable to attempt Range of Motion (ROM). The Physician was notified and ordered a stat X-ray of the left shoulder. A Radiology Report dated 6/23/13 identified no fracture or dislocation seen. An Orthopedic Consult dated 7/1/13 identified a left shoulder rotator cuff tear and recommended an MRI. Nurse's Notes dated 7/11/13 identified the resident was discharged home with medication and services in place. A Magnetic Resonance Imaging (MRI) report dated 7/25/13 identified a clinical history of pain, decreased ROM and a rotator cuff tear related to a fall. The results of the study identified moderate arthritic changes, a rotator cuff tear, and a likely tear of the long head of the biceps tendon. Interview, review of the clinical record, and facility documentation on 4/1/13 at 12:00 P.M. with the DNS identified that the NA responded to the resident's urgent request to go to the bathroom and failed to call for assistance. Interview and review of facility documentation on 4/1/14 at 2:30 P.M. with NA#1 identified that the resident was calling out and urgently needed to go to the bathroom. NA#1 was aware that the resident required the assistance of two but did not have time to call for help and transferred the resident independently. NA#1 received a written warning for not following the resident's RCP.

Based on review of clinical records, facility policy, observations, and interviews, for one of one resident who failed to receive two separate antibiotics for nine days after admission (Resident #158), and/or failed to discontinue a [MEDICATION NAME] in accordance with physician's orders [REDACTED]. 1. R # 158 was admitted on [DATE]. [DIAGNOSES REDACTED]. Additionally, R # 158 had a wound vac and two J.P. (Jackson Pratt) drains to the left groin. The discharge summary dated 9/7/10 identified the possibility of antibiotic therapy, however the physician was awaiting the results of the cultures, and the physician will write the recommendations for antibiotics. Nurse's notes dated 9/7/10 at 6:00 PM identified R # 158 was admitted to the facility. The left groin area was assessed, and noted to have 3 incision areas open to air with staples intact. The wound vac was applied as ordered. At 8:00 PM the resident was seen by the physician. Further review of the nurse's notes dated from 9/8/10 through 9/16/10 at 10:00 PM identified wound vac intact and functioning. Nurse's notes dated 9/16/10 at 10:30 PM identified the resident's temperature was 100.6 degrees Farenheit (F), blood pressure 122/60, pulse 64, respirations 20, and the resident had shaking chills. Also it identified that the wound vac was intact draining copious amounts of fluid into canister. Physician and family were notified and R #158 was sent to the hospital. An investigative report dated 9/17/10 identified a transcription error and omission of 2 medications since admission (9/7/10) [MEDICATION NAME] 250 milligram (mg) twice a day, and [MEDICATION NAME] 100 mg twice a day for 3 months. Additionally, the omission was identified when a nurse from the hospital called to inquire about the resident's antibiotics. The documentation further identified the medications were added to the W-10 that came with the resident and not on the faxed copy sent to the facility before the resident was admitted . Interview with LPN #3 on 9/24/10 at 10:25 AM stated that on 9/17/10 at 4:30 AM the nurse from the hospital called to inquire about R # 158's antibiotics, stating that they were not on the paperwork from the facility. LPN #3 further stated that she was not aware that R # 158 was on antibiotics until she checked the admission paperwork (9/7/10) the resident came in with. Interview with RN # 2 on 9/22/10 at 9:30 AM identified R # 158 had a temperature, chills and was shaking, and the wound vac canister had to be changed because it was draining copious amouts of fluid. The physician was notified and R # 158 was sent to the hospital after failed to receive antibiotics for a ten day period. Additionally, RN # 2 stated it was a very busy night when the resident was admitted and did not have time to review the admission paperwork, and the ADNS had already completed the physician orders [REDACTED]. Review of R # 158's discharge summary dated 9/21/10 identified a left groin infection with wound vac, antibiotic therapy was started in hospital and continued back at nursing facility. Interview with the DNS and ADNS on 9/21/10 at 12:50 PM identified that prior to a resident admission to the facility, the Admission Coordinator will call the hospital and ask for them to fax a W -10 to the facility. When that is received either the DNS or ADNS write the physician orders [REDACTED]. The DNS stated that the RN Supervisor did not review the admission paperwork upon admission and the medications were omitted for 9 days. 2. Resident # 166 ' s [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The physician's orders [REDACTED]. The MAR for April 2010 lacked documentation that the resident ' s [MEDICATION NAME] 37 mcg patch had been discontinued on 4/4/10 as directed by the physcian. A nurse ' s note on the 11:00 PM-7:00 AM shift dated 4/6/10 identified that Resident # 166 was lethargic, respirations moist 4-6 per minute (normal rate 12 to 20 breaths per minute), the resident showed no restlessness or discomfort. Facility documentation dated 4/6/10 identified that Licensed Practical Nurse (# 2) on the 11:00 PM-7:00 AM shift found Resident # 166 with two [MEDICATION NAME]es, a total of 37 mcg in place. Facility documentation dated 4/6/10, additionally noted that Resident # 166 was sedated and lethargic, the [MEDICATION NAME]es were removed, the physcian was notified and that the staff was directed to hold the resident ' s AM dose of [MEDICATION NAME] (MS)[MEDICATION NAME](Pain [MEDICATION NAME]) 15 mg if sedated. The nurse ' s notes dated 4/6/10 recorded at 2:45 PM identified that Resident # 166 was noted with increased respirations increased in labor remaining at 4 minutes / per breathe, that the resident was using accessory muscle to breathe and that staff administered [MEDICATION NAME] (pain medication) for respiratory discomfort. The nurse ' s notes dated 4/6/10 recorded at 3:10 PM. identified that the licensed staff was called to the resident ' s room by a nurse aide, the resident ' s family was present and that the resident ' s respiration ceased, pupils were fixed and dilated and that the resident had no pulse. Interview with the Director of Nursing on 9/16/10 at 3:00 PM identified that Licensed Practical Nurse # (3) failed to remove the [MEDICATION NAME]es on 4/4/10 as directed by the physician. Interview with LPN # (2) on 9/20/10 at 12:15 PM identified that on 4/6/10 on the 11:00 PM -7:00 AM shift while she/ he was assisting a nurse aide to reposition Resident # 166 he/she discovered [MEDICATION NAME]es two, totally 37 mcg. Interview with LPN # (3) on 9/20/10 at 1:30 PM identified that he/ she did not remove the [MEDICATION NAME] 37 mcg patches on 4/4/10 as directed by the physcian. LPN # 3 on 9/20/10 stated that he/ she could not find the [MEDICATION NAME]es on Resident # 166 chest and that he/ she did not reposition the resident to look for the patches because the resident was in pain. Interview with LPN # (3) on 9/20/10 at 1:30 PM identified that he/ she did not remove the [MEDICATION NAME] 37 mcg patches on 4/4/10 as directed by the physcian. LPN # 3 on 9/20/10 stated that he/ she could not find the [MEDICATION NAME]es on Resident # 166 chest, that he/ she did not reposition the resident to look for the patches because the resident was in pain, that he notified LPN # 4 on the evening shift that he/ she could not find the [MEDICATION NAME]es and requested that LPN # 4 look for patches. Additionally, LPN # 3 stated that he/ she did not inform the supervisor that he/ she could not locate the [MEDICATION NAME]es applied on 4/3/10.