Every finding on record at Apple Rehab Mystic

Based on observations, review of clinical records, review of facility policy/procedures and interviews for two sampled residents (Resident #24, #26) who were observed with medications at the bedside, the facility failed to ensure medication was administered according to professional standards and for two sampled residents (Resident #13 and Resident #31) on methadone maintenance, the facility failed to ensure the medication orders were accurately transcribed into the electronic health record. The findings include: Resident #13's diagnoses included opioid dependence, and chronic osteomyelitis. Observation of medication administration on 5/7/26 at 8:14 AM identified RN #5 administered Methadone liquid 80 mg to Resident #13. RN #5 broke the seal on the bottle and Resident #13 was able to hold the bottle and drink the contents. The methadone comes pre-poured, pre-measured and the sealed bottles are marked with the resident's name, the concentration and dose of the methadone and the day for administration. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #13 had intact cognition, required set-up or clean-up assistance with eating and oral hygiene, had frequent pain and was taking antidepressant and opioid medications The care plan dated 2/27/26 identified Resident #13 was on methadone maintenance for a history of substance use disorder with interventions to provide resident with methadone dose as ordered, resident to self-administer methadone, monitor for any adverse effects of methadone administration and report to MD and encourage resident to immediately report any cravings for illicit substances. Physician's order dated 3/16/26 directed administration of Methadone HCL oral tablet 10 mg, give 80 mg by mouth one time a day for chronic pain and give 80 mg by mouth only for substance use for 1 day. Review of the Methadone chain of custody record (received from the Methadone program) dated 4/27/36 to 5/10/26 identified the medication as methadone 10mg/ml concentration at a dose of 80 mg and received 14 doses. The record was signed by the nurse and the resident each day of administration. Review of the Medication Administration Record (MAR) dated March, April and May 2026 identified administration of Methadone oral tablet 10 mg daily from 3/17/26 through the observed administration on 5/7/26. Further review of the clinical chart identified the physician's order dated 1/12/26 and discontinued 3/16/26 directed the administration of Methadone HCL oral tablet 10 mg give 70 mg by mouth one time a day for chronic pain and give 70 mg by mouth one time only for chronic pain until 1/12/26. Resident #31 was receiving Methadone for opioid maintenance and received liquid methadone as provided by the Methadone program. Interview with RN #5 on 5/7/26 at 8:25 AM identified facility physician's order was for administration of Methadone tablet 10 mg for 80 mg by mouth one time a day. RN #5 identified that she looked at the administration dose of 80mg and verified that the total dose matched the dose being administered but did not notice that the form ordered was for tablets and not the liquid that was administered. RN #5 indicated that the medication was pre-poured and not supplied by the facility but did identify that the administration of medications should match the physician's order. Interview with the DNS on 5/7/26 at 8:40 AM identified medications should be administered as ordered. The DNS indicated that the methadone was obtained from a community program and residents were able to self-administer the medications. The DNS identified that orders are entered into the physician orders by the RN supervisors or whomever is taking the order or doing the admission and should be entered as ordered. The DNS identified the RN supervisors were expected to verify the orders and indicated the facility had fixed some incorrect orders and was not aware there were other incorrect orders. Additionally, the DNS indicated that the methadone is only supplied in liquid form. Interview with the Director of Quality and Compliant and the Director of Nursing for the community Methadone program (who supplies the methadone for the facility) on 5/8/26 at 10:32 AM identified the administration of the methadone should be exactly as indicated on the bottle that is provided for the resident. The Director of Nursing indicated that the concentration supplied is 10mg/ml, meaning 10 mg of active medication is in 1 ml of liquid provided, and identified that the physician order should reflect the correct concentration and dose that is ordered and being provided. They identified that the facility is provided a chain of custody signature sheet that requires the nurse and resident to initial for each administration that is returned to the community program when completed. Interview with the Medical Director on 5/8/26 at 12:48 PM identified his expectations for medication administration was that the proper dose and proper form and resident with the expectation that nursing are following nursing 101 standards and are doing their jobs correctly. The facility policy for medication administration identified medications must be administered only with a valid physician's order and should be documented clearly and include the resident's name, medication name, dosage, route, frequency, and duration. The policy identifies preparation for administration to verify the physician's order against the medication administration record and ensure the right resident, right medication, right dose, right route and right time and administer as per the right route. The facility policy for Methadone Maintenance identified the dose identified on the Methadone chain of custody record should match the individual bottles and should be compared to the current physician's orders for methadone and indicated that any discrepancies must be verified with the clinic and physician. The policy identified prior to administration, the licensed nurse will verify correct name, date and dose on the methadone bottle to the MAR and Methadone Administration worksheet. Resident #31 was admitted to the facility in April 2025 with diagnoses including pyogenic arthritis, opioid dependence and nicotine dependence. The quarterly MDS dated [DATE] identified Resident #31 had intact cognition, was independent with eating and oral hygiene, used corrective lenses (glasses) to see and received opioid medication. The care plan dated identified Resident #31 received methadone maintenance for a history of substance use disorder with interventions to provide resident with methadone dose as ordered for self-administration and to monitor for any adverse effects of methadone administration and report to MD/APRN. Physician's orders dated 4/2/25 (started) through 11/26/25 (discontinued) directed administration of Methadone HCL oral solution 10mg/5ml (concentration) with directions to administer 5 ml by mouth one time a day related to opioid dependence. At this concentration 5 ml would be a 10 mg dose. Review of facility Accident/Incident report dated 11/12/25 identified Resident #31 was administered the incorrect dose of Methadone. Resident #31 was administered (by LPN #1) Methadone 10mg/ml (concentration) at a dose of 100 mg, prescribed to a different resident. The report identified the nurse who administered the medication did not verify the medication label and received re-education on reading the methadone bottle labels. Review of the in-service form dated 11/12/25 identified LPN#1and an RN supervisor reviewed the medication administration policy. Review of Methadone chain of custody record dated 11/10/25 to 11/23/25 identified supply of Methadone 10 mg/ml (concentration) with a dose of 53 mg. Physician's order dated 11/26/25 (started) through 3/10/26 (discontinued) directed administration of Methadone HCL oral solution 10mg/5ml give 48 mg by mouth one time a day related to opioid dependence. At this concentration 48 mg would be 24 ml of liquid for administration. Review of the Methadone chain of custody record dated 11/24/25 to 12/7/25 identified supply of Methadone 10mg/ml (concentration) with a dose of 48 mg and initialed by Resident #31 and the staff administering the medication 11/24/25 through 12/7/25. At this concentration 48mg would be 4.8 ml of liquid. Physician's order dated 3/11/26 (started) through 3/16/26 (discontinued) directed administration of Methadone HCL oral solution 10mg/5ml give 44 mg by mouth one time a day related to opioid dependence. At this concentration 44 mg would be administered in 22 ml. Physician's order dated 3/16/26 (started) through 3/24/26 (discontinued) directed administration of Methadone HCL oral solution 10mg/5ml give 42 mg by mouth one time a day related to opioid dependence until 3/22/26 AND give 40 mg by mouth one time a day for opioid use and give 42 mg by mouth one time only for opioid use for 1 day. Review of the Medication Administration Record (MAR) from 4/2/25 through 3/24/26 identified the sign off of the administration of Methadone in the ordered concentration of 10mg/5ml and did not correspond with the concentration listed on the Methadone chain of custody record or the concentration on the medication bottles on hand. Review of the clinical chart identified the Methadone order was input incorrectly from the time of Resident #31's admission and although there was a medication error and the process was reviewed. However, the order continued to identify the concentration as 10mg/5ml and not the correct concentration as supplied by the methadone clinic of 10mg/ml. Interview with LPN#1 on 5/6/26 at 11:15 AM identified if the medication was signed off in the MAR by her, then she administered that medication. LPN#1 could not identify the discrepancy between the physician's order and the medication administered. Interview with the DNS on 5/7/26 at 8:40 AM identified medications should be administered as ordered. The DNS indicated that the methadone was obtained from a community program and residents were able to self-administer the medications. The DNS identified that orders are entered into the physician orders by the RN supervisors or whomever is taking the order or doing the admission and should be entered as ordered. The DNS identified the RN supervisors were expected to verify the orders and indicated the facility had fixed some incorrect orders and was not aware there were other incorrect orders. Additionally, the DNS indicated that the methadone is only supplied in liquid form. Interview with the Director of Quality and Compliant and the Director of Nursing for the community Methadone program (who supplies the methadone for the facility) on 5/8/26 at 10:32 AM identified the administration of the methadone should be exactly as indicated on the bottle that is provided for the resident. The Director of Nursing indicated that the concentration supplied is 10mg/ml, meaning 10 mg of active medication is in 1 ml of liquid provided, and identified that the physician order should reflect the correct concentration and dose that is ordered and being provided. They identified that the facility is provided a chain of custody signature sheet that requires the nurse and resident to initial for each administration that is returned to the community program when completed. Interview with the Medical Director on 5/8/26 at 12:48 PM identified his expectations for medication administration was that the proper dose and proper form and resident with the expectation that nursing are following nursing 101 standards and are doing their jobs correctly. The facility policy for medication administration identified medications must be administered only with a valid physician's order and should be documented clearly and include the resident's name, medication name, dosage, route, frequency, and duration. The policy identifies preparation for administration to verify the physician's order against the medication administration record and ensure the right resident, right medication, right dose, right route and right time and administer as per the right route. The facility policy for Methadone Maintenance identified the dose identified on the Methadone chain of custody record should match the individual bottles and should be compared to the current physician's orders for methadone and indicated that any discrepancies must be verified with the clinic and physician. The policy identified prior to administration, the licensed nurse will verify correct name, date and dose on the methadone bottle to the MAR and Methadone Administration worksheet. Resident #24's diagnoses included depression, hypochondriasis, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #24 was cognitively intact, was independent with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident ambulated and utilized a walker for mobility. The care plan dated 4/3/26 identified Resident #24 was at risk for changes in mood state related to anxiety and depression with interventions that included offer emotional support to me and my family as needed, offer to involve me in making my own schedule/sequencing of activities, provide medication as per my physician orders. Physician's orders for May 2026 directed ascorbic acid oral tablet 500mg give 500mg by mouth three times a day for supplement, vitamin B-12 oral capsule 1000mcg two times a day for supplement, vitamin D3 1000mcg tab by mouth daily once a day for vitamin deficiency, and Klonopin oral tablet 0.5mg give 1 tablet by mouth two times a day for anxiety. Observation on 5/4/26 at 10:20AM identified 4 medications located on the bedside table in a clear medication cup. Two white round pills, one pink round pill, one yellow round pill. Resident #24 was walking over to her bed and went to sit down on the bedside with the bedside table in front of the resident. Interview on 5/4/26 at 10:20AM with Resident #24 identified that the nurse had left them for him/her because the nurse knew he/she would take them eventually. Interview on 5/4/26 at 10:25AM with RN#4 identified she passed medication to Resident #24 and believed that the resident took the medication as she thought she saw the resident put the medication up to her mouth before turning around to prepare the medication for the roommate. However, RN#4 identified she did not watch Resident #24 swallow the medication like she should have. RN#4 further identified that Resident #24 did not have an order for self-medication administration. She believes there may be one for nose spray and maybe some creams however that was it. RN#4 identified one white round pill to be vitamin D3, the other white round pill to be ascorbic acid, the pink round pill to be vitamin b12, and the yellow round pill to be Klonopin. Interview on 5/4/26 at 10:35AM with the DNS identified medication should not be left at the bedside for a resident and that Resident #24 did not have a self-administration for pills. She noted that the nurse should have stayed with the resident to complete the medication administration. Review of Resident #24's self-administration of medication dated 4/8/26 identified the resident was approved to self-administer nasal spray, ketoconazole shampoo, and ketoconazole cream, no pills were identified. Review of the medication administration policy directed to prepare medication for one resident at a time to minimize errors, to administer medication as per the prescribed route, observe the resident for any adverse reactions for side effects and document the administration in the MAR immediately after giving the medication. Resident #26 had a diagnosis of fracture of the right humerus. The quarterly MDS assessment dated [DATE] identified Resident #26 was cognitively intact, supervision or touching assistance with bed mobility, transfers, personal hygiene and partial/moderate assistance with dressing. Resident #26 utilized a walker for ambulation. The care plan dated 4/20/26 identified Resident #26 had gastro-esophageal reflux disorder (GERD) and may experience heartburn, regurgitation, and/or nausea. Interventions directed encourage to remain upright after meals for at least 30 minutes, medications as ordered, watch for increase in nausea symptoms, heartburn, regurgitation, and report to MD/APRN. Observation on 5/4/26 at 10:23 AM identified a large yellow round tablet in a clear medication cup on the bedside table. Resident #26 was not in the room. Interview on 5/4/26 at 10:30AM with RN#4 identified the tablet in the clear medication cup at the bedside to be Tums. RN#4 identified that she did not pass any Tums to the resident and that it must have been given by someone else. Interview on 5/4/26 at 11:30AM with Resident #26 identified he/she received the Tums from the nurse following an upset stomach a few days ago after eating some dessert from a family member. Resident #26 did not recall which nurse they were from. However, did not take the tums and ended up taking Pepto Bismol because he/she thought it would work better. Physician's order dated May 2026 failed to identify an order for Tums listed in the medication order. Review of the MAR for May 2026 identified Resident #26 received Pepto Bismol oral solution 30ml every 6 hours as needed for heartburn, indigestion, diarrhea, gas and upset stomach. Interview on 5/4/26 at 10:35AM with the DNS identified medication should not be left at the bedside for a resident and that Resident #26 did not have a self-administration for pills nor can they self-administer. Interview on 5/5/26 with LPN #10 at 10:45AM identified she did give the resident Pepto Bismol but did not recall giving the resident Tums. LPN #10 identified the resident had an upset stomach after eating some food brought in by a family member. Review of the medication administration policy directed medications must be administered only with a valid physician's order. Orders should be documented clearly and include the resident's name, medication, dosage, route, frequency, and duration. Document the administration in the MAR immediately after giving the medication.

Based on observation, review of facility documentation, review of facility policy/procedure and interviews, facility failed to ensure a comprehensive system to account for the reconciliation of all controlled medications. The findings include: Observation of the emergency supply of controlled medications with RN #4 on 5/5/26 at 2:40 PM identified thirty-two controlled medications that were not resident specific but were house stock medications. Nine of the thirty-two medications were taken from the house stock medications and administered to residents. Observation of the sign-off sheets (the white copy of the Control Drug Record) for the medications failed to identify the resident the medication was administered to on several days. The administered medications were signed off as follows: Oxycodone 5mg tablet was administered on 4/23/26 (2 administrations) that did not list a resident to whom it was administered.Oxycontin 10 mg tab ER 1st dose administered was not designated for a resident.Diazepam 2 mg tablet administration on 11/6/25 not signed out to a resident.Oxycodone 10 mg administrations on 2/2/26, 2/18/26 and 2/19/26 administrations not designated to residents.Lorazepam 0.5 mg tablet administered 10/20/25 and 10/21/25 not designated to residents.Oxycodone 10 mg tablet administered 4/18/26 not designated to a resident.Alprazolam 1 mg tablet administered 1/21/25 and 1/22/25 not designated to residents.Tramadol 50 mg tablet administered 3/23/26 not designated to residents.Pregabalin 25 mg capsule administered 5/2/26, 5/3/26, 5/4/26, 2/5/26 and 2 additional administrations that the date is not legible, and the administrations were not designated to a resident.Interview with RN #4 on 5/5/26 at 2:45 PM identified that the resident receiving the house stock of controlled medications should be noted on the administration record. RN#4 additionally indicated that there was not a column that identified who was administered the medication and indicated that might confuse some nurses.Interview with the DNS on 5/5/26 at 2:35 PM identified that she has a controlled substance binder with duplicate (yellow) Control Drug Record forms that she takes around the facility biweekly to reconcile the controlled substances in the facility by counting the remaining controlled substances and verifying that all of the yellow Control Drug Records are accounted for in the facility. Additionally, the DNS uses the weekly pharmacy reports to verify delivery of controlled medications in the facility. The DNS indicated that the house stock medication is counted and verified as still in use, but the administrations are not verified. The DNS identified that the best practice would be to sign the residents' names but was not aware of the facility policy. Additionally, the DNS could not identify how the facility is ensuring the controlled substances are being administered to residents with an active order if they are being taken from house stock and signed out without a receiving resident listed.Interview with the Medical Director on 5/8/26 at 12:48 PM identified his expectation is that controlled substances be administered properly with a physician's order and that the nurses were expected to administer medications according to the rules and facility policy.The facility policy for medication administration identified medications must be administered only with a valid physician's order, and for administration, the physician's order should be verified with the resident's medication administration record and the administration documented in the MAR.The facility policy for controlled medication administration identified a controlled medication accountability record is prepared when receiving or checking in a Schedule II, III, IV and V medication information completed included the name of resident, prescription number, name, strength and dosage of medication, date received, quantity received and name of person receiving medication supply. The policy identified that when a controlled medication is administered the licensed nurse administering the medication enters the date and time of administration, amount administered, and signature of the nurse administering the dose. The policy does not speak specifically to house stock medications that are administered to specific residents but identified the DNS was responsible for reconciliation and controlled medication accountability records

Based on observation, review of clinical record, facility policy, facility documentation, and interviews for one sampled resident (Resident #7) reviewed for dialysis, the facility failed to ensure Enhanced Barrier Precautions (EBP) was implemented for a resident with an indwelling medical device and a review of the infection program, the facility failed to ensure the infection surveillance data was obtained and analyzed for trends with documented follow-up activity in response to when trends were identified. The findings include: Resident #7's diagnoses included end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic chronic kidney disease. The significant change MDS assessment dated [DATE] identified Resident #7 had moderately impaired cognition, required partial or moderate assistance with toileting hygiene, dressing and personal hygiene. The assessment further identified Resident #7 receives dialysis treatment.The physician order dated 1/16/26 through May/2026 directed to monitor temporary hemodialysis catheter to the right upper chest for redness, drainage and swelling every shift. Review of the physician order identified an order dated 2/17/26 directed enhanced barrier precautions due to indwelling medical device or fistula graft every shift but was then discontinued on 4/24/26. Observations throughout the survey period from 5/5/26 through 5/7/26 failed to identify a posted signage that identified the need for Enhanced Barrier Precautions (EBP) outside Resident #7's room, which noted the need for everyone to perform hand hygiene before entering and when leaving the room, providers, and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing, showering, device care or care of a urinary catheter.Observation on 5/6/26 at 9:10 AM identified Resident #7 was seated in his/her wheelchair and when asked what site does he/she receives his/her dialysis treatment when he/she pointed to the right upper chest and noted a dressing to the area. Interview with NA #5 on 5/6/26 at 2:00 PM identified that she knows when a resident is on EBP based on the signage posted on the outside of their room along with a cart containing personal protective equipment (PPE) that is placed near the entrance of the room. She further identified there will be an orange sticker placed beside the name of the resident who is on the EBP when there are 2 residents sharing a room. NA #5 further identified if a resident was recently placed on EBP or any precautions, the nurse would them know on report/huddle, but otherwise they used the signage posted on the outside of the room to tell when a resident is on EBP. Review of the EBP list provided by the facility failed to identify that Resident #7 was on EBP. Interview with the Infection Preventionist (RN #2) and Regional Clinical Nurse (RN #7) on 5/7/26 at 2:00PM identified it is the responsibility of the Infection Preventionist nurse to ensure resident with indwelling medical device to be place on EBP. He further identified that staff knows when a resident is on EBP based on the signage posted on the outside of their room, the PPE cart that is placed on the outside of the room, a physician order directing the type of precaution and the resident's care plan. RN #2 identified Resident #7 should have been placed on EBP as he/she has an indwelling medical device, which he/she uses for dialysis. RN #2 further identified that he did not think that Resident #7 had an indwelling medical device and thought the resident uses the fistula site for dialysis. RN #2 identified it was an oversight as the resident previous had an order for EBP. Review of the Enhanced Barrier Precautions policy identified the facility will implement enhanced barrier precautions (EBP) during high-contact resident care activities for those residents per the CDC Novel Targeted MDRO list and indwelling medical devices. The policy further identifies enhanced barrier precautions will remain in effect for the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the medical device that placed them at higher risk, and appropriate signage for EBP will be visible. Review of the Infection Control Surveillance data documentation with the Infection Preventionist (RN #2) and the Regional Clinical Nurse (RN #7) on 5/7/26 at 11:11AM failed to reflect analysis of the infection surveillance data that is tracked monthly for trends and documented follow-up activities in response to the trends for the period of October/2025 through April/2026. Further review of the infection surveillance data report on 5/8/26 with RN #2 failed to identify surveillance data for June/2025 through July/2025. Review of the Antibiotic Facility Summary report provided noted the following identified facility acquired infections which met the infection criteria rate: The records failed to identify monthly surveillance data and infection rate for June/2025 through July/2025. October 2025 a monthly facility acquired infection rate of 5.86.November 2025 a monthly facility acquired infection rate of 2.78.December 2025 a monthly facility acquired infection rate of 6.68.January 2026 a monthly facility acquired infection rate of 4.56.February 2026 a monthly facility acquired infection rate of 2.59.March 2026 a monthly facility acquired infection rate of 2.79April 2026 failed to identify a monthly facility acquired infection rate that was calculated. The records failed to identify an analysis of the surveillance data for any trends in infection type, nor did the report reflect the cause of the increase in the monthly infection rate for various months. Interview and review of the infection surveillance data and monthly infection calculations with RN #2 and RN #7 on 5/7/26 at 2:00 PM identified he would check for trends and discuss the trends at the weekly risk meetings and the quarterly medical staff meetings. However, RN #2 and RN #7 reviewed the reports and failed to identify that a trend was identified and what response was implemented at the time when an increase/trend was identified for the months with an elevated rate. RN #2 further identified he did not document the trends, but it was discussed verbally. When RN #2 and RN #7 were asked what caused the increase in the infection rates for October/2025 and the other months, when they responded that they would have to review the surveillance data to see what caused the increase. When asked if that should be already identified, when they responded the data is on the excel sheet, and they were then asked if it was analyzed and no response was provided. Interview with RN #7 on 5/8/26 at 12:22 PM identified the surveillance data should have being analyzed to identify trends. RN #7 further identified she does not know why the numbers were elevated and RN #2 indicated he discussed it at the quarterly medical staff meeting but moving forward they will document the analysis. Interview with RN #2 on 5/8/26 at 12:56 PM identified that he knows that the surveillance data should be analyzed for trends but on the excel tracking sheet provided it did not include a section for analysis of the surveillance data. RN #2 further identified there were no monthly infection surveillance data for June/2025 and July/2025 and he was not the IP nurse at the time. Review of the Infection Control Criteria Surveillance policy identified tracking and surveillance that the Infection Preventionist (IP) will maintain an infection surveillance log that includes resident names, type of infection, date of onset, diagnostic testing and results as appropriate, treatment and isolation measures as appropriate and outcomes/resolution. The policy further identifies infection trends will be reviewed to identify patterns and opportunities for prevention.

Based on observations, review of clinical records, review of facility policies/procedures and interviews for three sampled residents (Residents #5, #31, #57) reviewed for accidents and/or smoking, the facility failed to ensure appropriate supervision and monitoring to prevent smoking in the facility, failed to ensure the wheelchair leg rests were in place to prevent a fall and failed to ensure equipment was maintained to prevent a fall from a shower chair. The findings include: Resident #5's diagnoses included hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of the left carotid artery, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #5 was severely cognitively impaired, had no behaviors, required substantial/maximal assistance with bed mobility, and transfers, required total assistance for dressing and personal hygiene. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 11/19/25 identified Resident #5 was at risk for falls related to multiple risk factors with interventions that included rehabilitation screen for safe transfers, patient reeducation to use call bell for assistance, and nonskid slipper socks. The APRN note dated 12/15/25 identified Resident #5 fell from a shower chair and sustained a skin tear to the right elbow. The facility Reportable Event report dated 12/15/25 identified that during Resident #5's shower, the shower chair collapsed causing Resident #5 to strike his head, posterior trunk, and sustain a skin tear to the right elbow. The report did not identify interventions regarding shower chair use and did not identify that the shower chair was inspected. Interview with APRN#1 on 5/6/26 at 8:00 AM identified she was present when the shower chair broke. Resident #5 can tend to be behavioral however during the time leading up to and when the chair broke Resident #5 was very calm and there was no moving around or exhibiting any out of the ordinary behaviors at the time. APRN#1 further identified she was able to assess the resident following the witnessed fall and that he/she suffered a skin tear on the right elbow. Interview with the Maintenance Director on 5/7/26 at 12:15 PM identified the maintenance department does not complete regular inspections or maintenance on the shower chairs. They would intervene when a broken issue or repair issue is brought to their attention. There is a log kept for Hoyer lifts and wheelchair scales but not shower chairs. Interview with the Rehabilitation Director on 5/7/26 at 12:30 PM identified that the rehabilitation department does not do regular inspections of shower chairs for the facility. The only shower chair that they utilize is one that they work with residents on in the rehabilitation area. Interview with NA #2 on 5/8/26 at 2:27 PM identified she was with Resident #5 when the shower chair broke. The shower had been completed and APRN #1 had come into the shower room to assess the resident. The shower chair was made of PVC (Polyvinyl Chloride), and it broke at the seams of where it was put together. NA #2 identified that although, she didn't think Resident #5 had been severely hurt it scared her more than anything at what the outcome could have been. Interview with the DNS on 5/7/26 at 12:45 PM identified she completed the investigation for the fall from the shower chair. She could not identify any root cause of why the shower chair broke and identified it as a freak accident. Interview with the Administrator on 5/8/26 at 12:30PM identified she could not locate the age of the shower chair that broke on 12/15/26. There were no receipts of it found. She could only locate the receipt of the purchase of a new shower chair following the incident on 12/15/26. There is no way to tell how old the shower chair was at the time of the accident. Review of the policy for Accident and Incidents directed the DNS or designee to review to determine of any potential risks and interventions that need to be put into place. Review of the policy for Falls directed complete an Accident and Incident report for each fall. Obtain statements for every fall event. Resident #31 was admitted to the facility April 2025 with diagnoses that asthma, opioid dependence, peripheral vascular disease, and nicotine dependence (cigarettes). Physician's progress note dated 4/2/25 at 8:30 AM identified Resident #31 was admitted to the facility with nicotine dependence and indicated there were no changes to management at that time. The initial care plan dated 4/3/25 identified Resident #31 had a substance use disorder related to nicotine use and was actively smoking in the community prior to admission to the facility and indicated Resident #31 had been told and understood the facility was non-smoking and that Resident #31 agreed to not have any smoking materials in his/her possession. Interventions directed to offer a nicotine patch, gum or lozenges, provide resident with smoking cessation materials if requested and provide a copy of the facility's smoking policy. Nursing progress note dated 4/20/25 at 12:13 AM identified Resident #31 admitted to smoking a cigarette in his/her room after staff noted the smell of cigarette smoke in the hallway near Resident#31's room. The note indicated that a room search produced a lighter and Resident #31 was educated on the non-smoking policy. Nursing progress note dated 4/20/26 at 6:54 AM identified Resident #31's sister was educated on the non-smoking policy as she takes Resident #31 out of the facility frequently and was the source of the cigarette. Administrator note dated 4/21/25 at 1:28 PM identified Resident #31 was provided education on the smoking policy, and he/she signed the smoking policy agreement. The admission MDS assessment dated [DATE] identified Resident #31 had moderately impaired cognition, felt down, depressed or hopeless, little interest or pleasure in doing things, and felt tired or had little energy nearly every day of the previous 14 days, required set up or clean up assistance with eating, oral hygiene and utilized a walker for mobility and was independent with transfers and mobility. Physician's progress note dated 5/2/25 at 4:45 PM identified Resident #31 was seen for a regulatory visit and indicated a diagnosis of nicotine dependence with no changes made to the management of the condition. The care plan focus added 11/6/25 identified Resident #31 had a prohibited item violation with interventions to perform room and package search with resident's consent, provide resident with psychiatric and social work and encourage resident to immediately report any cravings for illicit substances. Social Services progress note dated 11/6/25 at 3:16 pm identified Resident #31 had a lighter and cigarette butt confiscated the day before by staff and indicated Resident #31 had denied the occurrence. Social Services progress note dated 11/7/25 at 3:02 PM identified Resident #31 admitted to having a cigarette and lighter. He noted it was without the family member's permission when out on leave of absence. The progress note further indicated that the family member was informed of the incident. Review of Resident #31's clinical record and facility documentation (A&Is) for April 2025 through May 2026 failed to identify any monitoring for prohibited items or follow up with smoking cessation/education and failed to identify any A&Is for the April and November 2025 cigarette incidents. Observation of Resident #31 on 5/4/26 at 11:00 AM identified Resident #31 in the resident bed propped up on pillows and in pajamas. Resident #31's room smelled of cigarette smoke, although there was no visible haze. Resident #31 had the resident room window open. There was a smoke detector on the ceiling inside of the resident room, but no smoking paraphernalia was observed. Interview with Resident #31 on 5/4/26 at 11:12 AM identified Resident #31 smoked cigarettes when out of the facility and indicated that sometimes the smoke smell stays on the resident's clothing when returning to the facility but Resident #31 could not identify if he/she had left the facility that morning and did not answer the direct question of whether or not a cigarette had been smoked that morning. Observation of Resident #31's room on 5/4/26 at 2:04 PM identified a cigarette smell in the room with an observation of the window being open with a slight breeze. Upon opening the bathroom door, there was a strong smell of cigarette smoke with slight haziness noted in the bathroom. There was no smoking paraphernalia observed by this surveyor. Observation with RN #9 (assigned to Resident #31) on 5/4/26 at 2:08 PM of Resident #31's room and bathroom identified the room, and bathroom smelled of cigarette smoke. RN #9 looked through bathroom trash and did not find any smoking paraphernalia. Interview with the Administrator and the DNS on 5/4/26 at 2:13 PM identified they were aware of Resident #31's smoking when out of the building. Interview with the Administrator on 5/4/26 at 3:10 PM identified Resident #31 surrendered a lighter and a cigarette and indicated obtaining items from a family member Nursing progress note dated 5/4/26 at 3:26 PM identified Resident #31 was questioned regarding smoke noted in the resident room and indicated Resident #31 surrendered cigarettes and a lighter. Social Services progress note dated 5/5/26 at 8:03 AM identified Resident #31 refused a referral to a smoking facility, admitted smoking in the facility, and was educated on the facility being a non-smoking facility. Interview with the Maintenance Director on 5/5/26 at 8:54 AM identified he had been in the director position for approximately a year and indicated he placed a smoke detector in Resident #31's bathroom. The Director indicated that Resident #31 identified the ability to smoke outside at a previous facility. Interview with the DNS on 5/5/26 at 11:15 AM identified she worked at the facility as a supervisor since March 2025 and as the DNS since November 2025 and indicated that she recalled some conversation regarding Resident #31 smoking in the facility but was unable to recall specifics. The DNS identified that she did not complete an A&I nor did she investigate or report the smoking incidents from April or November 2025. Interview with the Administrator on 5/6/26 at 12:12 PM identified that when a resident is found smoking or with smoking items, an incident report should be completed, and progressive monitoring should be implemented. Subsequent to surveyor inquiry, the facility implemented a check-off sheet for Resident #31 to be checked for prohibited items when returning from LOA. The Administrator identified that she was not aware of the previous incidents of smoking in the facility and that the supervision should have been implemented sooner. Smoking policy identified the facility was a smoke-free environment for employees, Residents, and visitors. The policy identified smoking as the lighting, smoking or carrying of a lighted cigarette, pipe or cigar and includes the use of smokeless tobacco products such as e-cigarettes and vaping materials and any similar type of products. The facility policy for prohibited items in the environment identified that violations of the prohibited items policy may result in measures to increase the level of supervision to maintain a safe environment, up to and including involuntary discharge at the discretion of administration. The prohibited items list identified that use, distribution, or possession of cigarettes, cigars, pipes, e-cigarettes, vapes, vape liquids, lighters, matches, or other fire sources. The facility policy for prohibited items violation identified that if a resident is found to be in possession of any substances indicated as prohibited items, an accident and incident (A&I) report will be completed for each prohibited item violation and identified the resident's care plan will be updated to reflect current interventions. The policy identified that the facility implements progressive measures to increase the level of supervision to maintain a safe environment and indicated progressive measures such as: Resident may be provided with education/re-education Resident may be asked to consent to random supervised room/package/person searches Resident may be placed on increased frequency of checks, increased monitoring or supervision, including 1:1 observation Resident may be asked to consent to a psychiatric evaluation, if applicable Modification of leave of absence orders. Notification of local law authorities Issuance of an involuntary emergency discharge notice. Resident #57's had diagnoses that included dementia, anxiety osteoarthritis of knee. The quarterly MDS assessment dated [DATE] identified Resident #57 had severely impaired cognition, had no behaviors and required maximal assistance with personal hygiene, transfers, dressing, bed mobility and dependent with toileting hygiene. The assessment further identified Resident #57 was dependent on staff with wheelchair mobility. The care plan dated 2/18/26 identified Resident #57 was at risk for falls due to multiple risk factors with interventions that included, have commonly used articles within easy reach, provide lit, clutter free environment and physical and occupational therapy screen to help increase strength and endurance. The facility's accident and incident report dated 4/11/26 at 12:00 PM identified Resident #57 was in the dining room and slid from the wheelchair to the floor. The report noted Resident #57 had no injuries and there were no witnesses. The fall scene investigation documentation dated 4/11/26 identified the root cause of the fall was lack of footrests on the wheelchair, and the intervention to prevent future falls was to ensure footrests are in place on the wheelchair. RN #1's progress note dated 4/11/26 at 12:18 PM identified Resident #57 was found sitting on the floor of the dining room, directly in front of his/her wheelchair and RN assessment showed no change to the skin, denial of pain, range of motion at his/her baseline and staff assist to return resident to his/her wheelchair. Interview with the Director of Rehabilitation (OT #1) on 5/5/26 at 12:00 PM identified Resident #57 does not self-propel so he/she would need the footrest/leg rest in place when transported by his/her wheelchair. OT #1 indicated on evaluation after the fall identified resident was noted to not have the footrest/leg rest on the wheelchair at the time of the fall. She further identified the purpose of the footrest for Resident #57 is for support and keeping the resident upright, given that the resident has poor posture he/she would need the footrest on while seated in the wheelchair. When asked if the fall would have been prevented if the footrests were in place, OT #1 responded that it is less likely Resident #57 would have slid/fallen from the wheelchair. Interview with the DNS in the presence of the ADNS and the Regional Clinical Nurse (RN #7) on 5/5/26 at 12:38 PM identified Resident #57 slid out of his/her wheelchair when he/she was trying to pick something up. The DNS further identified that the footrest/leg rest was not in place and the resident should have had the footrest in place on the wheelchair while in the wheelchair and transporting. Interview with NA #2 on 5/6/26 at 1:45 PM identified she was made aware that Resident #57 had fallen from the wheelchair because the resident did not have the footrest/leg rests in place. NA #2 further identified Resident #57 is unable to self-propel in the wheelchair, so the footrest/leg rests needed to be in place when transporting the resident and while he/she is seated in the wheelchair. Interview with the Nursing Supervisor (RN #1) on 5/6/26 at 2:04 PM identified she was the supervisor on duty when the resident fell on 4/11/26 and noted the resident was seated on the floor in front of the wheelchair with no leg rests in place. Review of the Chair/Wheelchairs policy and procedure identified resident will be provided with appropriate seating to maintain comfort, body alignment and promote maximum level of functioning. The procedure identifies to transfer the resident to the wheelchair and adjust, assure extremities are supported. The procedure further identifies that the leg rests are used if the resident is unable to self-propel wheelchair. The facility failed to ensure routine maintenance inspections of the shower chairs were conducted and failed to implement a plan to inspect the shower chairs following the collapse of the wheelchair where Resident #57 sustained minor injuries.

Based on review of the clinical record, review of facility policy/procedure and interviews for 1 of 2 sampled residents (Resident #6) reviewed for Range of Motion, the facility failed to ensure the care plan was reviewed and revised to reflect the resident status. The findings include:Resident #6 was admitted to the facility October 2025, originally and re-admitted after a hospital admission March 2026, with diagnoses that included Parkinson's disease with dyskinesia with fluctuations, polyneuropathy, diabetes mellitus, anxiety and depression.The Significant Change Minimum Data Set (MDS) dated [DATE] identified Resident #6 had intact cognition, had impairment on one side lower extremity, use of a wheelchair, dependent for transfers and substantial/maximal assistance with eating and oral hygiene and was taking anticoagulant and antiplatelet medication.The care plan dated 4/14/26 identified Resident #6 had a potential for adverse effects of psychotropic drug use with directions to monitor for side effects of use of the medication in addition to behaviors that would require the medication.The care plan identified monitoring of hypothyroidism and adverse effects including hair loss, fatigue, dry skin, intolerance to cold, mental status changes, decreased BP or heart rate and weight gain but failed to identify high risk medication use for the condition and monitoring of use of levothyroxine including hyperthyroidism including rapid heart rate, insomnia, nervousness, weight loss, and sweating.The care plan additionally identified a risk for cardiac issues (Heart attack, chest pain, stroke) related to cardiovascular disease, Atrial Fibrillation (AFIB), (CAD), Hypertension or high blood pressure (HTN) and Hyperlipidemia or high cholesterol (HLD) with monitoring of symptoms associated with the condition but failed to identify monitoring for side effects of medications used to treat these conditions including Apixaban, a blood thinner.The care plan identified monitoring of pain but failed to identify monitoring of side effects of medications used to treat the pain including oxycodone and gabapentin.The care plan identified monitoring of Parkinson's Disease and complications with interventions to provide medications as ordered but failed to identify monitoring side effects of administered medications including Carbidopa-Levodopa.The physician's orders dated 4/21/26 directed administration of:Apixaban oral tablet 5mg by mouth two times a day for AFIBLevothyroxine Sodium Oral tablet 125 mcg by mouth one time a day related to hypothyroidism.Oxycodone HCL oral tablet 5 mg by mouth every 6 hours as needed for pain related to left femur fracture.Gabapentin oral capsule 300 mg three times a day for neuropathyCarbidopa-Levodopa oral tablet 25-100 mg by mouth three times a day for Parkinson's Disease.Interview with the DNS on 5/8/26 at 12:15 PM identified Resident #6 should have a care plan that reflects the monitoring of all of the prescribed medications. The DNS indicated that medications would be included in the baseline care plan and then reviewed during the care plan meeting and placed into the comprehensive care plan. The DNS identified the MDS coordinator was ultimately responsible for putting the items into the care plan.Interview with the MDS Coordinator (RN#6) on 5/8/26 at 1:45 PM identified that high risk medications should be care planned for monitoring use and side effects and indicated that blood thinners, pain and thyroid medication should be represented in Resident #6's care plan.The facility policy for care planning identified a comprehensive care plan based on the identified needs to guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing.The facility policy for pain management identified the pain management plan should include administration of pain medications as prescribed, ensuring appropriate monitoring for effectiveness and side effects and residents on opioid therapy would be monitored for signs of opioid-related adverse effects including sedation and respiratory depression.The facility policy for medication administration identified residents will be monitored for therapeutic effects and potential side effects of medications.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for one sampled resident (Resident #31) who was administered the incorrect dose of methadone, the facility failed to ensure the methadone was administered in accordance with professional standards. The findings include:Resident #31 was admitted to the facility in April 2025 with diagnoses including pyogenic arthritis, opioid dependence and nicotine dependence.The quarterly MDS dated [DATE] identified Resident #31 had intact cognition and was independent with eating and oral hygiene. The care plan dated identified Resident #31 received methadone maintenance for a history of substance use disorder with interventions to provide resident with methadone dose as ordered for self-administration and to monitor for any adverse effects of methadone administration and report to MD/APRN.The physician's orders for November 2025 directed the administration of Methadone HCL oral solution once daily by mouth related to opioid dependence. A review of the methadone chain of custody record for the time period of 11/10/25 through 11/23/25 for Resident #31 identified a supply of individual bottles containing the daily methadone maintenance dose of 53mg (a concentration of 10 mg/ml). An accident and incident report dated 11/12/25 identified Resident #31 received the incorrect methadone maintenance dose. He/she was administered 100mg instead of the ordered dose of 53mg. The report further identified that LPN #1 had administered the incorrect dose in error and was provided re-education regarding reading and verifying the methadone labels.The APRN's progress note dated 11/12/25 at 12:46 PM identified Resident #31 was given the incorrect dose of methadone and vital signs would be monitored as well as signs of increased sedation for three days.The nursing progress note (SBAR) dated 11/12/25 at 2:16 PM identified Resident #31 was given a higher dose of methadone with no neurological or physical changes.The nursing progress note dated 11/12/25 at 4:17 PM identified Resident #31 was asleep with no signs or symptoms of respiratory distress noted.The APRN's progress note dated 11/14/25 at 10:20 AM identified Resident #31 was falling asleep during conversation. The note further identified Resident #31 denied feeling tired and indicated the neurological and vital signs were stable.Interview with LPN#1 on 5/6/26 at 11:15 AM identified she could not remember any specifics of the incident because the facility was crazy as heck that day and everyone is entitled to make mistakes. Interview with the DNS on 5/7/26 at 8:40 AM identified medications should be administered as ordered. The DNS indicated that the Methadone is obtained from a community program and residents are able to self-administer the Methadone. The DNS further identified that the bottles of Methadone are sent and contain the resident's daily dose. She noted that the bottle labels contain the resident's name, dose and date of when it should be administered. Interview with the Director of Quality and Compliance and the Director of Nursing for the community methadone program (who supplies the methadone for the facility) on 5/8/26 at 10:32 AM identified the administration of methadone should be exactly as indicated on the bottle that is provided for the resident. She identified that the doses are patient specific and labeled individually for each day's use. She further noted that an overdose of methadone can result in death.The National Institutes of Health identified methadone as a long-acting opioid, indicating its toxic effects can emerge later and last much longer than other drugs which increases the risk of fatal accumulation in the body. Excessive doses of methadone can result in extreme sedation, pinpoint pupils, confusion and disorientation, respiratory depression, circulatory issues and cardiac arrest.The facility policy for Methadone Maintenance identified the dose identified on the Methadone chain of custody record should match the individual bottles and should be compared to the current physician's orders for methadone and indicated that any discrepancies must be verified with the clinic and physician. The policy identified prior to administration, the licensed nurse will verify correct name, date and dose on the methadone bottle to the MAR and Methadone Administration worksheet.

Based on observation, review of facility policy/procedure and interviews, the facility failed to ensure drugs and biologicals were stored in locked compartments and failed to ensure only authorized personnel had access to the keys. The findings include:Observation of the T1 medication cart on 5/06/2026 at 3:02 PM to 3:12 PM in the hallway directly across from the facility staff time clock, unattended with the main lock unlocked and keys on a spiral wrist coil keychain located on top of the cart. Additionally, there was a medication cup on top of the cart that contained one pink in color oblong, scored tablet. Observations at this time included several staff members utilizing the time clock on the wall directly across the hall, approximately 3 feet from the medication cart. There were several employees, more than 6, including the ADNS and a corporate RN, who passed by the cart several times and did not address the unsupervised cart, keys or unsecured medication. Observation also included EMTs returning a resident who were standing next to the medication cart and 3 residents who passed by the cart. With the main lock not secured, all medications can be accessed without keys, and the controlled substances are only stored under one lock at this time which could be accessed by use of the unsecured keys left on the top of the cart. Interview with RN #4 on 5/06/2026 at 3:13 PM identified that she was directed by the supervisor to assist with another resident with EMS and indicated that although this was a hectic time, she should lock her cart and took her keys. RN#4 identified the pink pill as Carafate, a medication used to treat stomach ulcers. RN#4 indicated that the keys left on the top of the cart were the nursing keys that would be used to unlock the cart and the controlled substances on the cart. Interview with the ADNS on 5/06/2026 at 3:25 PM identified that he was not aware of the medication storage policy but indicated the keys should not be off of the nurses' person and the cart should be locked when left unattended. Interview with the DNS and 5/06/2026 8:27 AM Interview with the DNS and RN#11 (corporate nurse) identified that the medication carts should be locked when unattended, the keys kept in possession of the nurse and medications secured and not left out and unattended. Interview with the Medical Director on 5/8/26 at 12:48 PM identified that his expectation for nursing is that they are doing their job according to facility policy. The facility policy for medication storage in the facility identified that medications and biologicals are stored safely, securely and accessible only to licensed nursing personnel. The facility policy for medication administration identified all medications should be stored in a secure, locked area accessible only to authorized personnel and that narcotics and controlled substances must be double-locked and counted per facility protocol.

Based on review of clinical record, facility policy, facility documentation, and interviews for two of five sampled residents (Resident #24 and Resident #38) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by resident (Resident #24) and the facility failed to offer the influenza vaccine to the resident (Resident #38). The findings include: Based on review of clinical record, facility policy, facility documentation, and interviews for two of five sampled residents (Resident #24 and Resident #38) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by resident (Resident #24) and the facility failed to offer the influenza vaccine to the resident (Resident #38). The findings include: Resident #24 was admitted to the facility in April 2025 and had diagnoses of Lyme disease, anxiety, and hypertension. The significant change MDS assessment dated [DATE] identified Resident #24 had intact cognition. Interview and review of Resident #24 vaccine consent form on 5/11/26 at 11:11 AM with the Infection Preventionist (RN #2) and the Regional Clinical Nurse (RN #7) identified Resident #24's responsible party had given the facility permission to administer the pneumococcal vaccine according to the Centers for Disease Control and Prevention (CDC) updates per vaccine recommendation on 9/24/25. Further review of the records with RN #2 and RN #7 failed to identify that he/she had received the vaccine at the facility or had change his/her decision. RN #7 identified Resident #24 had received the Pneumococcal vaccine (PPV23) on 8/2/2012 (at age [AGE] years) and the Prevnar 13 vaccine on 4/14/2016 (at age [AGE] years). RN #4 further identified Resident #24 was then eligible to receive the pneumococcal vaccine (PCV20) based on the CDC guidelines. RN #2 identified the resident should have received the vaccine at time of his/her request, but he was not the Infection Preventionist at the time when the consent was obtained from the resident's responsible party. RN #2 identified the host vaccine clinics as well as order individual vaccine for administration outside of the clinic, so residents are able to receive vaccines when requested. Review of the Pneumococcal Vaccine policy identifies residents, or their responsible party will be offered the pneumococcal vaccine according to their specific eligibility that aligns with the current Centers for Diseases Control and Prevention (CDC) Adult Immunization Schedule upon admission. The policy further identified the facility should obtain historical pneumococcal vaccination history and collaborate with the MD to determine appropriate vaccine needs. The procedure section of the policy includes to obtain written orders from MD and to administer vaccine per MD order. Resident #38 was admitted to the facility in December of 2025 and had diagnoses of adult failure to thrive, atrial fibrillation and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #38 had moderately impaired cognition. The assessment further identified Resident #38 was not given the influenza vaccination. Review of Resident #38 clinical record on 5/11/26 at 11:11 AM with the Infection Preventionist (RN #2) and the Regional Clinical Nurse (RN #7) failed to identify that he/she was offered the current influenza vaccine for the year 2025 nor did the records reflect that he/she had received the vaccine historically or had refused the vaccine at the facility. Interview with RN #2 and RN #7 on 5/7/26 at 2:00 PM identified upon admission residents are offered vaccines and a consent form is provided to the resident or the resident responsible party to obtain consent. RN #2 further identified consents are also obtained within the various seasons from the resident or his/her responsible party. RN #2 identified it is the responsibility of the Infection Preventionist to ensure consents were obtained and the appropriate vaccine is administered to the resident either via a clinic hosted by the facility or by the facility licensed staff. RN #2 and RN #7 identified they were unable to locate a completed vaccine consent form for Resident #38 which should have been completed on admission or thereafter. RN #2 further identified they were having issues with obtaining consent from the resident's responsible party; however, the resident should have been offered the vaccine since his/her admission, and this was an oversight on his part.Review of the Influenza Policy identified according to the Centers for Disease Control and Prevention (CDC) the flu vaccine should be offered to immunize staff and residents against influenza annually. Eligible residents will be offered the influenza vaccine unless medically contraindicated. The policy further identifies residents or the resident's legal representative will be educated on the risk and benefits of the influenza vaccine on an annual basis.

Based on review of the clinical record, facility documentation, facility policy/procedures, and interviews for 1 of 5 sampled residents (Resident #38) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination was offered. The findings include:Based on review of the clinical record, facility documentation, facility policy/procedures, and interviews for 1 of 5 sampled residents (Resident #38) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination was offered. The findings include:Resident #38 was admitted to the facility in December of 2025 and had diagnoses of adult failure to thrive, atrial fibrillation and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #38 had moderately impaired cognition. The assessment further identified Resident #38 was not up to date with the COVID-19 vaccination. Review of Resident #38 clinical record on 5/11/26 at 11:11 AM with the Infection Preventionist (RN #2) and the Regional Clinical Nurse (RN #4) failed to identify that he/she was offered the COVID-19 booster vaccine for 2025-2026 nor did the records reflect that he/she had received the vaccine historically or had refused the vaccine while at the facility. Interview with RN #2 and RN #7 on 5/7/26 at 2:00 PM identified upon admission residents are offered vaccines and a consent form is provided to the resident or the resident responsible party to obtain consent. RN #2 further identified consents are also obtained within the various seasons from the resident or his/her responsible party. RN #2 identified it is the responsibility of the Infection Preventionist to ensure consents were obtained and the appropriate vaccine is administered to the resident either via a clinic hosted by the facility or by the facility licensed staff. RN #2 and RN #7 identified they were unable to locate a completed vaccine consent form for Resident #38 which should have been completed on admission or thereafter. RN #2 further identified they were having issues with obtaining consent from the resident's responsible party; however, the resident should have been offered the vaccine since his/her admission, and this was an oversight on his part. Review of the COVID-19 Vaccine Policy identified residents, or their responsible party will be offered the COVID-19 vaccine according to their specific eligibility that aligns with the current Centers for Disease Control and Prevention (CDC) guidance. The policy further identifies the facility should obtain historical COVID-19 vaccination history and collaborate with the MD to determine appropriate vaccine needs.

Based on review of the clinical record, review of facility policy and procedures, review of facility documentation, and interviews for one of two sampled residents (Resident #57) reviewed for an allegation of mistreatment, the facility failed to ensure that the MD/APRN was notified of a bruise of unknown origin in a timely manner. The findings include:Resident #57's had diagnoses that included dementia, anxiety and osteoarthritis of knee.The quarterly MDS assessment dated [DATE] identified Resident #57 had severely impaired cognition, had no behaviors and required maximal assistance with personal hygiene, transfers, dressing, bed mobility and was dependent for toileting hygiene. The assessment further identified Resident #57 was dependent on the staff with the use of a wheelchair and ambulation was not attempted. The assessment identified Resident #57 had no wounds or skin problems.The care plan dated 2/18/26 identified Resident #57 was at risk for skin breakdown related to decrease mobility and incontinence with interventions that included Geri-sleeves to be worn on arms as tolerated, gentle handling during transfers and care procedures, and to inspect skin when providing care for sign/symptoms of breakdown.The reportable event form dated 4/6/26 at 2:30 PM completed by the ADNS (RN #2) identified staff reports observation of bruising. The report further identified 2 bruise/purpura observed to right and left forearms, the resident denied pain and knowledge of its origin. In addition, the report identified APRN #1 was notified on 4/6/26.Review of the nursing progress note failed to identify any documentation that the APRN/MD was notified of the reported bruising identified on 4/6/26.The APRN's progress note dated 4/13/26 at 9:49 AM written by APRN #1 identified bruising to bilateral forearms and apparently these bruises were noted last week by the nursing staff, however, it was not brought to her attention until she received a phone call on Friday (4/10/26). The note further identified she was not back at the facility until Monday, and she advised them she would assess the resident then as long as there were no acute issues, but that if the physician came on Saturday, she advised them to also have the physician assess. APRN #1's note further identified nursing states that Resident #57 had a fall on Saturday with no sustained injuries but that the bruising predated that fall. The note further identified the physical examination of the skin which noted bilateral forearm bruising with dark red to maroon in color. Interview with the ADNS (RN #2) in the presence of the Regional Clinical Nurse (RN #7) on 5/5/26 at 12:38 PM identified he had completed the incident report on 4/6/26 and following any identification of a bruise of unknown origin the MD/APRN should be notified. RN #2 identified he had notified APRN #1 of the bruising via text or phone call and provided a text message sent to APRN #1 on 4/9/26, however, he was unable to identify that APRN #1 was notified of the bruising on 4/6/26 as stated on the reportable event form. The DNS then joined the interview, and they identified the APRN/MD should have being notified at the time when the bruising was identified and not 72 hours laterInterview with APRN #1 on 5/6/26 at 9:15 AM identified she is at the facility on Monday and Wednesday and she is on call daily until 6:00 PM and she was not made aware until Friday (4/10/26) of the bruising, in fact the resident told her that somebody hurt him/her and she then reported it to nursing. APRN #1 identified that nursing had concern whether the area was purpura or petechiae, so she had ordered blood work which she reviewed, and the area is in fact a bruise.Review of the Change in Resident Condition/Family/MD Notification policy and procedure identified when there is a significant change in the condition of a resident's physical, mental or emotional status, or in the event of an accident involving the resident that the resident's attending physician shall be notified, if the attending or covering physician is not available, the medical director or his associate shall be called and the nurse will document in the nurse's notes that the physician and family or responsible party have been notified of the change in condition.

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #6) reviewed for Range of Motion, the facility failed to ensure the resident was free from physical restraint not required to treat the resident's medical conditions. The findings include:Resident #6 was readmitted to the facility in March 2026 with diagnoses that included Parkinson's disease with dyskinesia with fluctuations, polyneuropathy, diabetes mellitus, anxiety and depression.The Significant Change MDS assessment dated [DATE] identified Resident #6 had intact cognition, felt down, depressed or hopeless 7-11 days (half or more of the days), feeling tired or having little energy 2-6 days (several days), Poor appetite or overeating (2-6 days several days). The MDS identified an impairment on one side lower extremity, use of a wheelchair, substantial/maximal assistance with eating and oral hygiene, and dependent with transfers.The care plan dated 4/14/26 identified Resident #6 needed staff assistance with ADLs, was a fall risk with a left hip fracture with interventions to include side rails per MD orders to assist with bed mobility and turn and reposition per nursing standards of care. Resident #6 also had a care plan for skin breakdown with interventions to encourage and/or assist with offloading pressure areas.Physician's orders dated 4/27/26 directed side rails two half up for bed mobility and transfers with the assistance of 2 staff with directions to get out of bed every day as tolerated.Review of the NA care card identified the assistance of 2 staff for transfers and indicated Resident #6 was non-ambulatory as of 3/2/26. The care card failed to identify positioning wedges.Observation of Resident #6 on 5/4/26 at 11:47 AM identified Resident #6 in bed in a supine position without heel boots in place. The heel boot was observed on the dresser, not in reach. Resident #6 appears asleep and does not respond to verbal attempts. There are 2 bolsters, they appear to be mattress extenders that are put at the end of the mattress if the bed needs to be longer, that are on the bedside table.Interview with NA #2 on 5/6/26 at 1:50 PM identified Resident #6 no longer gets out of bed a lot. NA#2 indicated that Resident #6 had Parkinson's Disease and had some spastic movements of the upper body and falls out of bed a lot when trying to get out of bed. NA #2 identified that she had placed the wedges under the mattress a few weeks ago so Resident #6 wouldn't fall out of bed and wouldn't hit arms on the bed rails with the spastic movements. NA#2 indicated she did not receive direction from anyone to do this and did not recall if she informed anyone but identified the bolsters were still in Resident #6's room although sometimes not in place on the bed. Observation of Resident #6 on 5/7/26 at 8:40 AM identified Resident #6 was in a supine position in bed with a bolster wedge on each side of the resident tucked under the sheet. The wedges are square shaped and long and appear to be bed extenders that would be placed in the space at the end of the mattress if the bed needed to be longer. The bolster placement left no space between Resident #6's shoulders and the bolsters and they blocked the bed rails making the handles inaccessible for mobility.Observation of Resident #6 with NA#2 and NA#3 on 5/7/26 at 10:28 AM identified Resident #6 in bed in a supine position with bilateral squared bolsters in place under the bed sheet and extending from the resident head to mid-thigh. Interview with NA#3 on 5/7/26 at 12:56 PM identified that she was directed by the ADNS that the bolsters had to be placed on the bed because Resident #6 kept trying to climb out of bed. Interview with OT#1 and OT#2 on 5/7/26 at 1:08 PM identified Resident #6 had been taken off of all therapy services last Friday 5/1/26 after being on service for 2 months after a fall with hip fracture. OT#1 indicated Resident #6 is non-compliant with positioning and requesting assistance with mobility or ADLs. OT#1 identified that positioning devices or things that deal with skin integrity are nursing interventions and indicated a therapy assessment was not completed for the use of the bolsters.Interview with the ADNS and RN#7 (Regional Clinical RN) on 5/7/26 at 2:39 PM identified the bolsters as French fry wedges and indicated they were put in place for Resident #6 as a fall prevention because of the frequency of falls and identified the French fry wedges do slow Resident #6 down from being able to get out of bed. The ADNS could not identify any indications for use other than mobility restriction and could not identify any assessments conducted for restraints, mobility or demonstration that the wedges were the least restrictive intervention. The ADNS indicated that the use of the wedges should be represented in the care plan and the care card but failed to locate the documentation. The ADNS failed to identify when the wedges were implemented for Resident #6. Additionally, the ADNS indicated that Resident #6's coccyx area had been resolved by wound care on 4/15/26 but could not identify any documentation regarding Resident #6's left heel.Observation with the ADNS, DNS and RN#7 on 5/7/26 at 2:54 PM identified Resident #6 had bolsters in place and would have to research the use of the bolsters/wedges. Resident #6 was able to be rolled by staff but was not able to reach the side rail to hold on to it with the bolster in place.Interview with PT on 5/8/26 at 11:02 AM identified that therapy does not do assessments for use of the bolsters. PT indicated Resident #6 is able to independently get out of bed, although not safely. PT identified Resident #6 had a large number of falls and does not call for assistance and indicated that the bolsters in place would limit the movement and ability to get out of bed.Interview with the Medical Director on 5/8/26 at 12:48 PM identified that positioning wedges are used with recommendations from nursing staff or the physical therapy staff and indicated that he expected residents to be free from restraints in the facility.Although requested, identification and manufacturer recommendations of the bolsters used in Resident #6's room were not provided by the facility.The facility policy for positioning identified residents who are unable to turn themselves will be repositioned at least every two hours and/or as needed. Residents who are unable to maintain proper body alignment with traditional positioning devices will be evaluated by rehab services and indicated the resident's care plan and NA care card will indicate that resident needs assistance with positioning.The restraint policy identified restraints shall be applied per physician's order after obtaining consent from the resident or legal representative. The policy indicated that restraints will not be used for purposes of discipline or convenience. The policy further identified that consultation with appropriate health care professional shall be obtained prior to using a physical restraint to ensure the least restrictive device is being utilized. Additionally, the restraint procedure includes checking resident every half hour for safety.

Based on observations, review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for two sampled residents (Residents #3 and #6) with a history of pressure ulcers, the facility failed to ensure care and services were implemented to prevent pressure injury development and failed to ensure treatments were continued from the hospital and measurements were made upon assessment of the wound as well as weekly assessments completed. The findings include: Resident #6 was admitted to the facility in October 2025, originally and re-admitted after a hospital admission in March 2026 with diagnoses that included Parkinson's disease with dyskinesia, polyneuropathy, diabetes mellitus, anxiety and depression. The Nursing admission assessment dated [DATE] identified Resident #6 had Moisture-Associated Skin Damage (MASD) is the inflammation, softening, and erosion of the skin caused by prolonged exposure to bodily fluids, such as wound drainage (exudate), urine, stool, or sweat. It weakens the skin's natural protective barrier, making it painful and vulnerable to infection) to the right and left buttock. The significant change MDS assessment dated [DATE] identified Resident #6 was cognitively intact, was dependent on staff for bed mobility, had a functional range of motion limitation to a lower extremity, was always incontinent of bowel and bladder, was non-ambulatory and dependent for wheelchair mobility, was at risk for pressure ulcers but did not have the presence of a pressure ulcer/injury, had MASD and pressure reducing devices to the bed and the wheelchair. It further identified the resident was not on a turning and repositioning plan. The Braden scale dated 4/6/26 identified Resident #6 was at high risk for the development of pressure injury. The care plan dated 4/14/26 identified Resident #6 was at increased risk of complications related to neuropathy, diabetes, dementia and depression with interventions that included, watch for any changes in mental status and mood state and report to MD/APRN, watch for increased pain and/or numbness, vascular changes in extremities and report to MD/APRN. Additionally, the care plan indicated Resident #6 required staff assistance with activities of daily living, was a fall risk with a left hip fracture. Interventions included side rails per MD orders to assist with bed mobility and turn and reposition per nursing standards of care. The care plan further noted the concern of weight loss and skin breakdown with interventions that included, encourage and/or assist with offloading pressure areas and inspect skin when providing care. The wound physician's progress note dated 4/15/ identified Resident #6 had a resolved stage 3 pressure injury to the left buttock. The note further identified a recommendation for the application of barrier cream to the base of the wound three times per day and as needed for soiling for a period of two weeks. The nursing quarterly/annual evaluation dated 4/20/26 identified Resident #6 utilized 2 side rails to assist with bed mobility, did not use restraints, and was at high risk for developing a pressure injury. Th physician's orders dated 4/27/26 directed to apply heel boot supports when in bed at all times every shift and directed to remove and inspect foot/heel for breakdown and then reapply the boot heel support, and half side rails for mobility and transfers with assistance of two staff. The orders further noted to get resident out of bed every day as tolerated. A review of the treatment administration record (TAR) for the month of April and May 2026 identified a treatment order that directed to apply Bacitracin to the left heel with skin prep applied around the open area, to be completed twice daily for seven days. The order had a start day of 4/27/26 and an end date of 5/4/26. A review of the clinical record failed to identify documentation regarding the assessment or monitoring of a left heel wound. Although review of the Treatment Administration Record (TAR) for April and May 2026 directed a treatment to apply bacitracin BID to left heel with skin prep around the open area for 7 days starting 4/27/26 and completed twice daily until 5/4/26, review of the clinical chart failed to identify any documentation regarding the left heel wound identification, monitoring or treatment. Review of the TAR for May 2026 identified the heel boots were in place daily as ordered. This is signed off by the nurse. The nurse aide's care card did not contain directions concerning the application of the heel boots. Review of physical therapy Discharge summary dated [DATE] identified Resident #6 met a goal transferring supine to sit with minimal assistance and 10% verbal cues for correct hand/foot placement and identified the met goal of sit to stand transfer with moderate assistance, meaning the resident does 50 to 74% of the physical effort, and 20% verbal cues for correct use of assistive device and for weight shift over center of gravity. The note indicated this goal was met on 3/27/26. Additionally, a goal of stand pivot transfers with minimal assistance and 20% verbal cues for weight shift over center of gravity and for correct use of assistive device with decreased complaints of pain. Observation on 5/4/26 at 11:47 AM identified Resident #6 lying in bed in the supine position appearing to be asleep and without the benefit of having the heel boots in place. The heels were on the surface of the mattress. The heel boot was observed on the dresser. There were two bed bolsters located on the bedside table. The bolsters appeared to be extenders that could be placed at the end of the mattress to extend the length of the mattress. Observation on 5/5/26 at 8:02 AM identified Resident #6 in bed positioned on the left side. With the right leg hanging off the side of the bed. The heel boot was located at the end of the bed but was not on the resident's foot. Observation on 5/6/26 at 4:58 AM identified Resident #6 lying in bed in the supine position without the benefit of having the heel boots in place. A heel boot was located on the resident's dresser. The heels were on the surface of the mattress. Observation of Resident #6 on 5/6/26 at 4:58 AM lying in bed in a supine position, with no heel boots observed. Resident #6 had a sock in place on the right foot and no sock on the left foot. The heel boot was on the dresser in the room. Interview with NA #2 on 5/6/26 at 1:50 PM identified Resident #6 no longer got out of bed much. She identified the resident had Parkinson's disease, spastic movements of the upper body and had frequent falls out of bed when attempting to get out of bed. NA #2 identified that she had placed the wedges under the mattress a few weeks ago so Resident #6 wouldn't fall out of bed and wouldn't hit arms on the bed rails with the spastic movements. NA#2 indicated she had not received direction to do this. Observation on 5/7/26 at 8:40 AM identified Resident #6 in bed lying in the supine position with a bolster wedge on each side of the resident tucked under the sheet. The wedges are long and rectangular in shape. The wedge placement left no space between Resident #6's shoulders and the wedges and the wedges blocked the bed rails making the handles inaccessible for mobility. Observation with NA#2 and NA#3 on 5/7/26 at 10:28 AM identified Resident #6 in bed in a supine position with bilateral squared bolsters in place under the bed sheet and extending from the resident's head to mid-thigh. The heel boots were not in place and were located on the resident's dresser with the heels touching the mattress. NA#2 and NA#3 rolled Resident #6 onto the right side, so the backside was able to be visualized. The resident's left heel appeared discolored with a scabbed area. Resident #6 also was noted to have a small open area to the left upper buttock with exudate noted on the resident's incontinent brief. Resident #6 was incontinent of bowel at this time and was changed by the NAs. However, no barrier cream was placed on the resident as it was not found in the room. Interview with NA#3 and NA#2 on 5/7/26 at 10:30 AM identified that neither of the NAs had cared for Resident #6 recently and indicated they had no knowledge of skin issues prior to observations at this time. NA#3 and NA#2 indicated they would notify the nurse of any new findings. Interview with NA#3 on 5/7/26 at 12:56 PM identified she was directed by the ADNS that the bolsters had to be placed on the bed because Resident #6 keeps attempting to climb out of the bed. NA#3 indicated that NAs are responsible for applying the heel boots with care. Interview with the ADNS and RN#7 (Regional Clinical Nurse) on 5/7/26 at 2:39 PM identified that barrier cream is a standard of care and NAs should apply with care provided. The ADNS identified the bolsters as French fry wedges and indicated they were put in place for Resident #6 as a fall prevention intervention because of the frequency of falls and identified the French fry wedges slow Resident #6 down from being able to get out of bed. The ADNS could not identify any indications for use other than mobility restriction and could not identify any assessments conducted for restraint use, mobility or demonstration that the wedges are the least restrictive intervention. Further, the ADNS indicated that the use of the wedges should be represented in the care plan and the care card but failed to locate the documentation. The ADNS also failed to identify when the wedges were implemented for Resident #6. Additionally, the ADNS indicated that Resident #6's coccyx area wound resolved on 4/15/26, She could not identify any documentation regarding Resident #6's left heel skin alteration. Observation with the ADNS, DNS and RN#7 on 5/7/26 at 2:54 PM identified Resident #6 had a re-opened area to the buttocks and identified an issue with the left heel, although none of the people present would identify the etiology of the heel injury. Interview with the Physical Therapist on 5/8/26 at 11:02 AM identified that therapy does not assess for the use of bed bolsters. The Physical Therapist (PT) indicated Resident #6 is able to independently get out of bed, although not safely. PT identified Resident #6 had a large number of falls and does not call for assistance and indicated that the bolsters in place would limit movement and the ability to get out of bed. Although requested, identification and manufacturer recommendations for the bed bolsters used in Resident #6's room were not provided by the facility. The facility policy for positioning identified residents who are unable to turn themselves will be repositioned at least every two hours and/or as needed. Residents who are unable to maintain proper body alignment with traditional positioning devices will be evaluated by rehab services and indicated the resident's care plan and NA care card will indicate that resident needs assistance with positioning. The facility policy for splints and orthotic devices identified the purpose for use are to enable proper joint alignment, promote skin integrity, enhance functional ability and prevent further deformity and indicated a physician's order will be obtained for the positioning device and will be transcribed on the resident's treatment Kardex. The facility policy for wound and skin protocol identified skin areas will have weekly documentation until healed. Subsequent to surveyor inquiry, nursing progress note by the ADNS dated 5/8/26 at 11:43 AM identified Resident #6 had a left heel deep tissue injury measuring 1.5 cm x 1.0 cm x 0.1 cm with MASD buttocks related open area measuring 0.5 cm x 0.5 cm with scattered diffuse surrounding tissues. The facility failed to ensure that interventions were implemented to prevent a pressure injury and to prevent the reopening of a pressure injury to the buttocks, and failed to assess the pressure injury upon discovery according to acceptable standards of practice. Resident #3's diagnoses included fracture of the lower end of the right femur, heart failure, and dementia. The admission MDS assessment dated [DATE] identified Resident #3 was cognitively intact, required substantial maximal assistance for bed mobility, was dependent for transfers and personal hygiene, was non-ambulatory, utilized a wheelchair for mobility and the presence of one Stage 4 pressure ulcer that was present upon admission. The care plan dated 12/9/25 identified Resident #3 had a Stage 4 pressure ulcer with interventions that included, check skin at least weekly on scheduled bath day, consult infection control nurse, consult wound consultant as needed, and treatment as ordered. The hospital Discharge summary dated [DATE] identified a physician's order for a dressing change to the coccyx wound (pressure ulcer) twice a day that directed to cleanse with soap and water, pack with wet to moist gauze, cover with a foam dressing and Z guarde (hospital grade skin protectant) past to the surround skin. The nursing RN progress note dated 11/29/25 identified pressure ulcer to coccyx with tunneling, tunneling present but unable to measure due to depth and limited visibility. The nursing assessment completed upon admission dated 11/29/25 identified wound tracking to include a Stage IV pressure ulcer on the sacrum with tunneling. No measurements were completed of the wound by the RN on the initial assessment. (Moved this above the MAR and TAR) Review of the MAR and TAR for November 2025 failed to identify any treatment to the stage 4 pressure injury to the coccyx implemented upon admission. Review of weekly skin monitoring identified the Stage 4 Coccyx Pressure Ulcer was reviewed by the wound care MD on 12/3/25 where the first implementation of a treatment was ordered for a daily and as needed dressing change to be completed. Cleanse the wound and apply triad to peri wound, and treatment was added to include hydrofera blue (antibacterial foam wound dressing) and apply a dry clean dressing. Measurements were taken by the wound physician to be 2.0cmL 2.00cmW 1.2cmD. This first measurement and the first treatment ordered to the area was completed on 12/3/25, five days following admission to the facility. A review of the clinical record failed to identify measurements and wound assessment between 12/3/25 and 12/17/25. The weekly skin assessment should have been on or around 12/10/25 however the clinical record failed to identify one. Once the wound was identified there should have been weekly wound measurements completed and documented in the clinical record. These measurements would include length, width, depth, color, drainage, tissue type, and an information regarding the surrounding area. Interview with RN#2 (the facility wound nurse/IP) on 5/6/26 at 11:10AM identified _an assessment would be completed by the RN on admission a wound would be measured and assessed. Treatments would be continued from the hospital if previously ordered or started once admitted to the facility, ordered by the admitting physician. However, the initial assessment would not include staging in which they would leave for the wound physician to complete. RN#2 further identified he does rounds with the wound physician and doesn't typically assess before the wound physician sees a new area. The wound physician visits the facility weekly. Interview with RN#3 on 5/7/26 at 10:26AM who completed the RN Assessment on admission identified the admission checklist would be followed and believed she did this for Resident#3. The orders from the hospital are given to the provider to add to the initial admission orders. If the resident came to the facility with an existing Stage 4 Pressure ulcer the treatment would be continued from the hospital. If there was no treatment from the hospital for the pressure ulcer a new order should have been received by the RN to implement. These orders would be placed into the electronic record from the RN who would then have the physician sign off the orders. If initial measurements were not completed the wound nurse would follow up and complete. However, measurements of a wound should be done upon admission. Interview with the DNS on 5/7/26 at 11:00AM identified upon admission a full assessment should be completed by the RN. Orders from the hospital should be followed for a wound and if there were none then new orders should be received. The wound assessment should include if there is any signs of infection, measurements, and what it looks like. The next morning the infection control nurse should assess the area. Orders should be verified with the physician upon admission and put into the computer to include treatments ordered. Weekly at minimum the wound physician or RN should assess and measure the wound. Review of the wound and skin care policy directed all skin areas will have weekly documentation until healed. The care plan including the admission will address preventative and or treatment of impaired skin integrity/pressure ulcer. Review of the admission policy directed obtain the W-10 and discharge summary from transport personnel. Contact attending physician or medical director to verify all admitting orders, including medication, treatment and therapies. Transcribe verified orders into PCC. The admitting nurse will complete all required nursing assessments and admission documentation in PCC.

Based on review of the clinical record, review of facility documentation, review of facility policy and procedures, and interviews for one of two sampled residents (Resident #57) reviewed for an allegation of mistreatment, the facility failed to ensure that a thorough investigation was completed regarding a bruise of an unknown origin. The findings include:Resident #57's had diagnoses that included dementia, anxiety osteoarthritis of knee.The quarterly MDS assessment dated [DATE] identified Resident #57 had severely impaired cognition, had no behaviors and required maximal assistance with personal hygiene, transfers, dressing, bed mobility and dependent with toileting hygiene. The assessment further identified Resident #57 was dependent on the staff with the use of a wheelchair and ambulation was not attempted. The care plan dated 2/18/26 identified Resident #57 was at risk for skin breakdown related to decrease mobility and incontinence with interventions that included Geri-sleeves to be worn on arms as tolerated, gentle handling during transfers and care procedures, and to inspect skin when providing care for sign/symptoms of breakdown.The reportable event report dated 4/6/26 at 2:30 PM identified staff reported bruising to Resident #57's arms. The report further identified 2 bruises observed to the right and left forearms, the resident denied pain and knowledge of its origin. In addition, the report identified there were no witnesses.APRN #1's progress note dated 4/13/26 at 9:49 AM identified bruising to bilateral forearms was noted last week by the nursing staff. The note further identified APRN #1 was notified on Friday (4/10/26) and she saw the resident on 4/13/26 when Resident #57 told APRN #1 that somebody hurt him/her and due to the resident's significant dementia, the resident could not give her any other information beyond that. The note further identifies the physical examination of the skin which noted bilateral forearm bruising with dark red to maroon in color.The reportable event report dated 4/13/26 at 10:00 AM identified Resident #57 reported bruising noted on arm on 4/6/26 was caused by someone hurting him/her. The report further identified an injury of bruising on bilateral arm, no pain or acute distress.Interview and review of the clinical record with the ADNS (RN #2), and the DNS in the presence of the Regional Clinical Nurse (RN #7) on 5/5/26 at 12:45 PM identified statements were not obtained when the bruises were first identified on 4/6/26. The DNS identified statements should have being collected from staff who cared for Resident #57 24 hours prior to the identification of the bruise to identify how the bruise had occurred. The DNS identified that statements were not obtained until when the resident reported on 4/13/26 that somebody hurt him/her. The DNS further identified there was a delay in the investigation process, hence, why she identified on the 4/13/26 reportable a follow-up of the 4/6/26 reportable which she should have thoroughly investigated 4/6/26 incident separately. She then indicated because the investigation was not completed on 4/6/26 when she interviewed staff following the 4/13/26 report she included who cared for the resident during the 4/6/26 reported incident. The DNS further identified they had no excuse as to why 4/6/26 reported bruise was not thoroughly investigated, and a care plan was put in place to prevent recurrence. She identified that the in-service was not started until 4/14/26 and the care plan was updated to include the interventions that were initiated on 4/14/26 until 4/21/26, which should have been done at the time of the 4/6/26 reported incident. RN #2 identified he was reviewing the 4/6/26 reportable event when he realized the post assessment monitoring was not done so he then initiated the assessment form, assessed the area and wrote a note, which should have done early instead of 72 hours after the incident was reported. Interview and review of the clinical record with APRN #1 on 5/6/26 at 9:15 PM failed to identify that Resident #57 was ever on any blood thinner. APRN #1 identified the areas identified on Resident #57's bilateral forearm are bruises as they were perfectly symmetrical. She further identified that based on the laboratory work results, the areas identified on the resident bilateral arms were not purpura or petechia but in fact bruises. APRN #1 identified the bruises she observed on 4/13/26 on Resident #57's bilateral forearms were not new but appeared a few days old.Review of the Accident/Incident/(Resident) Reportable event policy identified any injury of unknown origin will be investigated and all staff that cared for the resident 24 hours prior to the observation of the injury will be interviewed, ensuring all statements are documented. The policy further identified is unable to determine a cause through the investigation, documenting the investigation as inconclusive. The Abuse policy identifies all allegations will be thoroughly investigated, and appropriate action will be taken. The policy further identifies staff must identify and report any suspicious bruising, patterns of injury, or behavioral changes that may indicate abuse. Any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the DNS, and the administrator. The policy identifies the investigation will include interviews with all witnesses, including the accused, interviews with any individuals with relevant information, signed and dated statements from all parties involved and review of the accused staff member's employment record.

Based on review of clinical records, review of facility documentation, review of facility policies/procedures and interviews for one sampled resident (Resident #57) found with bruises of unknown origin, the facility failed to ensure the bruising was assessed according to acceptable standards of practice and the facility's policy/procedure and for one sample resident (Resident #12) reviewed for surgical wound care, the facility failed to ensure that a surgical wound treatment was provided in a timely manner. The findings include: Resident #57's had diagnoses that included dementia, anxiety osteoarthritis of knee. The quarterly MDS assessment dated [DATE] identified Resident #57 had severely impaired cognition, required maximal assistance with personal hygiene, transfers, dressing, and bed mobility, and was dependent on staff for toileting hygiene and wheelchair mobility. The care plan dated 2/18/26 identified Resident #57 was at risk for skin breakdown related to decreased mobility and incontinence with interventions that included Geri-sleeves to be worn on arms as tolerated, gentle handling during transfers and care procedures, and to inspect skin when providing care for signs/symptoms of breakdown. The reportable event report dated 4/6/26 at 2:30 PM completed by RN #2 (ADNS) identified staff reported Resident #57 had bruises on the right and left forearms, the resident denied pain or knowledge of its origin. The reportable event report did not contain a description of the bruises inclusive of color, the presence or absence of swelling, what the skin around the bruise looked like, location and measurements of the bruises. The clinical record also failed to identify the above information for the date that the bruises were first observed. Interview and review of the clinical record on 5/5/26 at 12:45 PM with the RN #2, the DNS and the Regional Clinical Nurse (RN #7) identified the clinical record failed to contain documentation of a thorough assessment of the bruises to the resident's bilateral arms found on 4/6/26. RN #2 identified that he was responsible for completing the assessment and writing the note at the time the bruises were reported to him. He further noted that he had not completed a thorough assessment of the bruises at the time they were found and noted that he documented an assessment of the bruises on 4/9/26 (3 days after the bruises were reported). In addition, he noted that the facility practice/procedure is that the assessment of the bruise should include details about the bruise such as location, measurements of the bruise, color, notification of MD/APRN and family. On further review of the clinical record on 5/5/26 at 12:45 PM with the RN #2, the DNS and RN #7 identified that following changes in condition/injuries, post-accident/incident forms are initiated and completed each shift for 72 hours. This form would include continued assessments of the injury/skin condition. Further review also failed to identify a treatment order. RN #2 further identified that he had not notified the APRN or physician at the time the bruising was reported. The DNS and RN #7 identified that the post-accident/incident assessment should have been implemented on 4/6/26 when the bruising/incident was first identified instead of on 4/9/26 and noted that the accident/incident 72-hour monitoring/assessment is completed to note changes and/or improvements in the resident's condition. Review of the Change in Resident Condition/Family/MD Notification policy and procedure identified when there is a significant change in the condition of a resident's physical, mental or emotional status, or in the event of an accident involving the resident that a RN assessment will be conducted and a nurse will document in the nurse's notes that the physician and family or responsible party have been made aware of the change in condition. Resident #12 was admitted to the facility on [DATE] with diagnoses that included a displaced bicondylar fracture of the left tibia and an encounter for other orthopedic aftercare. The admission MDS assessment dated [DATE] identified Resident #12 had intact cognition and required extensive assistance with toileting, personal hygiene, bed mobility, transfer. The RCP dated 3/18/26 identified Resident #12 as being at risk for skin breakdown, which could affect the resident's health condition and potentially contribute to an alteration in skin integrity. The care plan interventions directed staff to consult with the wound care nurse specialist as ordered, inspect the skin during care for signs and symptoms of skin breakdown, provide wound treatment per physician orders, and keep the skin clean and dry with the application of barrier cream. The nurse's note dated 4/15/26 at 12:55 PM indicated Resident #12 was out of the facility for an orthopedic appointment and did not return. The note further identified the resident was sent to the hospital for further evaluation. The clinical record identified Resident #12 was out of the facility from 4/16/26 through 4/24/26. The hospital Discharge summary dated [DATE] identified Resident #12 was discharged with exposed orthopedic hardware. The discharge summary further indicated that wound care to the left lower leg was to include applying Xeroform (yellow gauze) to the incision, securing it with kerlix, and applying an ACE wrap with gentle compression daily or as needed when soiled. The nurse's notes dated 4/25/26 identified Resident #12 was readmitted to the facility at 12:20 PM and had been treated in the hospital for an infection of the left lower leg and for a revision of the left lower tibia fracture. The notes also indicated that the resident had been treated for a pulmonary embolism during the hospitalization, and Eliquis (an anticoagulant) was newly prescribed. Review of the physician's orders from 4/25/26 through 4/27/26 failed to identify Resident #12 had an active treatment order for the left lower leg surgical wound. The physician's order dated 4/28/26 directed staff to cleanse the left lower tibia with warm, soapy water, without scrubbing, and to pat the area dry. The order further directed staff to apply Xeroform (yellow gauze) to the incision, secure it with Kerlix wrap, and apply an ACE wrap for gentle compression once daily. Additional instructions indicated to not apply lotions or ointments to the surgical site. Review of the Treatment Administration Record (TAR) from 4/25/26 through 4/29/26 identified that the first documented wound treatment to Resident #12's left lower leg occurred on 4/29/26, which was three days after the resident's readmission on [DATE]. Interview with RN #2 (wound nurse) on 5/5/26 at 10:55 AM identified he is responsible for weekly wound monitoring, including the monitoring of surgical wounds, and noted that the wound specialist typically does not monitor surgical wounds because the surgeon is responsible for directing wound care for those wounds. He further identified that the admitting nurse is responsible for ensuring that treatment orders are in place and for following the wound care instructions in the hospital discharge summary. Upon reviewing Resident #12's treatment record, he identified that there had been no wound treatment orders in the physician's orders when the resident was readmitted on [DATE]. He further identified that wound care for the surgical wound on the left lower leg tibia should have been implemented on the day of admission and not three days later. Interview with the DNS on 5/5/26 at 11:15 AM identified that the surgical wound care instructions in the discharge summary were to be followed and transcribed into the physician's orders on the day of admission. She identified that the admitting nurse was responsible for ensuring that the treatment for the surgical wound was entered into the physician's orders. Although she could not provide a reason why there had been no treatment order for Resident #12's left lower leg surgical wound, she identified that she would have expected the admitting nurse to ensure that a treatment order was in place and that RN #2 would also have reviewed Resident #12's record to verify that the surgical wound treatment had been implemented. Interview with RN #1 (admitting nurse) on 5/6/26 at 2:20 PM identified that the admitting nurse is responsible for reviewing the hospital discharge summary upon admission and for following all instructions contained in the summary, including wound care. She identified that she admitted Resident #12 on 4/25/26 and observed that the resident had an immobilizer on the left lower leg and a dressing in place on the left lower tibia. She reported that she thought the surgeon wanted the dressing to remain in place until the resident's follow up visit with the surgeon. She further identified that she missed the wound care instructions in the discharge summary and acknowledged that the treatment should have been initiated on the day of the resident's admission. The facility's Wound and Skin Care Protocol established that the facility would provide a high quality resident care and support positive clinical outcomes by maintaining skin integrity and promoting wound healing through the consistent use of an evidence based skin and wound care protocol.

Based on review of facility documentation, review of facility policy/procedures and interviews for 3 out of 3 Nurse Aides reviewed for annual performance evaluations, the facility failed to ensure they were completed and available for review. The findings include: NA#9 was hired on 3/26/24 and was due to have an annual evaluation completed 3/2025 and 3/2026. No evaluation was available to review in the personnel record or could be located for NA#9.NA#8 was hired on 4/26/22 and was due to have an annual evaluation 4/2025 and 4/2026. No evaluation was available to review in the personnel record or could be located for NA#8.NA#2 was hired on 5/18/23 and was due to have an annual review 5/2025, and 5/2026. No evaluation was available to review in the personnel record or could be located for NA#2. Interview on 5/8/26 at 10:00AM with Human Resources Personnel identified that she started in February of 2026 and was unable to locate the missing reviews since her hire. The reviews should be completed annually and going forward she has been providing a few a day to the DNS to review and complete in hopes of catching up to get back on track. Interview on 12/2/25 at 9:27AM with the DNS identified that she completes the nursing reviews, however she started in her role recently and due to multiple staff changes recently they had not been maintained. Her hope going forward is that they will be on a good path to get completed.The performance and review policy directed you provide a formal and documented performance review at the end of an employee's introductory period and will endeavor to give reviews at least annually thereafter.

Based on review of facility documentation, review of facility policy/procedures and interviews for 2 out of 3 Nurse Aides reviewed for annual in-service training, the facility failed to ensure they were completed and available for review. The findings included:Based on review of facility documentation, review of facility policy/procedures and interviews for 2 out of 3 Nurse Aides reviewed for annual in-service training, the facility failed to ensure they were completed and available for review. The findings included: Review of personnel records for Nurse Aide annual in-service records identified:NA#9 was hired on 3/26/24 and was due to have annual in-service training in 2025. No annual in-service training was completed. NA#8 was hired on 4/26/22 and was due to have annual in-service training in 2024. No annual in-service training was completed.Interview on 12/2/25 at 9:27AM with the DNS identified that she in conjunction with the Infection Preventionist, and Administrator complete the annual training however she started in her role recently and was unsure why it was not done previously. The DNS identified that there had been several changes recently in staffing and that hopefully going forward things would run smoother. Review of the mandatory annual education directed all staff receive mandatory annual education and are up to date with current standards of practice. Mandatory education is provided on hire and annually. The staff development coordinator or designee is responsible for providing education to all staff on an annual basis. Annual education should total 12 hours comprised of eight hours of dementia specific, 2 hours of pain, and 2 hours of additional education.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse after staff were aware and documented the incident in the medical record. The findings include:Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse after staff were aware and documented the incident in the medical record. The findings include: A. Resident #1 was admitted with diagnoses that included bipolar disorder (manic episodes with high energy, decreased need for sleep and loss of touch with reality alternating with depression). A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 (indicative of moderate cognitive impairment) and was independent for transfers and ambulation with a walker. The Resident Care Plan (RCP) dated 5/1/2025 identified Resident #1 was impulsive and not always able to control his/her behavior directing anger at staff and residents that sometimes resulted in verbal and physical aggression. Interventions directed to assist resident to another area if mood change was observed, and spend a few minutes in quiet conversation until anger subsides. B. Resident #2 was admitted with diagnoses that included stroke and opioid dependance. A quarterly MDS assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating he/she was alert and oriented) and was independent with transfers and ambulation with a walker. A RCP dated 4/2/2025 identified Resident #2 had negative feelings regarding self and social relationships. Interventions directed to encourage self-control and problem-solving skills and direct energies into stress reducing behaviors. A social services note dated 6/30/2025 at 3:45 PM written by SW #1 identified Resident #1 was noted walking up near the social worker's office when he/sheengaged in a verbal confrontation with Resident #2 that included threats of physical violence. The two residents were separated, and Resident #1 went into the social worker's office. Initially Resident #1 was highly irritated but eventually was able to be diffused and was walked back to his/her room. Shortly thereafter, Resident #1 came back to the social worker's office, cursing and making threats of violence. The Administrator and ADNS intervened with the ADNS escorted Resident #1 to his/her room, distracting Resident #1 through conversation. Social Services note for Resident #2 dated 6/30/2025 at 3:53 PM identified Resident #2 when a verbal altercation occurred, the residents were separated, and Resident #2 went out on the patio and denied any wrongdoing in the incident. A nursing note for Resident #1, dated 6/30/2025 at 8:09 PM written by LPN #3 identified Resident #1 was observed screaming and swearing at other residents and staff at the beginning of the shift. Resident #1 was evaluated by psychiatric APRN with new orders obtained. A psychiatric APRN #1 note for Resident #1, dated 6/30/2025 at 4:01 PM written by APRN #1 identified she evaluated Resident #1 due to an alleged verbal aggression. Resident #1 was anxious and irritable and had some difficulty decreasing his/ her irritability and anxiety. A PRN (as needed) and a one-time dose of Trazadone (anti-depressant medication also used to treat anxiety) 50 milligrams (mgs) were ordered. A psychiatric APRN #1 note for Resident #2, dated 6/30/2025 at 4:50 PM identified she evaluated Resident #2 after the indicated, and Resident #2 was pleasant and denied initiating the incident. Resident #2 reported feeling safe at the facility. Interview and medical record review with SW #1 on 8/20/2025 at 12:50 PM identified that on 6/30/2025 she observed Resident #1 following Resident #2 into the lobby area in front of her office. Resident #1 was yelling, both residents called each other b-tch and Resident #1 responded, you know what happened the last time. SW #1 identified Resident #1 was referring to a previous resident to resident incident on 6/14/2025 when Resident #1 slapped Resident #2 during a verbal altercation, and Resident #1 told Resident #2 this would end the same way, with Resident #1 slapping Resident #2, if the argument continued. There was no physical contact between the residents and they were separated. SW #1 stated a short time later Resident #1 returned to her office, was yelling and swearing, and threatened to hit her. The former Administrator and the ADNS (currently the DON) responded and assisted to calm Resident #1. SW #1 could not recall if she told the Administrator or the ADNS about her observation of the initial resident to resident verbal aggression and physical threat that occurred prior to this incident. Interview and medical record review with RN #2 on 8/21/2025 at 9:40 AM identified she was the supervisor on 6/30/2025 but she could not recall that she was informed about the resident-to-resident event on 6/30/2025 observed by SW #1. Although attempted, interview with APRN #1 and LPN #3 were not obtained during the survey. Interview and medical record review with the DON (prior ADNS) on 8/21/2025 at 11:40 AM, identified she responded to a call for assistance to the social workers office on 6/30/2025 at approximately 3:45 PM. She observed Resident #1 cursing and yelling at SW #1 and was able to distract Resident #1 and escorted Resident #1 back to his/her room. Although SW #1, APRN #1 and nursing staff all documented the incident in their notes, the DON stated that staff did not inform her of the incident that SW #1 observed earlier between Resident #1 and Resident #2. The DON stated if she had been notified, she would have identified it as a resident-to-resident incident of alleged verbal abuse, notified the Administrator and the DON and reported the incident to the State Agency. Subsequent to the surveyor inquiry, the facility notified the State Agency on 8/20/2025 at 12:29 PM (51 days after the incident occurred). The facility Abuse Policy directed in part, that abuse, or mistreatment was strictly prohibited. Verbal abuse is defined as the use of oral, written or gestured language that included derogatory or threatening terms directed at a resident or within hearing distance. Allegations of abuse were reported promptly; the supervisor is notified immediately who would notify the DON and the Administrator who were responsible for reporting. The Administrator/DON or designee must submit an online report to the State authority within two (2) hours.

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for nine (9) of nine (9) residents (Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11) reviewed for Enhanced Barrier Precautions (EBP), the facility failed to ensure trash cans were positioned inside the residents rooms and near the exit for discarding Personal Protective Equipment (PPE) after removal and failed to ensure periodic monitoring of resident rooms with EBP supplies and staff adherence to EBP. The findings include: Review of the facility Multidrug Resistant Organisms (MDRO) and Precautions Log dated 5/14/25 identified that Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11 were on precautions, requiring PPE. Observations and interview with RN #2 (Infection Control nurse) on 5/21/25 at 1:35 PM failed to identify that trash receptacles were placed in the doorways of Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11's room. The closest trash receptacles in each room were located behind closed doors of the bathrooms. RN #2 identified she was responsible for ensuring each room had the proper precaution supplies, spot checking rooms intermittently to ensure proper precaution signage, PPE was available and in place, a trash receptacle was located inside each doorway and that staff were donning and doffing PPE appropriately when entering and exiting identified rooms. She identified she had not done the spot checks. RN #2 reported that the MDRO and Precautions Log was up-to-date and that Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11 required precautions. Additionally, she identified that the facility did not have enough trash receptacles available for all the residents currently on precautions and reported that she was going to the store to purchase more. Interview with NA #4 on 5/21/25 at 1:42 PM identified that since a trash receptacle was not available to discard PPE upon exiting residents' rooms, she either removed the PPE and placed it in the bathroom trash or in the community trash in the hallway. She identified there was a shortage of trash receptacles within the facility. Interview with RN #1 (Regional nurse) on 5/21/25 at 2:01 PM identified that for infection control, trash receptacles should be located inside the doorway of each resident room on precautions for easy disposal of contaminated PPE. She reported she was unaware that trash receptacles were not located inside the doorway of Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11's room. Observation on 5/22/25 at 10:58 AM identified covered trash receptacles were located inside the doorway of Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11's room. Review of Center for Disease Control (CDC) guidance for the Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24 identified that when implementing Contact Precautions or Enhanced Barrier Precautions, a trash can is to be positioned inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Additionally, it identified that the facility is to incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Although received, the Enhanced Barrier Precautions policy dated 5/5/24 did not speak to trash receptacle location or periodic monitoring to the adherence of EBP.

Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of three (3) residents (Residents #1, 2 and 3) reviewed for skin impairments, the facility failed to review and revise the Resident Care Plans (RCP) to include additional interventions to prevent further deterioration following the identification of new skin impairments. The findings include: 1. Resident #1's diagnoses included cellulitis (bacterial skin infection), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet) and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 11), required setup assistance for eating and bed mobility and supervision assistance with transfers. A nurse's note dated 3/16/25 at 7:51 AM by RN #5 identified Resident #1 had an irregularly shaped open area to the right lateral (outer) foot, the area was painful, and warm to touch. The note identified Resident #1 needed podiatry (foot) services and/or a wound care follow-up and that an order was obtained to cleanse the area and apply a scant (tiny) amount of Santyl (an ointment that's used to remove damaged tissue from skin ulcers and severely burned areas) followed by a dry dressing and gauze wrap to protect the area daily and as needed. Review of the facility census identified Resident #1 was admitted to the hospital from [DATE] through 3/26/25. Review of the hospital documentation dated 3/19/25 identified Resident #1 was noted with diffuse (spread over a wide area) rheumatoid arthritis nodules (firm lumps under the skin that form close to joints), an open foot ulcer and lower extremity cellulitis. The documentation identified the skin impairments as a right upper calf rash, an ulcer to the right medial (closer to the midline) first toe and an ulcer to the right posterior (backside) calf. The Nursing admission assessment dated [DATE] identified Resident #1 was readmitted to the facility with right lower leg cellulitis and a right medial (closer to the midline) foot vascular wound (an open sore that develops due to problems with blood circulation and can be slow to heal). A wound physician note dated 4/2/25 at 4:13 PM identified Resident #1 was evaluated for right lower leg and right foot wounds. The note reported the wounds were full thickness (extending through all layers of the skin and can affect deeper tissues like muscle, bones or tendons) and that only the largest of the two (2) wounds were measured identifying the size as 20 centimeters (cm) by 16 cm by 1.5 cm with 25 to 49 percent (%) granulation tissue (newly formed connective tissue that develops at the wound site in the process of healing), 50 to 74 % slough (a collection of dead tissue and debris that's a pale yellow or brown color and can hinder the healing process) and a moderate amount of serosanguinous drainage (a thin and watery fluid that's pink in color due to small amounts of red blood cells). The Resident Care Plan (RCP) dated 4/22/25 (36-days after the skin impairements were identified and 4-days after the resident passed away at the facility) identified Resident #1 was at risk for skin breakdown due to decreased mobility and incontinence and other risk factors included poor nutrition, pronounced bony prominences (bones close to the surface), poor circulation and altered sensation. The RCP identified that on 3/26/25 Resident #1 was identified with cellulitis of the lower extremities. Interventions included inspecting skin when providing care for signs and symptoms of skin breakdown and consulting with the wound care nurse as ordered/needed. Interview with LPN #1 on 5/21/25 at 12:45 PM identified Resident #1 had rheumatoid arthritis nodules to both lower extremities since admission and they should have been documented in the RCP. 2. Resident #2's diagnoses included subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissue covering the brain) and epilepsy (repeated seizures due to abnormal electrical signals produced by damaged brain cells). The RCP dated 3/11/24 identified Resident #2 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required substantial assistance for bed mobility and was dependent on staff for personal hygiene and transfers. The facility wound tracker identified Resident #2 acquired a right lateral foot pressure ulcer on 12/30/24 and a right lateral ankle pressure ulcer on 2/13/25. The facility wound tracker identified that as of 5/14/25 the right lateral foot pressure ulcer and the right lateral ankle pressure ulcer were still open, requiring wound care treatments. A nurse's note dated 5/14/25 at 7:15 PM identified the right lateral ankle and right lateral foot pressure ulcers remained unhealed and that the RCP was updated with new interventions as appropriate. Review of the clinical record failed to identify revisions or additional interventions were added to the RCP since 3/11/24 (one year, two months ago). 3. Resident #3's diagnoses included dementia without behavioral disturbances, type 2 diabetes mellitus, peripheral vascular disease (a circulatory condition when narrowed blood vessels reduce the blood flow to the limbs) and neuropathy (weakness, numbness and pain from nerve damage most often in the hands and feet). The Resident Care Plan (RCP) dated 6/18/24 identified Resident #3 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), was independent with bed mobility and dependent on staff for personal hygiene and transfers. A nurse's note dated 4/26/25 at 1:52 PM identified Resident #3's family member notified nursing of redness between the right great toe and right second toe. The note identified the area was assessed, cleansed, dried and lambs wool was applied to the area followed by gauze, Resident #3 denied pain and the Advanced Practice Registered Nurse (APRN) was notified. The facility wound tracker identified Resident #3 acquired a right second toe diabetic wound on 4/30/25. A nurse's note dated 5/14/25 at 7:39 PM identified the right second toe wound remained unhealed and that the RCP was updated with new interventions as appropriate. Review of the clinical record failed to identify any revisions or additional interventions to the RCP since 6/18/24 (eleven months ago). A nurse's note dated 5/20/25 at 1:13 PM identified, in part, that Resident #3 was receiving doxycycline (antibiotic) for a right second toe infection with no adverse (unwanted) effects. Interview with RN #2 (Infection Control nurse) on 5/21/25 at 1:35 PM identified that upon the discovery of a new skin impairment, the charge nurse is responsible for initiating/revising the RCP. She identified that if any additional interventions need to be added or if she evaluates the resident with the wound physician and new recommendations or interventions are initiated, she would be responsible for revising the RCP. RN #2 reported that the skin RCP's for Residents #1, 2 and 3 should have been revised following the discovery of skin impairments but was unable to explain why interventions had not been added timely to prevent further deterioration of the skin. Interview with RN #1 on 5/21/25 at 2:01 PM identified that RCP's should be an interdisciplinary effort but reported that for any resident change in condition, including a new skin impairment, the charge nurse or whoever assessed the area should initiate/revise the RCP immediately and then RN #2 would be responsible for ensuring the revision was made and further revising the RCP with any updated interventions and changes until the area is healed. RN #1 identified that she was unaware the RCP's of Residents #1, 2 and 3 had not been revised timely and that the RCP should be revised immediately but not to exceed 72-hours. Interview with RN #4 on 5/21/25 at 2:32 PM identified that following a new skin ulcer or skin irregularity, the charge nurse or RN #2 should have updated the RCP immediately to include a new intervention to prevent worsening of the area. She identified that she was unsure why the RCP hadn't been revised for Residents #1, 2 and 3 but reported she would revise the RCP for areas she identified as missing and for Resident #1, she updated the 3/26/25 occurrence when she closed out the MDS following his/her death in the facility. Review of the Wound and Skin Care Protocol policy (undated) directed, in part, that weekly body audits will be completed on bath/shower day by a licensed nurse and all skin areas will have weekly documentation until healed. The interdisciplinary plan of care will address problems, goals and interventions directed towards the prevention and/or treatment of impaired skin integrity/pressure ulcer, consistent with resident/family goals. The care plan including the admission/readmission care plan will address preventative and/or treatment of impaired skin integrity/pressure ulcer. Review of the Care Planning policy dated 10/30/20 directed, in part, that the care plan is developed by the Interdisciplinary Team (IDT) in collaboration with the resident and/or family/responsible party and the resident's physician. The IDT may include, but is not limited to, the Resident Care Coordinator, Charge Nurse, NA, Dietary Manager or Dietician, Social Worker, Rehab Therapist and Activities Director. The care plan will include: a statement of the problem/focus; reasonable and measurable goals; interventions to achieve these goals and the discipline(s) responsible for carrying out the interventions. The care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the residents' status.

Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of three (3) residents (Residents #1, 2 and 3) reviewed for skin impairments, the facility failed to complete weekly skin assessments per physician's order. The findings include: 1. Resident #1's diagnoses included cellulitis (bacterial skin infection), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet) and chronic pain syndrome. A physician's order dated 1/23/25 directed that a body audit was to be completed weekly on the shower day. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 11), required setup assistance for eating and bed mobility and supervision assistance with transfers. Review of the Weekly Body Audit dated 2/20/25 identified that a body audit was completed, and no new areas were identified. Review of the clinical record from 2/21/25 through 3/15/25 failed to identify any further Weekly Body Audits for Resident #1. A nurse's note dated 3/16/25 at 7:51 AM by RN #5 identified Resident #1 had an irregularly shaped open area to the right lateral (outer) foot, the area was painful, and warm to touch. The note identified Resident #1 needed podiatry (foot) services and/or a wound care follow-up and that an order was obtained to cleanse the area and apply a scant (tiny) amount of Santyl (an ointment that's used to remove damaged tissue from skin ulcers and severely burned areas) followed by a dry dressing and gauze wrap to protect the area daily and as needed. Review of the facility census identified that Resident #1 was admitted to the hospital from [DATE] through 3/26/25. Review of the hospital documentation dated 3/19/25 identified Resident #1 was noted with diffuse (spread over a wide area) rheumatoid arthritis nodules (firm lumps under the skin that form close to joints), an open foot ulcer and lower extremity cellulitis. It reported Resident #1 had a [NAME] Blood Cell (WBC) count of 15.7 (signaling infection) and Resident #1 was continued on antibiotics and admitted for further evaluation. The documentation identified the skin impairments as a right upper calf rash, an ulcer to the right medial (closer to the midline) first toe and an ulcer to the right posterior (backside) calf. The Nursing admission assessment dated [DATE] identified Resident #1 was readmitted to the facility with right lower leg cellulitis and a right medial (closer to the midline) foot vascular wound (an open sore that develops due to problems with blood circulation and can be slow to heal). A wound physician note dated 4/2/25 at 4:13 PM identified Resident #1 was evaluated for right lower leg and right foot wounds. The note reported the wounds were full thickness (extending through all layers of the skin and can affect deeper tissues like muscle, bones or tendons) and that only the largest of the two (2) wounds were measured identifying the size as 20 centimeters (cm) by 16 cm by 1.5 cm with 25 to 49 percent (%) granulation tissue (newly formed connective tissue that develops at the wound site in the process of healing), 50 to 74 % slough (a collection of dead tissue and debris that's a pale yellow or brown color and can hinder the healing process) and a moderate amount of serosanguinous drainage (a thin and watery fluid that's pink in color due to small amounts of red blood cells). The Resident Care Plan (RCP) dated 4/22/25 (36-days after the skin impairments were identified and 4-days after the resident passed away at the facility) identified Resident #1 was at risk for skin breakdown due to decreased mobility and incontinence and other risk factors included poor nutrition, pronounced bony prominences (bones close to the surface), poor circulation and altered sensation. The RCP identified that on 3/26/25 Resident #1 was identified with cellulitis of the lower extremities. Interventions included inspecting skin when providing care for signs and symptoms of skin breakdown and consulting with the wound care nurse as ordered/needed. 2. Resident #2's diagnoses included subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissue covering the brain) and epilepsy (repeated seizures due to abnormal electrical signals produced by damaged brain cells). The RCP dated 3/11/24 identified Resident #2 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required substantial assistance for bed mobility and was dependent on staff for personal hygiene and transfers. A physician's order dated 1/27/24 directed a body audit be completed on admission and weekly by a licensed nurse on shower day and that it was to be documented on the body audit form. The facility wound tracker identified Resident #2 acquired a right lateral foot pressure ulcer on 12/30/24 and a right lateral ankle pressure ulcer on 2/13/25. Review of the Weekly Body Audit dated 2/2/25 identified that a body audit was completed, and no new areas were identified. Review of the clinical record from 2/3/25 through 5/21/25 failed to identify any further Weekly Body Audits for Resident #2. Review of nurse's notes from 2/6/25 through 5/21/25 failed to identify any documentation on the resident's wounds the week of 3/9/25, the week of 4/13/25, the week of 4/20/25, the week of 4/27/25 or the week of 5/4/25. A nurse's note dated 5/14/25 at 7:15 PM identified the right lateral ankle and right lateral foot pressure ulcers remained unhealed and that the RCP was updated with new interventions as appropriate. The facility wound tracker identified that as of 5/14/25 the right lateral foot pressure ulcer and the right lateral ankle pressure ulcer were still open, requiring wound care treatments. 3. Resident #3's diagnoses included dementia without behavioral disturbances, type 2 diabetes mellitus, peripheral vascular disease (a circulatory condition when narrowed blood vessels reduce the blood flow to the limbs) and neuropathy (weakness, numbness and pain from nerve damage most often in the hands and feet). The Resident Care Plan (RCP) dated 12/17/24 identified Resident #3 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. A physician's order dated 12/31/24 directed a body audit be completed on admission and weekly by a licensed nurse on shower day and that it was to be documented on the body audit form. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), was independent with bed mobility and dependent on staff for personal hygiene and transfers. Review of the clinical record from 3/1/25 through 4/14/25 failed to identify any completed Weekly Body Audits. A physician's order dated 4/15/25 directed that a body audit was to be completed weekly by a licensed nurse on shower day. Review of the clinical record from 4/15/25 through 4/25/25 failed to identify any completed Weekly Body Audits. A nurse's note dated 4/26/25 at 1:52 PM identified Resident #3's family member notified nursing of redness between the right great toe and right second toe. The note identified the area was assessed, cleansed, dried and lambs wool was applied to the area followed by gauze, Resident #3 denied pain and the Advanced Practice Registered Nurse (APRN) was notified. The facility wound tracker identified Resident #3 acquired a right second toe diabetic wound on 4/30/25. Review of nurse's notes from 4/27/25 through 5/14/25 failed to identify weekly skin notes until 5/14/25. A nurse's note dated 5/20/25 at 1:13 PM identified, in part, that Resident #3 was receiving doxycycline (antibiotic) for a right second toe infection with no adverse (unwanted) effects. Interview with RN #1 (Regional) on 5/21/25 at 2:01 PM identified that all residents are to have a skin/body audit weekly and that nursing should follow physician's orders. She was unsure why weekly skin audits were not done consistently for Residents #1, 2 and 3 but indicated they should have been. She reported that around mid-April 2025, the company adopted a new skin process where licensed nurses only chart by exception and if a new skin area is found, nurses should document the area in the clinical record, notify the provider and transcribe any new orders. RN #1 was unsure why the physician's orders for Residents #2 and #3 still directed to document the skin assessment on the body audit form but identified that prior to mid-April, licensed nurses should have been documenting on the Body Audit Form for each resident weekly. Although attempted, an interview with RN #5 was not obtained. Review of the Wound and Skin Care Protocol policy (undated) directed, in part, that weekly body audits will be completed on bath/shower day by a licensed nurse and all skin areas will have weekly documentation until healed. The interdisciplinary plan of care will address problems, goals and interventions directed towards the prevention and/or treatment of impaired skin integrity/pressure ulcer, consistent with resident/family goals. The care plan including the admission/readmission care plan will address preventative and/or treatment of impaired skin integrity/pressure ulcer. Although requested, a policy on following physician's orders was not obtained.?

Based on clinical record review, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was a recent admission and had acknowledged full Cardio-Pulmonary Resuscitation (CPR) in the advance directive and physician's order, the facility failed to continue cardiopulmonary resuscitation after CPR was initiated, failed to call Emergency Medical Services and the licensed staff did not have knowledge of the procedure when the resident was noted to be unresponsive and pulseless which resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included hypertension and diabetes. The Medical Interventions Consent Form dated [DATE] signed by Resident #1 elected Cardio-Pulmonary Resuscitation (CPR). The Resident Baseline Care Plan dated [DATE] identified Resident #1 had an established advanced directive. Interventions directed full code. A physician's order dated [DATE] directed CPR. The physician's progress note dated [DATE] identified code status: full code. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily living, required substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of bed and sit to stand. The nurse's note, written by the 11PM-7AM Nursing Supervisor dated [DATE] at 6:00 AM identified she was called to Resident #1's bedside at 4:56 AM to pronounce Resident #1. The note indicated no spontaneous movements were present, there was no response to verbal or tactile stimuli, the pupils were fixed, no breath sounds were noted over entire lung fields, the carotid pulses were not palpable, no heart sound was auscultated for over sixty (60) seconds. Resident #1 was pronounced deceased at 5:15 AM. Interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on [DATE] at 11:10 AM identified she and the Nursing Supervisor, Registered Nurse (RN) #1, were sitting at the nurse's station around 4:,d+[DATE]:50 AM when one (1) of the nurse aides came to the nurse's station and stated Resident #1 had expired. LPN #1 indicated she followed the nurse aide to Resident #1's room and RN #1 also followed them. LPN #1 indicated once at Resident #1's bedside, RN #1 closed Resident #1's eyes, covered Resident #1 with a blanket up to his/her neck and at that time LPN #1 left Resident #1's room, however RN #1 stayed with Resident #1. LPN #1 identified she went back to the nurse's station, obtained Resident #1's chart to find Resident #1's advanced directives and found out Resident #1 was a full code. LPN #1 indicated at the point RN #1 was walking back to her medication cart which was located at the nurse's station down the hall from Resident #1's room and she told RN #1 that Resident #1 was a full code and RN #1 had to perform CPR. LPN #1 identified RN #1 stated she already did CPR and RN #1 came behind the nurse's station and called the on-call physician service. LPN #1 indicated she did not hear the conversation RN #1 had with APRN #1 and RN #1 did not tell her what was said. LPN #1 identified at that point she called the DON repeatedly because the Director of Nursing (DON) needed to know what was going on. LPN #1 indicated then RN #1 directed her to call Resident #1's family, to call the funeral home and she did. LPN #1 identified she never went back to Resident #1's room, and she did not witness RN #1 administering CPR to Resident #1. LPN #1 indicated neither RN #1 nor she called 911 when Resident #1 was found unresponsive and pulseless. Interview with the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1, on [DATE] at 11:20 AM identified Resident #1 was on her assignment, and she was alerted by the nurse aide at 4:56 AM that Resident #1 was dead. RN #1 indicated she along with LPN #1 immediately went to Resident #1's room to assess Resident #1. RN #1 identified Resident #1's upper and lower extremities were cold, stiff, and blue, Resident #1 was pulseless, pupils were fixated, eyes were wide open without movement, Resident #1's mouth was wide open, and Resident #1 was not responding to her or LPN #1. RN #1 indicated she asked LPN #1 at that time if Resident #1 was a full code because they immediately got up, ran to Resident #1's room when the nurse aide stated Resident #1 was dead and she did not check Resident #1's code status. RN #1 identified LPN #1 and RN #1 left Resident #1's room and RN #1 went to gather the equipment to come back to Resident #1's room. RN #1 indicated she grabbed two (2) blood pressure cuffs, an automatic and a manual one, a thermometer, the glucometer, pulse oximeter and a stethoscope. RN #1 identified as she was gathering the equipment LPN #1 told her Resident #1 was a full code. RN #1 indicated she returned to Resident #1's room within one (1) to two (2) minutes and assessed Resident #1 all over again. RN #1 identified as she was auscultating Resident #1's heart, Resident #1's roommate was talking to her and she thought she had heard something when she was auscultating the heart and immediately started CPR. RN #1 indicated she administered fifteen (15) to twenty (20) compressions, she heard a crack on Resident #1's bones and had stopped administering CPR. RN #1 identified she then started auscultating Resident #1's heart all over again and heard nothing, she checked Resident #1's carotid and radial pulses again and there were no pulses, auscultated lungs sound on Resident #1's back and front and there were no breaths sounds, the automatic blood pressure monitor, and manual blood pressure monitor could not detect blood pressure. RN #1 indicated that at that point she closed Resident #1's eyes and covered Resident #1 with a blanket around 5:15 AM, left Resident #1's room, went back to the nurse's station and LPN #1 was on the phone trying to call the DON for some guidance because there was nothing outlining what to do when staff finds a resident deceased . RN #1 indicated while LPN #1 was calling the DON, she went into the nursing office to try to find some guidance. RN #1 identified then she called the on-call physician service and received a call back from the Advanced Practice Registered Nurse, APRN #1, and she told APRN #1 she found Resident #1 unresponsive, pulseless, and asked APRN #1 what to do in a case when a resident was deceased . RN #1 indicated APRN #1 directed her to release Resident #1's body to the funeral home and write a note. RN #1 identified she did not call 911 because Resident #1 had expired and LPN #1 stated to her that a RN may pronounce a resident 's death in the nursing home setting. Interview with the 11PM-7AM Nurse Aide (NA) #2, on [DATE] at 12:37 PM identified last time she provided care to Resident #1 around 2:,d+[DATE]:30 AM and Resident #1 stated he/she was okay. NA #2 indicated around 5:00 AM another nurse aide, NA #1, asked her to come and see Resident #1 because Resident #1 had expired. NA #2 identified she went to Resident #1's room and then ran to notify the nurse. Interview with the Attending Physician (MD) #2 on [DATE] at 2:08 PM identified if Resident #1 was a full code, was found unresponsive, cold, blue, stiff, and pulseless CPR should have been initiated by the facility staff and 911 should have been called regardless of Resident #1's state. Interview with the Medical Director (MD) #1 on [DATE] at 2:35 PM identified RN #1 and LPN #1 should have been following the protocol and he would expect the nurses to perform CPR and call 911, however the outcome would not have been any different if the nurses performed CPR. Interview with the Director of Nursing (DON) on [DATE] at 12:40 PM identified once RN #1 was made aware Resident #1 was unresponsive the expectation was for RN #1 to direct either LPN #1 or one of the nurse aides to call 911, check Resident #1's code status and gather the crash cart and Automated External Defibrillator (AED) while RN #1 went to Resident #1's room to assess Resident #1. The DON indicated if Resident #1 was identified as a full code, RN #1 should have initiated CPR and continued until EMS arrived and took over the cardiopulmonary resuscitation efforts. The Cardiopulmonary Resuscitation (CPR) policy directed CPR will be initiated per physician orders and in accordance with the resident's advance directives. Once it has been determined the resident has no pulse and has stopped breeding, CPR must be started immediately. The nursing supervisor or designee will direct the provision of CPR until relieved by professional ambulance personnel. The attending physician or medical director will be notified as soon as possible of events. The events will be documented in the resident's medical record. Although attempted, interviews with NA #1 and APRN #1 were unsuccessful.

Based on a review of clinical records, facility documentation, facility policy, and interviews, for one 1 of two (2) residents reviewed for Cardio-Pulmonary Resuscitation, (Resident #1), the facility failed to initiate Cardio-Pulmonary Resuscitation when it was identified that the resident was without respirations and a pulse, failed to ensure a physician's order was written in the clinical record that directed the resident to have Cardio-Pulmonary Resuscitation, and further failed to ensure physician orders were written for two (2) additional residents, (Resident #2, and Resident #3) for a full code status when the residents or their responsible party were undecided on advanced directives which resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI), urinary retention, and Covid 19. A nurse's note written by the interim Director of Nursing Services dated [DATE] at 7:09 PM identified Resident #1 was admitted to the facility, however, the nurse's note failed to identify if Resident #1 was educated on advanced directives and if his/her code status was addressed. A history and physical completed by Physician #1 (MD#1) dated [DATE] identified Resident #1 was a Full Code (to initiate Cardio-Pulmonary Resuscitation (CPR) if found without a pulse or respirations). Review of Resident #1's Medical Interventions Consent Form identified the form had Resident #1's name, date of birth, and room number on the form but failed to indicate Resident #1's code status and required signatures. Physician orders for November and [DATE], failed to identify the code status for Resident #1. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition. A Care Plan dated [DATE] failed to identify Resident #1 had an advanced directive. A RN death pronouncement form dated [DATE] at 8:30 AM identified RN #1 pronounced Resident #1's death. The form identified the funeral home was contacted at 9:30 AM and Resident #1's body was released to the funeral home at 11:45 AM. A late entry nurse's note dated [DATE] at 8:49 PM identified License Practical Nurse (LPN) #1 was called to Resident #1's room by Nurse Aide (NA)#1 because Resident #1 was not responding. On arrival LPN #1 found Resident #1 unresponsive with a very low rate of respirations at eight (8) a minute, the supervisor was notified (RN #1), and LPN #1 left the room to retrieve vital sign equipment. Upon return, LPN #1 identified that Resident #1 had no pulse or respirations, and a call was placed to the family and the physician to notify of the death of Resident #1. A late entry nurse's note dated [DATE] written by RN #1 at 8:52 PM identified she was called into Resident #1's room to check on the resident and observed the resident was unresponsive with a low respiratory rate and then shortly after entry into the room the resident passed away. Interview with LPN #1 on [DATE] at 11:00 AM identified on [DATE], NA #1 told him to go to Resident #1's room because the resident was unresponsive, he notified the supervisor and they both entered Resident #1's room. Upon entry, the resident was not responding to verbal or physical stimuli and his/her respiration were about 8 breaths per minute (normal rate is ,d+[DATE] breaths a minute). LPN #1 identified he left Resident #1's room to go get vital sign equipment and RN #1 remained with Resident #1, he was gone for approximately three (3) minutes and when he returned to Resident #1's room the resident had passed away. LPN #1 then went to Resident #1's chart (approximately ,d+[DATE] minutes after the resident expired) to identify which funeral home to contact and noted Resident #1 had a blank advanced directive form, he further identified that facility policy states that if there is no advance directive form filled out, the resident should be a full code, knowing that they did not perform CPR on Resident #1, he immediately told the Administrator. LPN #1 identified that he did not think to check the resident's chart for code status at the time of the resident's death, and he was unable to identify why he did not. Interview with RN #1 on [DATE] at 9:30 AM identified she was called into Resident #1's room by LPN #1 and identified Resident #1's respirations were retracted (a sign of respiratory distress) and were about 12 breaths per minute. RN #1 identified that LPN #1 went to get the pulse oximeter as she stayed with Resident #1, and within a few minutes Resident #1 stopped breathing, she listened to Resident #1's heart and lung sounds and took his/her blood pressure and none were present. She identified she did not think to check Resident #1's chart for code status, because she was going through the motions and the deaths she had dealt with previously were all Do Not Resuscitate. She further identified she thought Resident #1 was a DNR because s/he was ninety-four (94) years old, frail and would most likely not survive chest compressions. She further identified that she was aware that if a resident does not have a completed code status form, they will be a full code. She identified she knows now to check the residents' orders and code status during a code. Interview with RN #2 on [DATE] at 1:18 PM identified she was the nurse that admitted Resident #1 on [DATE]. She identified that Resident #1 could not decide on a code status at the time of admission. RN #2 stated that she failed to communicate this to any other staff members, and further failed to follow up on Resident #1's code status. Interview with MD #1 on [DATE] at 1:35 PM identified he depends on facility staff to discuss code status with the residents. On [DATE] he documented Resident #1 was a full code on his progress note because Resident #1 did not say h/she wanted to be a DNR. He further identified that he did not inform staff of Resident #1's code status or write an order. MD #1 further identified if a resident does not have a code status on file, they would be full code, and CPR should have been initiated when Resident #1 stopped breathing and had no pulse. Interview with the Medical Director on [DATE] at 1:20 PM identified the code status should be checked during a code, and if he code status was undecided or a resident did not have a code status on file, he would expect the resident to be treated as a full code and staff to perform CPR. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Meniere's disease, Covid 19, and a cognition communication deficit. An undated face sheet identified that Resident #2 had a conservator of person and estate. Review of Resident #2's current electronic orders and clinical record failed to identify Resident #2 had a code status order or a signed medical interventions consent form identifying the resident's decision about code status. Review of the Physician order sheet identified an order dated [DATE] (greater that 10 months from admission) that directed the resident to be a full code, the conservator had been contacted three times without success. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, adult failure to thrive, and Covid 19. An undated facility face sheet identified Resident #3 had a conservator of person and estate. Review of Resident #2's current electronic orders and clinical record failed to identify Resident #3 had a code status order or a signed medical interventions consent form identifying the resident's decision about code status. Review of the Physician order sheet identified an order dated [DATE] (greater than 5 months since admission) that directed the resident to be a full code, the conservator had been contacted three times without success. Interview with the Director of Clinical Services (DCS) on [DATE] at 1:45 PM identified she would expect staff to perform CPR for a resident who has no code status on file. She further identified the admission nurse is responsible for reviewing the code status with the resident and if they do not decide, a note must be documented in the clinical record that explains the resident will have CPR if they are undecided and report must be given to the next charge nurse for follow up. The DCS further identified that the physician should communicate with the staff if a decision on the code status is made, and a physician's order should be written once the decision is made. Review of the Advanced Directive policy directed that the facility provides each resident or the resident's representative, upon admission, with notice of this policy and of resident's rights regarding declining of treatment and advance directives and will be reviewed with the facility staff or attending physician. If a decision is made regarding advance directives, the advance directive consent form will be signed and dated by the resident or substitute decision maker(s), and the person who explained the advance directives. A physician's order will be obtained regarding advance directives. It further identified, if no decision is made related to advance directives the resident will remain a full code until a decision if made by the resident or substitute decision maker(s). The attending physician will address the resident's advance directives in the physician progress notes. The resident's advance directives will be documented in the resident's care plan and will be reviewed on a quarterly basis and as needed for any changes. Immediately following the incident on [DATE] the facility began staff education on the advanced directive policy, electronic orders must be compared and ensure they match the consent, and staff are to ensure timely follow up to any concerns regarding an advanced directives. A resident who is full code and found with no signs of life CPR must be initiated and 911 called and there must be clear documentation in the medical record when a code occurs. An audit of all residents advanced directives and staff CPR certification was conducted on [DATE] and [DATE]. However, the facility failed to address the physician's failure to communicate the patient's advanced directives with staff, and the need to write the advanced directives in the physician's orders. An immediate action plan was requested and received by the state agency on [DATE] that included education to all physicians about the advanced directives policy, and to immediately communicate with staff when an advanced directive is formulated, and to ensure a physician's order is written. An onsite visit on [DATE] verified that the action plan was implemented and the Immediate Jeopardy was removed as of [DATE].

Based on clinical record review, facility documentation, Emergency Medical Services (EMS) records, hospital medical records and interviews for the one sampled resident (Resident #1) who experienced a medical emergency, the facility failed to provide the necessary emergency basic life support when the resident was unresponsive and in respiratory distress to promote adequate airway clearance and effective breathing. The findings include: Review of Resident #1's clinical record on [DATE] identified that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1's admission care plan as an advance directive to begin cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. An admission Minimum Data Set assessment dated [DATE] identified that the resident had moderate cognitive impairment, a height of sixty-one (61) inches, weight of two hundred sixty (260) pounds, was without a swallowing disorder, had the ability to feed self after staff provided assistance with the set-up of the food, required extensive assistance of two staff for other activities of daily living (ADL) and was totally dependent on staff for transfers. Review of a twenty-four hour shift to shift report dated [DATE] (time unknown) indicated Resident #1 had experienced an acute change in condition. The report identified that the resident had a temperature of 97.4 degrees Fahrenheit, a pulse rate of 106 beats per minute, respirations of 20 breaths per minute, blood pressure of ,[DATE] and an oxygen saturation level of 84 percent. The twenty-four report further identified Resident #1 was slow to respond and was experiencing a cough, congestion and excessive oral secretions. 911 was called, and the resident was transferred to an acute care hospital for evaluation on [DATE]. Clinical record review identified that Resident #1 returned to the facility on [DATE] following a seven-day hospitalization A hospital discharge summary dated [DATE] identified that the resident had been admitted to the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. Further clinical record review identified Resident #1 was again transferred to the hospital and admitted on [DATE] at 12:10 PM. The resident remained hospitalized until [DATE] when a discharge summary identified primary [DIAGNOSES REDACTED]. On [DATE] at 6:13 AM a nurse's note identified Resident #1 had been found in acute respiratory distress on [DATE] at approximately 5:40 AM by Nurse Aide #1. The note indicated that Registered Nurse (RN) #1 subsequently assessed the resident and identified Resident #1 with irregular respirations with periods of apnea and skin color that was grayish blue. The nursing note further identified that when the nurse attempted to obtain the resident's oxygen saturation level, Resident #1 vomited, and frothy white liquid flowed out of the nose and mouth. Further review of the note identified that after EMS responders subsequently arrived, they used the facility's suction machine to attempt clearance of the vomit from the resident's mouth. Review of the EMS run report identified that a 911 call was received from the facility on [DATE] at 5:48 AM with EMS personnel dispatched at 5:51 AM. The report indicated that the EMS personnel arrived at the nursing home at 5:59 AM and reached the patient at 6:00 AM, twenty minutes after Resident #1 was found to be experiencing acute respiratory distress. The EMS report identified Resident #1 was unconscious/unresponsive with cyanotic, mottled skin, lying on his/her back (supine) in bed with vomitus in and outside the mouth. The report further indicated that fire department first responders who were the first to arrive started to suction the patient to clear the mouth and reported a rapid heart rate and a low oxygen saturation level of fifty percent (50%). Further review of the report identified the resident was placed on high flow oxygen at 15 liters per minute with a non-rebreather mask and was transferred onto a stretcher, placed in an upright seated position and moved into an ambulance before Resident #1 stopped breathing and became pulseless. The report identified cardiopulmonary resuscitation (CPR) was immediately started, suctioning of the airway was performed twice prior to transport and continuous CPR was administered during Resident #1's transport to an acute care hospital. The EMS report identified that a facility nurse had stated Resident #1 was last seen conscious, alert and oriented at 2:30 AM on [DATE]. Review of Resident #1's hospital medical record for the period from [DATE] through [DATE] identified Resident #1 arrived at the hospital emergency department on [DATE] at 6:44 AM for evaluation of [MEDICAL CONDITION]. The record indicated the resident required advanced life support with resolution of spontaneous circulation/blood pressure. A hospital respiratory therapy progress note dated [DATE] at 8:10 AM identified treatment continued for respiratory arrest which presented after [MEDICAL CONDITION], The progress note further indicated that there was evidence of significant neurological changes which suggested an oxygen deficiency had occurred. A physician's note dated [DATE] at 11:29 AM identified Resident #1 had experienced a clear-cut aspiration event during the episode. A subsequent physician's consultation note dated [DATE] at 2:15 PM identified Resident #1 was provided ventilatory support, and diagnostic imagery testing had identified devastating changes on head computerized topography consistent with severe hypoxic [MEDICAL CONDITION] with poor prognosis for the future. On [DATE] at 6:43 AM Resident #1's advance directives were changed to Do Not Resuscitate (DNR) with no CPR. The record further identified Resident #1 was extubated from life sustaining ventilatory support with family at the bedside and expired on [DATE] at 4:13 PM. Interview with Nurse Aide (NA) #1 on [DATE] at 6:25 AM identified s/he worked from 11:00 PM to 7:00 AM on the night of [DATE] to [DATE]. Nurse Aide #1 stated that Resident #1 was provided with care during rounds that were completed for all facility residents between 2:00 AM and 4:00 AM. S/he indicated the rounds were conducted with Nurse Aide #2, and during the 4:00 AM rounds s/he observed Resident #1 from the door, noted the resident looked comfortable and noticed the resident was lying on his/her back with the feet elevated on a pillow and without signs of restlessness. NA #1 further identified that when s/he and NA #2 conducted 4:00 AM rounds on [DATE], neither nurse aide entered Resident #1's room, provided care or offered the resident repositioning. NA #1 further stated that subsequent rounds started at 5:00 AM. S/he indicated that upon entering Resident #1's room with NA #2 at approximately 5:40 AM, the resident looked awful, was sweaty, and did not respond when his/her name was called or to tapping on the arm. NA #1 indicated fluids were coming out of Resident #1's mouth and nose, and NA #2 stayed with Resident #1 while s/he ran to obtain assistance from RN #1. Interview and clinical record review with Registered Nurse #1 on [DATE] at 7:05 AM identified that when vital signs were obtained on [DATE] at approximately midnight, Resident #1 was alert, joking with staff and denied distress or discomfort. Review of the Medication Administration Record [REDACTED]. RN #1 stated the last time s/he had checked on Resident #1 was a little after 2:00 AM when s/he observed the resident from the doorway and saw Resident #1 was lying on his/her back with signs of rhythmic breathing. RN #1 stated that when NA #1 reported Resident #1's change in condition, s/he attempted to obtain vital signs using the medical equipment located outside the resident's room. RN #1 further indicated that although a pulse oximeter was applied to several of the resident's fingers and a toe, s/he was unable to obtain a reading. S/he noted that NA #1 and NA #2 remained with Resident #1 when s/he left the room to call 911. RN #1 indicated that after calling 911, s/he obtained a vital signs kit that contained a digital blood pressure cuff and found that the resident's vital signs were all over the place with a very rapid pulse. RN #1 stated s/he left the resident's room a second time to obtain the facility's emergency crash cart and was preparing to use the suction machine when the first EMS responders arrived and started suctioning the resident's mouth. Interview with EMS Person #1 on [DATE] at 12:48 PM identified Resident #1 was found in a supine position on [DATE] at 6:00 AM without the benefit of effective airway management. S/he identified that because the resident was lying on his/her back, the vomit pooled in the back of the mouth and nose which obstructed the airway. EMS Person #1 indicated that as additional EMS personnel arrived and prepared to transport Resident #1 to the hospital, the resident was found to be cyanotic and subsequently stopped breathing and became pulseless while being moved into an ambulance. S/he stated that EMS personnel immediately initiated cardiopulmonary resuscitation (CPR) as the ambulance began to transport the resident to an acute care hospital. The facility failed to ensure that the necessary measures were immediately implemented to promote adequate airway clearance and sustain breathing when Resident #1 was found unresponsive and in respiratory distress while in bed in a supine position. After Resident #1 vomited, expectorated fluids pooled inside the mouth while the resident remained in a supine position. When first responders subsequently arrived, suctioning of the resident was initiated with the use of the facility's suction machine. Following admission to an acute care hospital, Resident #1 was diagnosed with [REDACTED].

Based on clinical record reviews, staff interviews, observations, and review of facility policy and procedure for two of six residents reviewed for pressure ulcers (R #31, #90), the facility failed to implement interventions in accordance with the resident's plan of care and/or implement interventions prior to the development of a pressure ulcer and/or complete a comprehensive skin assessment when the resident was noted with a change in skin condition. The findings include: 1. Resident #31's [DIAGNOSES REDACTED]. a. The quarterly MDS assessment dated [DATE] identified Resident #31 was cognitively impaired and required extensive assistance with bed mobility and transfers. The pressure ulcer risk assessment dated [DATE] identified a risk score of 12 indicating a high risk for pressure ulcer development. The care plan dated 10/26/16 identified the resident was at risk for skin breakdown. Interventions included to assist/offer to turn and reposition every two hours and provide a pressure redistributing mattress. A wound assessment record dated 12/19/16 identified the presence of a right foot, lateral heel pressure ulcer; unstageable measuring 3.5 cm x 1.5 cm and black in color. Interview and review of the clinical record and facility documentation with the DNS on 6/22/17 at 11:05 AM failed to provide documentation identifying preventative measures put in place prior to the development of the pressure ulcer on 12/18/16. A physician's orders [REDACTED]. b. The quarterly MDS assessment dated [DATE] identified Resident #31 was cognitively impaired, required extensive assistance with bed mobility and was totally dependent on staff for transfers. No pressure sores were identified although nurse's notes dated 5/2/17 at 9:35 AM identified that the right heel pressure sore was seen on wound rounds, was well scabbed with no s/s of infection, and a new order for Allevyn dressing was written. The physician's orders [REDACTED]. The resident care plan dated 6/9/17 identified the resident needed assistance with personal care, and was at risk for skin breakdown due to altered mobility. Interventions included a stage two blister on the right foot, apply treatment as indicated, weekly wound rounds, off load pressure to feet in bed, use a heel manager to off load pressure, while in w/c, position so feet do not rest against the foot box or remain crossed at the ankle, pressure redistributing mattress, and encourage/assist to reposition every two hours. The skin/wound assessment form dated 6/20/17 identified a right heel unstageable pressure sore measuring 0.3 x 0.3 cm; the wound was stable with no change. Observations on 6/19/17 at 12:10 PM identified the resident in the dining room with a blue boot on his/her right foot. Observation of Resident #31 on 6/20/17 at 11:00 AM identified the resident in the dining room, in the wheelchair, with both feet in the foot box attached to the wheelchair without the benefit of the blue boot on the right foot. Every 15 minute observations of Resident #31 on 6/21/17 from 6:45 AM until 7:15 AM identified the resident in bed with the heel manager in place but with the right heel resting on the mattress. Every 15 minute observations of Resident #31 from 7:32 AM through 10:45 AM (3 hours and 13 minutes) identified the resident seated in his/her wheelchair, with both feet in socks resting in the foot box without the benefit of the blue off loading boot. A blue off-loading boot was noted on the bedside chair. Interview, observation and review of facility documentation with RN#1, on 6/21/17 at 10:50 AM identified the Resident #31 according to the treatment kardex and physician's orders [REDACTED]. RN#1 identified that he/she must have forgotten to check for the off loading boot yesterday and today since it was not observed on the resident by the surveyor. RN#1 identified that the NA's are responsible to don the off loading boot, but review of the care card and the kiosk (directed care computer screen) failed to provide documentation that the NA's had been directed in writing/assignment to apply the off loading boot. Interview with NA#1 on 6/21/17 at 10:57 AM identified that he/she is directed to provide the resident's care according to the NA care card and kiosk information but that he/she was not able to find any information directing the placement of the off loading boot. Additionally NA#1 identified that he/she thought the boot was used over night while in bed. Interview and review of facility documentation with the DNS on 6/21/17 at 1:07 PM identified the resident's treatment kardex directed that the Allevyn dressing was discontinued on 5/9/17 and that the resident was to have lotion applied to the right heel, but s/he was unable to find a physician's orders [REDACTED].#31's heel was healed and had new pink skin, the heel should still be off loaded. Interview and observation of Resident #31's wound with the DNS and RN#1 on 6/21/17 at 1:15 PM identified that the DNS had seen the resident's right heel wound on 6/17/17 and the area was noted to be healed with only pink skin visible. On observation there was a pressure sore that was a scabbed area on the right heel that measured 0.6 cm x 1.5 cm, with no depth.The DNS identified the area was now hard and unable to be staged (unstageable). Interview with RN#2 on 6/22/17 at 11:35 AM identified that he/she worked the 3-11 shift on 6/21/17. He/she had reviewed the documentation dated 6/20/17 with the DNS and the measurements of the right heel documented on 6/20/17 were 0.3 x 0.3 cm. 2. Resident #90 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified the right forehead had two small skin tears and no pressure ulcers were present. The interim care plan dated 2/22/17 noted a risk for pressure ulcer development. Interventions included to off load heels in bed, and provide incontinent care. Physician orders [REDACTED]. The clinical record failed to reflect documentation that an assessment of the right buttocks was completed when the resident was identified with a change in skin condition. The admission MDS assessment dated [DATE] identified the resident had intact cognition, no mood or behaviors were exhibited, required extensive assistance with toilet use and personal hygiene and supervision with bed mobility, and transfers, occasional incontinence with bladder and was frequently incontinent of bowel, at risk for pressure ulcer development and did not currently have any pressure ulcers. Nurse's notes dated 3/4/17 noted an abrasion to the coccyx was identified. The clinical record failed to reflect documentation that an assessment of the abrasion was completed at that time or a reportable event completed to indicate the origin of the abrasion injury. Facility policy and procedure for wound and skin care identified all residents will be assessed for risk of skin breakdown on admission/readmission, every week for four weeks, upon a significant change in condition, quarterly and yearly. A complete wound assessment and documentation will be done when a new pressure ulcer is identified and continued weekly until healed. Included in the wound documentation will be the site/location, stage of the wound, size including length, width, and depth, appearance of the wound bed, undermining/tunneling and if there is any exudate. Interview and review of the clinical record with the DNS on 6/21/17 at 12:40 PM noted when staff identify a change in the resident's skin condition, a thorough assessment should be completed and documented in the clinical record. The DNS noted that the documentation should include the location of the wound, stage, measurement of the wound, if there is any drainage and the condition of the periwound. The clinical record failed to reflect a comprehensive skin assessment was completed when the resident was identified with a change in skin condition.

Based on clinical record review and interview for one of three sampled residents reviewed for pressure sores (R#100), the facility failed to Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified the resident had [MEDICAL CONDITION] of the lower extremities (pitting plus 1). Further review of the body /skin assessment on admission identified no skin integrity issues on the heels. Admission nursing note dated 4/10/14 at 8 PM identified the resident had [MEDICAL CONDITION] of both lower extremities. Admission care plan dated 4/11/14 identified the problem of pressure ulcer risk with interventions that included to off load heels in bed. Admission assessment data ((MDS) dated [DATE] identified the resident was moderately cognitively impaired, required limited assistance with bed mobility, transfers and toilet use of one person, and supervision with ambulation in room and corridor, and was at risk for pressure sore development with no skin issues identified. Review of the treatment kardex (TAR) for April 2014 noted documentation that the heels were off loaded while in bed starting on 4/29/14. Further review failed to identify documentation that the heels were offloaded while in bed from 4/11/14 until 4/29/14 ( total of 18 days). Further review of the TAR documentation identified that the heels were offloaded with a "heel manager" beginning on 4/29/14. Nursing notes dated 4/28/14 identified the resident had a complained that the left heel was sore at night and was elevated. Further review of the nursing note failed to document an assessment of the left heel by a registered nurse. Nursing notes dated 4/29/14 identified conflicting assessments of the left and right heel. One nursing note identified 2 plus [MEDICAL CONDITION] of the left leg, red, warm, weeping and a closed left heel blister which measured 2 cm x 3 cm. The physician order [REDACTED]. The skin/ wound assessment record dated 4/29/14 identified a left heel Deep Tissue Injury (DTI) which measured 2 cm x 3 cm, purple colored with a blister. Continued documentation of the wound identified that the DTI area opened on 5/8/14 and a new treatment was ordered. Physician orders [REDACTED]. Observation of the resident on 5/14/14 at 2 PM identified a wound on the left heel that measured 2.8 cm x 3 cm round, circular with a blue purple center that measured 0.6 cm x 0.8 cm surrounded by whitish colored skin and brown colored edging. The resident's legs were [MEDICAL CONDITION], dry and flaky. Interview and review of the clinical record, care plan, nursing notes and treatment kardex with RN #1 who co-signed the admission care plan, on 5/14/14 at 10:30 AM identified that off loading of the heels should have been done from 4/11/14 as per the care plan. Further review of the clinical record failed to provide documentation that preventive measures were implemented as per care plan . Although the care card identified off load heel pressure, no documentation could be found to ensure that this intervention was initiated from admission until 4/29/14 when the DTI was found. Further interview identified that RN#1 would have expected documentation of off loading in the treatment kardex and or nursing notes. Interview and record review with the infection control nurse (RN#2) who over sees the wound care program on 5/15/14 at 11:40 AM identified that she/he never assessed the resident's wound on the left heel. Further interview identified that an LPN does the wound rounds and she/he should have seen the wounds on wound rounds but only assesses the wounds once or twice a month. Interview with the DON on 5/15/14 at 12:30 PM identified that he/she was unaware that the wound RN#1 failed to assess the wound at all.