Every finding on record at Apple Rehab Rocky Hill

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for medication administration, the facility failed to ensure medications were administered to the correct resident when Resident #2, who had no physician orders for Methadone, received 120 milligrams (mg) of Methadone prescribed for Resident #1. Specifically, the licensed nurse failed to use two resident identifiers, failed to verify the resident against the electronic Medication Administration Record (MAR) prior to administration, and the Methadone Chain of Custody Medication Administration Record (CCMAR) contained Resident #2's room number rather than Resident #1's room number. Additionally, the facility failed to ensure an electronic name alert was in place for Resident #1 and Resident #2, who had similar names. As a result, Resident #2 received 120 mg of Methadone, resulting in an accidental opioid overdose, acute encephalopathy, respiratory compromise requiring BiPAP and a Narcan infusion, acute kidney injury (AKI) requiring emergent dialysis, and a ten (10) day hospitalization. This finding resulted in immediate jeopardy. The findings include: 1. Resident #1 was admitted to the facility in May of 2026 with diagnoses that included psychoactive substance abuse, type II diabetes and adjustment disorder. Resident #1 was responsible for his/herself.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and had been taking opioids during the last seven (7) days.The Resident Care Plan (RCP) dated 5/2/26 identified Resident #1 received Methadone (long-acting opioid medication that is used to reduce withdrawal symptoms in people addicted to narcotics) maintenance for a history of substance use disorder (SUD). Interventions included to provide Methadone as ordered and Resident #1 was to self-administer the Methadone.A Physician's order dated 5/24/26 directed Methadone 120 mg by mouth daily for SUD, supervised self-administration, administer at 8:00 AM.A Physician's order dated 5/24/26 directed for Resident #1 to self-administer Methadone one time a day for SUD.A Physician's order dated 5/24/26 directed to ensure Resident #1 co-signed the Methadone administration worksheet one time a day for pain.Review of the MAR dated 6/8/26 identified Methadone was documented as administered by LPN #2.Review of the CCMAR identified the 6/8/26 entry included a nurse's initials of MG, and the resident initials were illegible. Previous entries contained legible resident initials. Additionally, the CCMAR had Resident #2's room number written at the top of the record rather than Resident #1's room number.A nurse's note by RN #2 dated 6/8/26 at 10:26 PM identified that at 5:00 PM, Resident #1 was administered the Methadone bottle scheduled for administration on 6/9/26. The DNS and Methadone clinic were notified, and Resident #1 would go to the Methadone clinic the following day for dosing.2. Resident #2 was admitted to the facility in August of 2024 with diagnoses that included Type II diabetes, generalized anxiety disorder, schizophrenia and mood disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9) and was not receiving opioid medications.The Resident Care Plan (RCP) dated 3/18/26 identified Resident #2 primarily spoke Spanish, understood basic English and had periods of confusion. Interventions included to provide Spanish speaking staff as needed.A Physician's order dated 6/1/26 directed to check the identification band prior to medication administration.Review of physician's orders identified Resident #2 had no orders for Methadone since admission.A nurse's note by RN #1 dated 6/8/26 at 1:19 PM identified Resident #2 had a mental status change, increased confusion and disorientation. Resident #2 was sweating with a blood sugar of 206, had decreased mentation, unsteady gait and an oxygen saturation level of 76% (normal range: 95-100%). The physician and Emergency Medical Services (EMS) were called.The Reportable Event form by the DNS dated 6/8/26 identified Resident #2 had a decline in health status, with oxygen saturation in the 70's and was sent to the hospital. Resident #2 was later found to have received Methadone of another Resident with the same initials.A nursing note by the DNS on 6/9/26 at 1:56 PM identified a late entry for 6/8/26. Resident #2 was subsequently sent to the ED secondary to a decline in physical status and oxygenation in the 70's per the temporary Supervisor, RN #1. RN #1 obtained the order and Resident #2 was sent to the ED. During the afternoon, Resident #1 approached the DNS and indicated he had not received Methadone. However, the CCMAR was signed by the Supervisor and another Resident. Upon review of the CCMAR, it was observed that the Resident signature did not match any of Resident #1's other signatures. The DNS instructed the Supervisor to count all Methadone bottles to ensure they were accounted for. Resident #1's bottle was unaccounted for and documented as received, although Resident #1 was adamant he/she had not received the scheduled dose. The DNS directed the Supervisor to call the Emergency department (ED) to report the facility believed Resident #2 was administered another Resident's dose of Methadone, as they share the same initials. Resident #2 tested positive for Methadone at the hospital.The Hospital Discharge summary dated [DATE] identified Resident #2 had a diagnosis of acute encephalopathy, AKI and accidental or unintentional methadone overdose. The accidental administration of 120 mg Methadone was confirmed by positive urine toxicology, despite Resident #2 not being prescribed methadone. Resident #2 developed worsening encephalopathy, requiring escalation to BiPAP and initiation of a Narcan infusion for ongoing opioid toxidrome. Due to rapid progressive AKI, emergent dialysis was recommended, a right femoral dialysis catheter was placed and dialysis was initiated on 6/9/26.The nursing note dated 6/18/26 at 10:25 PM identified Resident #2 was re-admitted from the hospital with diagnoses of acute encephalopathy methadone overdose-accidental or unintentional, leukocytosis and hyperkalemia.Interview with the DNS on 7/30/26 at 11:55 AM identified on 6/8/26 Resident #1 reported he/she did not receive their scheduled Methadone. She reviewed the CCMAR and identified Resident #1's Methadone was signed off as administered for 6/8/26, however, the initials did not match previous administration initials. She further identified RN #1 had left for the day. She then recalled that Resident #2 was sent to the ED for a change in condition and had the same initials as Resident #1. She directed RN #2 to notify the hospital and request a toxicology report. The hospital toxicology report was positive for Methadone. She identified she attempted to reach RN #1 but was unable to. She further identified RN #1 should have verified the Resident during medication administration with two identifiers, which could include a name band, picture in the electronic medical record (EMR), asking the Resident their name and asking other staff to verify. She identified Resident #1 and Resident #2 did not have EMR name alerts despite having the same last name and same first name initial, because they were not roommates.Interview with the Medical Director on 7/30/26 at 1:39 PM identified the medication error that occurred on 6/8/26 was significant. He identified Methadone 120 mg was a substantial, large dose of an opioid. He identified the side effects of an opioid overdose would include severely impaired mental status and lethargy, which was the side effects Resident #2 presented with. He identified Resident #2 was already impaired due to multiple comorbidities and required hospitalization. He further identified the staff should verify the medication and correct Resident before administration.Interview with RN #1 on 7/30/26 at 1:40 PM identified she was the Supervisor on 6/8/26 during the 7:00 AM to 3:00 PM shift. She identified it was her first day at the facility. She identified her process when administering the Methadone on 6/8/26 was obtaining the CCMAR then proceeding to the room which was indicated on the CCMAR. She identified she did not bring the computer with her and did not use the MAR. She identified the Resident was in bed and she matched the Resident's name with the CCMAR. She identified she did not open the MAR, did not review the Resident's picture and the Resident was not wearing a name band. She further identified she did not know there were two Resident's in the facility with the same last name and same first name initial. She identified administration of the Methadone was documented on the CCMAR and she did not document in the MAR. She identified she did not review the CCMAR Resident signatures (where the Resident's signature from 6/8/26 did not match the previous signatures documented). She identified near the end of her shift, the DNS asked if she administered Resident #1's Methadone, which she identified she did. The DNS did not tell her anything else, and RN #1 left for the day.Interview with the DNS and Regional Clinical Nurse on 7/30/26 at 2:20 PM identified they were unaware that RN #1 did not know there were two Resident's in the facility with the same last name and same first initial because they had not spoken to her. They identified the facility had no statement from RN #1 regarding the medication error. The Regional Clinical Nurse identified name alerts should have been on Resident #1 and Resident #2's EMR and that adding a name alert was not only for roommates who had same or similar names but should be added for any residents with same or similar names. Subsequently, the DNS identified she added name alerts to Resident #1 and Resident #2's EMR.Interview with the VP of Clinical Services on 8/4/26 at 10:00 AM identified the nurse administering the medication was responsible for documenting the administration in the MAR and that the MAR contained the resident's name, photograph, and room number for resident verification. He identified RN #1 should have had access to and used the MAR in conjunction with the CCMAR. Review of Resident #1's CCMAR identified that Resident #2's room number was written at the top of the record. The VP of Clinical Services identified that the incorrect room number on the CCMAR further contributed to the medication administration error.Review of the Medication Administration policy directed medication administration shall be performed safely and accurately utilizing the principles of medication administration, including; right resident, right medication, right dose, right route, right time and right documentation. It directed to verify the medication order against the MAR and confirm the resident identity using at least two identifiers prior to medication administration.Review of the Methadone Maintenance policy identified Methadone is a scheduled II controlled substance. All applicable controlled substance regulations, facility policies, chain-of-custody procedures, and state and federal requirements will be followed. Prior to administration of Methadone, the licensed nurse will verify the resident identity, methadone dose, physician order, medication label and MAR. The IJ Template was presented to the Administrator on 7/30/26 at 2:30 PM for F760 failure to prevent significant medication errors.The facility submitted a removal plan, which included:Conducting audits for all residents who received methadone to ensure the order and administration were correct and that methadone was given to the correct residents with similar last names.Residents with similar last names were updated in the electronic medical record (EMR) with name alerts for staff to identify different first names.RN Supervisors were educated to ensure they administer methadone to the correct resident using two identifiers at all times.Staff education will continue to ensure medications are administered correctly to residents with similar last names by using two resident identifiers, EMR name alerts, and adherence to the Five Rights of Medication Administration to ensure medications are administered accurately as prescribed.Random daily audits of residents receiving methadone and residents with similar last names will be conducted to ensure methadone is administered to the correct residents. Audits will continue for a period of 30 days or until substantial compliance is achieved. Results of the audits will be reported to the facility QAPI Committee.Compliance Date: July 30, 2026Responsible Party: Director of Nursing Services (DNS)The removal plan was was reviewed on site by the State Agency and approved on 7/30/26 at 5:02 PM

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #67 and Resident #64) reviewed for pressure ulcer/injury, the facility failed to ensure offloading interventions were implemented for a resident unable to self-position and identified as being at high risk for the development of pressure ulcers. The lack of interventions to off-load Resident #67's heels/feet resulted in the development of a deep tissue injury (DTI) to the left heel. Subsequent to the development of a left heel DTI, Resident #67 developed a pressure ulcer to the left malleolus (ankle) from the lack of initiating interventions that directed measures to off-load the feet/heels. Additionally, for Resident #64, the facility failed to complete timely assessment/documentation of wound descriptions/measurements and initiation of wound treatments for pressure and non-pressure wounds. The findings include: 1. Resident #67 was admitted to the facility in July 2024 with diagnoses that included dementia, chronic obstructive pulmonary disease, and dysphagia (difficulty swallowing). A Quarterly Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] identified Resident #67 as moderate risk for the development of pressure ulcers/injuries. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was significantly cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #58 was at risk for developing pressure ulcers/injuries and did not currently have a pressure ulcer. A progress note written by the wound Advanced Practice Registered Nurse (APRN #1) and dated 2/18/26 at 9:33 AM identified Resident #67 was seen for an initial consultation for evaluation and management of a new wound to the left heel. Assessment of the left heel wound noted it was caused by pressure and was staged as a deep tissue injury (DTI) (non-blanchable purple discoloration) with measurements of 3.1 centimeters (cm) by 1.6 cm by 0.0 cm. Treatment recommendations for the left heel were to apply Skin prep to the peri wound and base of the wound every shift and leave open to air. Additionally, the progress note indicated the importance of offloading was discussed with nursing. The Resident Care Plan (RCP) dated 2/20/26 identified Resident #67 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included pressure reducing mattress and turning and positioning per standards of nursing practice. The RCP failed to identify offloading of the lower extremities or any measures to off load the feet/heels as an intervention. APRN #2's progress note dated 3/4/26 at 10:25 AM identified Resident #67 was seen for follow-up evaluation and management of the pressure induced DTI of the left heel. Assessment noted the left heel wound remained a non-blanchable purple discoloration which was deteriorating with increased measurements of 6.1cm by 3.9 cm by 0.0 cm. Treatment recommendations were to continue to apply Skin prep to the base of the wound every shift and leave open to air. Additionally, the progress note indicated the left heel DTI had not improved as evidenced by size increase observed compared to assessment 1 week ago. The APRN again noted she discussed the importance of offloading with nursing. APRN #2's progress note dated 3/25/26 at 11:47 AM identified Resident #67 was seen for follow-up evaluation and management of the pressure induced deep tissue damage of the left heel. Assessment noted the left heel wound remained a non-blanchable purple discoloration which was stable with measurements of 6.1cm by 3.9 cm by 0.0 cm. Treatment recommendations were to continue to apply Skin prep to the base of the wound every shift and leave open to air. APRN #2 again noted she discussed the importance of offloading with nursing. A revision to the RCP for Resident #67 initiated on 3/30/26 directed an intervention to off-load as appropriate but failed to identify directions/devices to implement off loading. APRN #2's progress note dated 3/31/26 at 1:42 PM identified Resident #67 was seen for follow-up evaluation and management of the pressure induced deep tissue damage of the left heel. Assessment noted the left heel wound had epithelialized and resolved. Treatment recommendations were to continue to apply Skin prep every shift for 7 days for protection. A nursing note written by the Infection Preventionist (RN #2) and dated 4/8/26 at 3:15 PM identified weekly wound rounds had been completed and Resident #67 was found to have a purple, dry and intact discoloration to the left malleolus (ankle area) of the foot which measured 2.0 cm by 1.1 cm by 0.0 cm with surrounding blanchable erythema. The area was identified as a pressure ulcer of the left ankle, unstageable. The nursing note further indicated new orders for offloading boots to the bilateral lower extremities and application of Skin prep to the area were implemented. A revision to the RCP for Resident #67 initiated on 4/8/26 directed an intervention of off-loading boots. Interview with NA #3 and NA #6 on 4/23/26 at 11:51 AM identified Resident #67 was dependent with bed mobility and unable to offload his/her feet/heels by him/herself. NA #3 and NA #6 indicated although the resident was being turned and positioned frequently, they did not recall Resident #67's lower extremities being offloaded before he/she developed the pressure area to the left heel. NA #6 identified she was not made aware by the charge nurse or supervisor that the resident's lower extremities should have been offloaded until after the left heel pressure area had developed. Additionally, NA #3 further indicated that the resident later developed a pressure area to the left ankle before the offloading boots were ordered for Resident #67. Interview and review of clinical record with Licensed Practical Nurse (LPN) #4 on 4/23/26 at 12:02 PM identified Resident #67 was dependent with care and unable to offload his/her feet/heels or reposition by him/herself. LPN #4 indicated he recalled when the resident developed the left heel pressure area and although the resident was being turned and positioned at that time the resident's lower extremities were not being offloaded. Review of the nursing notes with LPN #4 identified the left heel pressure area had developed on or around 2/18/26 and the physician order of offloading as appropriate was not initiated on the RCP until 3/30/26. LPN #4 was unsure why offloading was not initiated sooner and indicated the offloading boots were also not ordered until after Resident #67 had developed the second pressure area to the left ankle. Interview and review of the clinical record with the DNS on 4/24/26 at 9:35 AM identified the APRN note on 2/18/26 was the initial visit for Resident #67's left heel DTI. Review of the clinical record failed to indicate documentation of when the area was first discovered or by whom and the DNS indicated she would have expected to see a note from the charge nurse or supervisor. Further review of Resident #67's RCP with the DNS failed to indicate offloading was in the RCP prior to the resident's development of the pressure area to the left heel on 2/18/26. The DNS identified Resident #67 was unable to offload him/herself, was dependent with bed mobility and due to the resident's risk for pressure injuries, there should have been more interventions implemented to address the risk in the RCP. Additionally, the DNS indicated care plans were a team effort and the intervention of 'offload as appropriate', which was initiated on the RCP on 3/30/26 (after the development of the left heel DTI on 2/18/26), should have been more specific. The DNS further identified she would have expected more interventions such as heel booties and an air mattress to be put in place sooner. Interview and review of the clinical record with the Infection Preventionist (RN #2) on 4/24/26 at 10:45 AM identified Resident #67 was first evaluated by the wound APRN on 2/18/26 for the left heel DTI. RN #2 indicated she would have expected the care plan at that time to have had interventions to offload the resident's lower extremities, and it did not. RN #2 recalled when the resident developed a new pressure area to the left ankle on 4/8/26 offloading boots were ordered at that time. RN #2 further indicated she was unsure why offloading or the offloading boots were not implemented prior to Resident #67 developing the left heel DTI. Interview with APRN #2 (wound APRN) on 4/24/26 at 1:25 PM identified another nurse practitioner was covering for her when Resident #67 was initially seen on 2/18/26. Review of the nursing notes with APRN #2 failed to indicate when or who discovered the area to Resident #67's left heel and she was unsure why that was not documented by the charge nurse or nursing supervisor in the clinical record. APRN #2 stated the RCP should have had offloading as an intervention to avoid skin breakdown prior to the development of the left heel DTI (on 2/18/26) based on risk factors and unavoidable areas of pressure due to Resident #67's lower extremity contractures. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hyperglycemia, and cirrhosis.a. A hospital Inter-Agency Patient Referral Report (W-10) dated 1/2/26 at 5:29 PM identified Resident #64 had been hospitalized from [DATE] to 1/2/26 for acute hypoxic respiratory failure. The W-10 indicated Resident #64 had an active skin impairment of a right gluteal excoriation which was first assessed on 12/27/25 and that measured 10 centimeters (cm) length by 10 cm width by 0.1 cm depth (10 x 10 x 0.1 cm) on 12/29/25. The W-10 further identified the treatment was Triad (a thick topical wound paste) barrier cream.A nursing note written by Registered Nurse (RN) #3 on 1/2/26 at 10:40 PM identified Resident #64 was admitted to the facility at approximately 7:15 PM on 1/2/26 and had redness to the skin of the groin, and pressure ulcers to the coccyx and bilateral buttocks.A physician order dated 1/2/26 directed to perform a weekly body audit on shower day every Thursday at 9:00 AM but failed to include a treatment for the right gluteal excoriation.A Nursing admission Assessment completed by Registered Nurse (RN) #3 on 1/2/26 at 9:39 PM identified Resident #64 had 4 skin areas documented: a coccyx pressure ulcer measuring 9.2 cm, a left buttock pressure ulcer measuring 9.0 cm, a right buttock pressure ulcer (no measurement), and an area of redness to the groin. The assessment failed to indicate full measurements of the 3 pressure ulcers with length, width, and depth. Additionally, the assessment failed to include the stage of each of the 3 identified pressure ulcers, a description of the wounds (color, tissue type, odor, drainage, periwound), and the area of redness to the groin, the assessment failed to identify if that redness was blanchable or non-blanchable. The assessment further identified a Braden Scale (a tool for assessing a resident's risk for developing a pressure ulcer) score of 13 which indicated moderate risk for the development of pressure ulcers. The Resident Care Plan (RCP) dated 1/3/26 identified Resident #64 was at risk for skin breakdown related to comorbidities that may contribute to alterations in skin integrity. Interventions included consulting with the wound care nurse specialist as ordered/needed, encourage and/or assist with offloading of pressure areas as needed, inspect skin when providing care for signs/symptoms of skin breakdown, offload heels when in bed, pressure reducing mattress, and provide lotions/creams as ordered, and apply barrier cream with incontinent care.Physician orders for January 2026 failed to identify an order for application of any lotion/cream, barrier cream, and/or treatment to Resident #64's coccyx, left buttock, right buttock, or groin. b. A nursing Situation, Background, Assessment, Recommendation (SBAR) assessment written by RN #3 on 1/6/26 at 10:52 PM identified Resident #64 was sent to the hospital for a critically low hemoglobin test result. A hospital W-10 dated 1/16/26 at 2:15 PM identified Resident #64 had been hospitalized from [DATE] to 1/16/26 for anemia and indicated Resident #64 had active skin impairments consisting of a right medial buttocks Stage 2 pressure ulcer, present on admission to the hospital which was re-assessed prior to discharge from the hospital on 1/16/26 and appeared dry (no drainage) and pink, Also, Resident #64 had a medial labial Stage 2 pressure ulcer present which was re-assessed prior to discharge from the hospital on 1/16/26 and appeared pink and reddened with no drainage. Additionally, the W-10 identified Resident #64 had additional skin impairments identified after admission consisting of Moisture Associated Skin Damage (MASD) of the sacral spine and appeared moist, red, pink, with scabbing; a rash to the left axilla re-assessed prior to discharge from the hospital on 1/16/26 and appeared dry, irregularly shaped, pink and red. The W-10 further identified wound/pressure ulcer instructions were to provide routine interventions of low air loss bed, turn and position every 2 hours, waffle cushion when out of bed to chair, limit sit times to 1 hour, elevate heels off bed, optimize nutrition, and apply a thick layer of Triad to the coccyx, buttocks, sacrum, and medial thighs and if possible apply foam dressings over the Triad on the sacral and coccyx/buttock areas.Review of the clinical record failed to identify a skin assessment was completed upon his/her re-admission from the hospital on 1/16/16 regarding Resident #64's wounds.Physician orders for January 2026 failed to identify a physician order for application of any lotion/cream, barrier cream, topical wound paste (Triad), and/or treatment to Resident #64's coccyx, buttocks, sacrum, and medial thighs as directed by the hospital W-10 dated 1/16/26.An RN nursing note dated 1/16/26 at 5:21 PM identified Resident #64 was said to have returned to the facility towards the end of the 1st shift following hospital care for anemia, the note further indicated Resident #64 was being seen for a fall. The note identified there was no obvious swelling or bruising noted but failed to identify a full body assessment was conducted by the RN to assess for skin impairment from re-admission and unrelated to the fall. Review of the Treatment Administration Record (TAR) from 1/1/26 through 1/31/26 identified Resident #64's weekly body audit on shower days were signed off as completed on 1/29/26 but did not identify any skin issues despite Resident #64 having many wounds. c. A nursing note written by APRN #1 on 1/29/26 at 10:15 AM identified Resident #64 was sent to the hospital for urgent evaluation related to worsening of recurrent C. Difficile infection, severe acute kidney injury, hyperkalemia, metabolic acidosis, and altered mental status.A hospital W-10 dated 2/23/26 at 5:12 PM identified Resident #64 had been hospitalized from [DATE] through 2/23/26 and indicated Resident #64 had active skin impairments consisting of a medial labial Stage 2 pressure ulcer as an intact deep tissue injury (DTI), an unstageable coccyx wound and measured 8.0 cm x 4.0 cm x 2.0 cm, a left medial heel DTI and measured 2.5 cm x 2.5 cm x 0.0 cm with purple discoloration, a right upper lateral back DTI with purple and maroon discoloration, a right lateral malleolus DTI that measured 3.0 cm x 3.0 cm x 0.0 cm with a blister and purple discoloration, and a right lateral midfoot DTI and measured 1.0 cm x 0.7 cm x 0.0 cm with purple discoloration. The W-10 identified wound care instructions: provide routine interventions of low air loss bed, turn and position every 2 hours, waffle cushion when out of bed to chair, limit sit times to 1 hour, optimize nutrition, and glucose control. The W-10 identified for the coccyx with erosion extending to the bilateral buttocks: cleanse with Normal Saline, apply Triad to the peri wound (superficial erosion), then apply a nickel thick layer of Santyl (topical wound debridement) to the wound bed, cover with a moist gauze, then cover with a foam dressing. The W-10 identified for the right heel, right lateral foot, right lateral malleolus, and left heel to cleanse with Normal Saline, then apply barrier spray and cover with a foam dressing changed every 3 days and instructed to elevate heels off mattress. Additionally, for the right lateral back: cleanse with Normal Saline, then apply a nickel thick layer of Santyl to the wound bed covered with a moist gauze and then covered with a foam dressing and to apply a thick layer of Triad to the left groin/upper medial thigh area.A re-admission nursing note written by RN #4 on 2/23/26 at 11:18 PM identified Resident #64 had been re-admitted from the hospital at 6:05 PM and had an unstageable coccyx wound, right shoulder wound, and bilateral heel wounds. The note failed to identify measurements and descriptions of the wounds (type, stage (if pressure ulcer), measurements, wound characteristics (wound base, drainage, odor, peri wound, color of tissue). Additionally, the note failed to identify wounds to the right lateral malleolus, right lateral midfoot, and labial pressure ulcer.A physician order dated 2/24/26 directed to apply a wet to dry dressing to the coccyx wound every day on the 7:00 AM to 3:00 PM shift until seen by the wound nurse. Additionally, the physician order directed for the right and left heels, right lateral foot, and right lateral malleolus: cleanse with Normal Saline, apply barrier spray, then apply a foam dressing every 3 days on the 7:00 AM to 3:00 PM shift until seen by the wound nurse.Additionally, a physician order dated 2/24/26 directed to apply a wet to dry dressing to the right lateral back/shoulder every day on the 7:00 AM to 3:00 PM shift until seen by the wound nurse.A physician order dated 2/24/25 directed to apply Santyl ointment topically to the coccyx wound every day on the 7:00AM to 3:00 PM shift. The physician order failed to identify to cleanse the wound prior to application of the Santyl ointment and failed to identify to apply the Santyl nickel thick and to cover with a dry clean dressing.A wound progress note written by APRN #2 on 2/25/26 at 8:00 PM (2 days after Resident #64 was re-admitted from the hospital) for date of service 2/25/26 at 11:01 AM identified she had a consultation with Resident #64 for evaluation and management of wounds. The note identified that she evaluated 2 wounds for the first time, a coccyx Stage 4 pressure ulcer and a right posterior trunk full thickness abrasion. The note identified the coccyx wound measured 7.2 cm x 4.1 cm x 2.6 cm and had undermining of 3.0 cm from 8 o'clock to 6 o'clock, the wound base was 75% slough and 25% eschar, and there was a large amount of serosanguinous drainage. The note identified the right posterior trunk wound was a full thickness abrasion that measured 1.1 cm x 0.6 cm x 0.1 cm and was 25 % granulation tissue with a small amount of serosanguinous drainage. The note failed to identify the heels were evaluated despite Resident #64 being re-admitted with a left medial heel DTI. The note identified the treatment recommendation for the coccyx was to cleanse with Normal Saline then apply Silver Alginate to the base of the wound then cover with a dry clean dressing and change daily. The note further identified for the right posterior trunk abrasion to cleanse with Normal Saline then apply Silver Alginate to the base of the wound the cover with a dry clean dressing and change daily.A Nursing admission Assessment completed by RN #4 on 2/25/26 at 2:54 PM (2 days after Resident #64 was re-admitted to the facility) identified Resident #64 had a pressure ulcer to the coccyx that measured 7.2 cm x 4.1 cm x 2.6 cm, and a pressure ulcer to the right posterior shoulder that measured 1.1 cm x 0.6 cm x 0.1 cm. The assessment failed to identify the areas to the bilateral heels RN #4 indicated were present in her readmission note on 2/23/26 at 11:18 PM. Additionally, the assessment failed to identify description of the wounds with the wound stage and wound characteristics (wound base, drainage, odor, periwound, color of tissue).A physician order dated 2/26/26 at 3:06 PM directed to discontinue the wet to dry dressing to the coccyx wound every day on the 7 AM-3 PM shift until seen by the wound nurse. (a discrepancy to Resident #64's treatment of Santyl to the coccyx wound in place which started on 2/24/26)A physician order dated 2/26/26 at 3:11 PM directed to discontinue the wet to dry dressing to the right lateral back/shoulder every day on the 7:00 AM to 3:00 PM shift until seen by the wound nurse. The clinical record failed to identify that another treatment was put in place for the right lateral back/shoulder. APRN #2 had given a treatment recommendation on 2/25/26 for the right posterior trunk abrasion, but this treatment was not ordered or put in place.A nursing note dated 2/27/26 at 11:39 PM identified Resident #64 had a left hip ulcer. The note failed to identify if this was a new area of skin impairment as there was no prior documentation of a left hip ulcer identified in the clinical record except for a history of a Stage 2 pressure ulcer listed within APRN #2's wound note. A weekly wound rounds nursing note dated 3/5/26 at 1:04 PM identified wound rounds were completed with APRN #2 for Resident #64 and the right posterior trunk and coccyx wounds were evaluated. The note failed to identify evaluation of a left hip ulcer indicated in multiple nursing notes and the dietician note. Additionally, the note failed to identify evaluation of the right and left heels, right lateral foot, and right lateral malleolus which had an active treatment order in place.d. A hospital W-10 dated 3/11/26 at 4:17 PM identified Resident #64 had been hospitalized from [DATE] to 3/11/26. The W-10 indicated Resident #64 had active skin impairments consisting of a Stage 4 coccyx wound, appearing moist with slough, granulation and measured 7.0 cm x 6.0 cm x 1.5 cm with undermining of 2.5 cm from 6 o'clock to 8 o'clock, a left medial heel DTI measuring 2.5 cm x 2.5 cm x 0.0 cm with a blister and purple discoloration, a right upper lateral back DTI, unstageable (no measurements), a right lateral malleolus DTI , unstageable with moist black eschar and measured 2.5 cm x 1.5 cm x 0.1 cm, a right lateral midfoot DTI measuring 1.0 cm x 0.5 cm x 0.0 cm with purple discoloration, and a new right foot ulceration (site not specified) first identified 3/11/26 that measured 3.0 cm x 3.0 cm x 0.0 cm with maroon/purple discoloration. Discharge wound care instructions: for the coccyx/sacrum daily, cleanse with Normal Saline, apply barrier spray to the peri wound, then moisten 1 roll of gauze roll with 1/2 strength Dakin's solution (wound treatment solution) and wring out excess, then apply a nickel thick layer of Santyl to sloughy areas of the wound bed from edge to edge, then loosely pack the wound bed with the Dakin's moistened gauze roll and be sure to fill undermining area, then trim excess gauze and cover with a foam dressing and change. For the right lateral ankle, right lateral midfoot, right dorsal foot, left heel, and right back: cleanse with normal saline then apply barrier spray and cover with a foam dressing every 3 days. A nursing note written by RN #4 on 3/11/26 at 8:35 PM identified Resident #64 was readmitted from the hospital at 7:05 PM and that the coccyx wound had shown necrotizing fasciitis. The note further identified Resident #64 refused a head to toe nursing assessment and body audit. The note failed to identify any wound other than a sacral wound despite other wounds documented on the hospital discharge W-10.A nursing note written by RN #4 on 3/11/26 at 10:46 PM identified at 9:30 PM after multiple attempts Resident #64 continued to refuse the body audit, stating that the wound dressings were just changed at the hospital and he/she didn't want to go through the pain of having them changed again. The note identified Resident #64 had dressings in place from the hospital to the right foot and heel wounds, the coccyx wound, the left heel wound, and the right upper lateral back wound. The note further identified the wound care instructions from the hospital related to the coccyx wound but failed to identify the wound care instruction related to the additional wounds.A Nursing admission Assessment completed by RN #4 on 3/11/26 at 11:46 PM identified Resident #64 had a skin impairment to the coccyx, right outer ankle, right heel, left heel, and right upper lateral back. The assessment failed to identify what type of wounds they were or identify description of the wounds with the wound stage and wound characteristics (wound base, drainage, odor, periwound, color of tissue) due to Resident #64's continued refusal.A wound progress note written by APRN #2 on 3/12/26 at 1:00 AM for date of service 3/12/26 at 6:11 PM identified she had a consultation with Resident #64 for follow-up evaluation and management of wounds. The note identified she evaluated 2 wounds, a coccyx Stage 4 pressure ulcer and a right posterior trunk full thickness abrasion. The note failed to identify an evaluation was conducted to the right foot and heel wounds, or the left heel wound identified as having wound treatments in place on admission on [DATE] and which were identified by the hospital W-10 as pressure injuries.A physician order dated 3/12/26 directed to apply Santyl ointment topically to the coccyx wound every day on the 7:00 AM to 3:00 PM shift.A nursing note dated 3/12/26 at 2:58 PM identified Resident #64 had a left hip ulcer.A nursing note dated 3/12/26 at 10:54 PM identified Resident #64 had a left hip ulcer with no skin changes noted and that he/she was receiving surgical wound care for a surgical wound.A wound progress note written by APRN #2 on 3/25/26 at 9:00 PM for date of service 3/25/26 at 10:40 AM identified she had a consultation with Resident #64 for follow-up evaluation and management of their wounds. The note identified she evaluated 2 wounds, a coccyx Stage 4 pressure ulcer and a bilateral buttocks rash and included measurements. The note failed to identify an evaluation was conducted to the right foot and heel wounds, or the left heel wound identified as having wound treatments in place since admission on [DATE] and which were identified by the hospital W-10 as pressure injuries.A physician order dated 3/25/26 directed to cleanse the coccyx/sacrum wound with 1/4 strength Dakin's solution then apply house antifungal to the peri wound, then pack with 1/4 strength Dakin's soaked gauze, then cover with a dry clean dressing, to cleanse the bilateral buttocks rash with wound cleanser, then pat dry, then apply house antifungal cream, then cover with a dry clean dressing every day on the 7:00 AM to 3:00 PM shift.A physician order dated 3/29/26 at 5:25 PM directed to discontinue the treatment: for the right and left heels, right lateral foot, and right lateral malleolus: cleanse with Normal Saline, then apply barrier spray, then apply a foam dressing every 3 days on the 7 AM- 3 PM shift until seen by the wound nurse. No new order was identified to have been put in place for these wounds, and no documentation was identified to indicate these wounds were healed and/or resolved.A physician order dated 3/31/26 directed to perform a weekly body audit on shower day every Tuesday on the 3 PM-11 PM shift.A wound progress note written by APRN #2 on 4/8/26 at 5:33 PM for date of service 4/8/26 at 11:09 AM identified she had a consultation with Resident #64 for follow-up evaluation and management of their wounds. The note identified she evaluated 2 wounds, a coccyx stage 4 pressure ulcer and a bilateral buttocks rash and included measurements. The note failed to identify an evaluation was conducted to any other wound sites.A wound progress note written by APRN #2 on 4/22/26 at 11:01 PM for date of service 4/22/26 at 6:51 AM identified she had a consultation with Resident #64 for follow-up evaluation and management of their wounds. The note identified she evaluated 1 wound, a coccyx stage 4 pressure ulcer with measurements but failed to identify an evaluation was conducted to any other wound sites.Resident #64 was discharged to the hospital on 4/23/26 prior to surveyor observation of his/her pressure injuries.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 9:50 AM identified the wound MD/APRN should be notified immediately of all new admissions with pressure ulcers, or suspected pressure ulcers requiring wound care visits. She identified when the nurses were completing weekly body audits, they should document all active skin issues even if they were already previously identified. She identified the wound nurse should have been following Resident #64's wounds with documentation by the wound nurse in the clinical record since Resident #64's initial admission. She further identified the wound APRN should have been notified in January 2026 that Resident #64 required a wound consultation and that he/she should have been seen on wound rounds prior to 2/25/26. She was unable to identify the reason Resident #64's wounds had not been followed prior to 2/25/26, nor why there was no documentation in January 2026 by the wound nurse after Resident #64's admission on [DATE] which identified the presence of a pressure ulcer on the Nursing admission Assessment.Interview with APRN #1 on 4/24/26 at 11:20 AM identified she had never been asked by the nursing staff to evaluate Resident #64's wounds. She identified she did not follow the wounds of the residents because there was a wound APRN that came in and performed wound rounds with the facility wound nurse. She identified the wound nurse and wound APRN performed weekly wound rounds so she did not evaluate resident wounds herself. She further identified she was unaware of the wounds that Resident #64 had.Interview with RN #3 on 4/24/26 at 11:35 AM identified she completed the nursing admission assessment on 1/2/26 and completed the skin assessment with the charge nurse. She identified when a new admission was admitted she would assess the wounds and call the on-call APRN to review what treatment orders they wanted to put in place. She identified she routinely would suggest to the on-call APRN that the wound be cleansed, a small amount of Bacitracin applied, then a dry protective dressing applied until the wound nurse evaluated the wound the next day, and that she would initiate the orders from the APRN in the clinical record. She was unable to identify the reason she had not obtained a treatment order for either of the pressure injuries that she had observed on Resident #64's admission and stated that she must have forgotten. Interview with the DNS on 4/24/26 at 12:01 PM identified when a resident was admitted , the nursing supervisor should perform a nursing admission assessment every time even with a readmission, and then they should contact the APRN to obtain treatment orders for all identified wounds including pressure injuries. She further indicated that the nursing supervisor should then notify the wound APRN that there was a new admission that needed a wound consultation. The DNS identified there should be a treatment in place for all wounds. The DNS also noted new admissions were reviewed the following day, and that the hospital W-10, nursing assessments and nursing notes were reviewed to identify any skin issues that needed to be followed by the wound nurse and wound APRN. She identified that a treatment should be initiated on admission for all pressure ulcers whether it was a new admission or a readmission. She identified wound rounds were performed weekly by the wound nurse and wound APRN, the wound nurse was responsible for notifying the wound APRN of the which wounds needed to be followed for each resident. and that the wound nurse would write a note in the clinical record after the wound rounds. She identified when the nurses performed diabetic foot checks they should be looking at the feet to identify any skin issues and then documenting what they observed in a nursing note. Interview with APRN #2 (the wound APRN) on 4/24/26 at

Based on interviews, observations, review of the clinical record, facility documentation, and facility policy for 1 of 2 sampled residents (Resident #11), reviewed for positioning and mobility, the facility failed to apply left extremity splints per the physician's order for a resident with contractures which led to a worsening and progression of the resident's 4th digit (finger) contracture. The findings include: Resident #11's diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non-dominant side, Type 2 diabetes mellitus and peripheral vascular disease. An Occupational Therapy (OT) Discharge summary dated [DATE] at 11:38 AM identified Resident #11's left upper extremity hand splint was modified and the left elbow splint was adjusted prior to discharge and the residents left elbow extension was measured at -75, with 2nd digit at -35, 3rd digit at -90, 4th digit at -60 and 5th digit at -25. A physician's order dated 1/16/25 and currently in effect directed a left resting hand splint to be donned at AM care and doffed after lunch. A physician's order dated 1/16/25 and currently in effect directed a left elbow splint to be donned (put on) after lunch and doffed (removed) at PM care. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #11 was cognitively intact and dependent with toileting, bed mobility, and transfers. The MDS failed to indicate Resident #3 had an upper extremity impairment on one side and failed to indicate the use of orthotics or splint/brace assistance. The Resident Care Plan (RCP) dated 3/30/26 identified Resident #11 had hemiplegia, partial paralysis or weakness on the left side. Interventions included fall prevention and administering medications as ordered. The RCP did not identify Resident #11 had contractures and was to have a left resting hand splint and left elbow splint applied daily. Review of the Nurse Aide (NA) Care Card on 4/25/26 at 10:57 AM failed to indicate the application of a left elbow splint or left resting hand splint for Resident #11. Review of the Treatment Administration Record (TAR) for April 2026 failed to include the physician order for the application and removal of a left elbow splint or left resting hand splint. Observations on 4/20/26 at 11:22 AM, 4/21/26 at 2:00 PM, 4/22/26 at 11:25 AM, and 4/23/26 at 3:00 PM noted Resident #11 lying in bed with clothing on and without the benefit of a left resting hand splint or left elbow splint being applied. Interview and observation with NA #6 on 4/24/26 at 10:05 AM identified she had not applied the splints for Resident #11 because she did not know Resident #11 needed splints. NA #6 indicated although she had not observed splints on the resident or in the room, she proceeded to search and located the left resting hand splint on the seat of the resident's wheelchair (at the bottom of a large pile of clothing and blankets) and located the left elbow splint in the bottom drawer of Resident #11's dresser. NA #6 identified although she had taken care of Resident #11 often, she had not applied either splint. NA #6 then set out to find LPN # and asked him how the splints were to be applied. Additionally, NA #6 indicated she had not received education on how or when to apply Resident #11's splints. Interview and observation with NA #3 on 4/24/26 at 10:10AM identified she had not applied splints to Resident #11 and did not know Resident #11 needed splints. NA #3 indicated she was assigned Resident #11 often in the last several months and although she had observed the splints in the resident's room, she did not know how or when the splints were to be applied for the resident and never asked the charge nurse. Further, NA #3 indicated she had not received education from the facility on how or when to apply Resident #11's splints. Interview, observation and review of the clinical record with LPN #4 on 4/24/26 at 10:15 AM identified he was not aware Resident #11's left resting hand splint and left elbow splint were not being applied by the NAs. LPN #4 indicated the physician orders for application of both splints were not transcribed in the TAR, so he was not tracking or signing for splint application and removal. LPN #4 identified although the NAs should have been applying the left resting hand splint and the left elbow splint, he was unsure how he or the NA's would know to put the splints on the resident if the orders were not on the TAR and not on the NA care card. Further, LPN # 4 indicated he had not received education from the facility on how or when to apply Resident #11's splints and would need to speak to the OT. Interview and review of the clinical record with OT #1 identified although she had put in the physician's orders on 1/16/25 directing left resting hand splints and left elbow splints, they were not reflected onto the TAR as they should have been when orders were entered into the electronic health record. OT #1 indicated she was unsure why both orders had not populated onto the TAR (where the nurse would document the application and removal of the splints). OT #1 identified Resident #11 had joint contractures of the elbow, hand and fingers and the splints were for joint contracture control. OT #1 indicated if the resident did not wear the left resting hand splint and the elbow splint applied as ordered the resident's joints could get further contracted and the resident could get skin breakdown on his/her hand. OT #1 stated Resident #11 was discharged from OT after the splints were issued and she was not notified by staff that splints were not being worn, were missing or had been refused. Additionally, OT #1 was certain she had provided splint education to the nursing staff but was unsure if she educated everyone she should have or had documented the education. Interview and review of the clinical record with the DNS on 4/27/26 at 10:00 AM identified if a left resting hand splint and left elbow splint were ordered, they should have been applied to the resident as ordered. The DNS indicated the NA or nurse should have applied the splints and if the resident refused application of the splints, the charge nurse or supervisor should have been notified. Review of physician's orders and TAR with the DNS failed to indicate the orders for Resident #11's left resting hand splint, and the left elbow splint were transcribed on the TAR (where the nurse would document the application and removal of the splints) and she was unsure why that happened. The DNS identified LPN #4, NA #3 and NA #6 should have received education on the application of both splints and she was unsure why that was not provided by OT. Subsequent to surveyor inquiry, an observation on 4/24/26 at 12:00 PM noted Resident #11 to be in bed with the left resting hand splint applied and an observation on 4/24/26 at 3:00 PM found the resident in bed with the left elbow splint applied. Subsequent to surveyor inquiry a physician's order dated 4/24/26 was initiated for Resident #11 which directed left elbow splint to be donned after lunch and doffed at PM care in the afternoon for contracture management. Additionally, a physician's order was initiated for the left elbow splint to be donned after lunch and doffed at PM care in the afternoon for contracture management. Both splint orders were now reflected on the TAR where the nurse would document the application and removal of the splints. Subsequent to surveyor inquiry, an OT Evaluation and Plan of Treatment dated 4/27/26 at 11:07 AM (signed by OT #1) identified Resident #11 would be re-started on therapy services 3 times per week for 6 weeks and the resident had been referred to OT due to an exacerbation of a decrease in range of motion (ROM). The evaluation indicated Resident #11 had impaired left upper extremity ROM due to left hemiparesis/hemiplegia with elbow extension measured at -70 degrees, wrist flexion at 50 degrees, 2nd digit at -25, 3rd digit at -70, 4th digit at -65 and 5th digit at -25. Another interview with OT #1 on 4/27/26 at 11:55 AM identified she had just completed an OT screen with joint contracture measurements for Resident #11. Comparison of the same measurements from 12/31/24 (which OT #1 indicated were the most recent measurements) to today's measurements with OT #1 identified a worsening and progression of the resident's 4th digit (finger) contracture (12/31/24 measurement of -60 and 4/27/26 measurement of -65). OT #1 indicated if the left resting hand splint was not applied to the resident as ordered that would have caused the worsening of the resident's finger extension (due to the resident's fingers being contracted and not extended by the splint). OT #1 stated the application of Resident #11's hand and elbow splints daily was to prevent his/her contractures from getting worse and it was her mistake that the splint orders dated 1/16/25 were put in incorrectly and did not populate onto the TAR. OT#1 indicated both splint orders were corrected on 4/24/26, Resident #11 would start OT services 3 times a week and she would complete splint education for all the staff that cared for Resident #11. Although OT #1 provided in-service education documentation dated 12/18/24 for Resident #11's hand and elbow splints (which had only 3-4 staff signatures), the documentation failed to indicate LPN #4, NA #3, and NA #6 had received education on the application of Resident #11's splints. Review of the facility policy, Splints and Orthotic Devices, undated, directed splints or orthotic devices are those which are given to maintain range of motion, enable proper joint alignment, promote skin integrity, enhance functional ability and prevent further deformity. Therapy and/or the physician will issue appropriate positioning splint determined by the resident's needs and therapy and the nursing staff that have been educated on the device will apply and remove per physician's orders. The order for the positioning device will be transcribed onto the resident's treatment kardex (TAR) and nursing staff will be educated on the proper application and wearing schedule related to the device being used.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 residents (Resident #2, Resident #14 and Resident #43) reviewed for dental, the facility failed to ensure dental services were provided to Medicaid recipients. The findings include: 1.Resident #2 had diagnoses that included dental caries (cavities), diabetes, and jaw pain.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact, had obvious or likely cavity(s) or broken natural teeth, required setup or clean-up assistance with eating and bed mobility, and supervision or touching assistance with transfers and ambulation. An Advanced Practice Registered Nurse (APRN) order written by APRN #1 and dated 2/11/26 directed to book an (in house or outpatient) dental appointment as soon as possible (ASAP) related to moderate to severe left rear upper and lower dental pain with the referring provider listed as APRN #1.The Resident Care Plan (RCP) dated 2/29/26 identified Resident #2 required staff assistance with activities of daily living (ADLs). Interventions included visiting the dentist as ordered/needed. The RCP further identified Resident #2 required a higher level of care related to a psychiatric diagnosis with interventions that included obtaining a dental evaluation. An APRN progress note written by APRN #1 on 3/2/26 at 8:15 AM identified Resident #2 was seen for complaints of right jaw pain and swelling to the right eye. APRN #1's note identified Resident #2 reported right jaw pain and intermittent right eye swelling over the weekend and discomfort with chewing. The note identified there was no active eye swelling noted and Resident #2 had previously complained of chronic right sided dental pain for which an order was put in place for Anbesol (topical oral anesthetic) and was awaiting a dental evaluation. APRN #1's progress note further indicated a new reminder had been entered into the electronic medical record (EMR) for staff to obtain a dental consult for Resident #2 as soon as possible (ASAP) due to he/she likely had dental caries.An order by APRN #1 and dated 3/2/26 directed a REMINDER to book an (in house or outpatient) dental appointment ASAP related to moderate to severe left rear upper and lower dental pain with the referring provider listed as APRN #1.An APRN progress note written by APRN #1 on 3/5/26 at 9:30 AM identified Resident #2 was seen for complaints of edema. The note identified the review of systems indicated right jaw pain, intermittent swelling of the right eye (currently resolved), discomfort with chewing, and chronic right sided dental pain. The note further indicated Resident #2 was pending dental consultation for right-sided dental pain.An APRN progress note written by APRN #1 on 3/9/26 at 1:00 PM identified Resident #2 was seen for weight loss. The note indicated the need for follow-up related to a dental consultation ASAP for suspected dental caries and chronic right sided dental pain.An APRN progress note written by APRN #1 on 3/10/26 at 7:15 AM identified Resident #2 was seen for review of lab work, anemia, and hypocalcemia follow-up. The note indicated the need for follow-up related to a dental consultation ASAP for suspected dental caries and chronic right sided dental pain.An APRN progress note written by APRN #1 on 3/12/26 at 9:45 AM identified Resident #2 was seen for significant right sided periorbital edema which was nontender and without warmth or redness, but which presented with an abnormal neurological assessment of left eye lateral drift. The note indicated Resident #2 thought he/she had a dental abscess. The APRN progress note further identified Resident #2 was sent to the emergency department (ED) for evaluation due to the severity of the swelling.A nursing note written by Registered Nurse (RN) #1 on 3/12/26 at 2:58 PM identified Resident #2 was transferred to the hospital for evaluation due to acute periorbital edema with delayed right pupillary reaction, abnormal drift of the left eye, and edema of the right face with complaints of dental pain.A nursing note written by RN #9 on 3/13/26 at 2:13 AM identified Resident #2 had returned from the hospital and the hospital work-up indicated Resident #2 did not have a dental abscess, did have a dental [NAME] and was prescribed an antibiotic regimen with Augmentin 875-125 milligrams (mg) by mouth twice daily.An APRN progress note written by APRN #1 on 3/16/26 at 12:30 PM identified Resident #2 was seen for follow-up after his/her ED transfer. The note identified Resident #2 was sent to the ED on 3/12/26 with significant right side facial swelling, dental pain, and an abnormal cranial nerve assessment. The note identified there were also concerns related to weight loss over the last 2 months and x-rays done in the ED showed some dental caries without significant abscess and Resident #2 was started on antibiotics which had shown positive effects. The note identified Resident #2's facial swelling was significantly decreased, he/she reported improved pain, and he/she had a referral for a dental consult in place which was still pending for management of dental caries.A nursing note dated 3/17/26 at 12:01 AM identified Resident #2 complained of difficulty or pain with swallowing.An APRN progress note written by APRN #1 on 3/17/26 at 8:15 AM identified Resident #2 was seen for follow-up for weight loss. The note identified Resident #2 was seen on 3/16/26 for follow-up after an ED transfer for facial swelling with dental pain, and that a dental referral remains pending for management of dental caries and to monitor for dental pain and signs of abscess formation and update the provider for any changes.An APRN progress note written by APRN #1 on 3/24/26 at 10:15 AM identified Resident #2 was seen for lost glasses and need for an ophthalmology referral. The note identified the need for evaluation of dental caries through a dental referral.A nursing note dated 3/24/26 at 2:22 PM identified Resident #2 verbalized having pain but failed to identify the location of the pain or the pain level.An APRN progress note written by APRN #1 on 3/25/26 at 10:15 AM identified Resident #2 was seen for review of valproic acid level. The note identified Resident #2 was pending a dental referral for management of dental caries.A nursing note dated 3/29/26 at 2:42 PM identified Resident #2 verbalized having pain but failed to identify the location of the pain or the pain level.An APRN progress note written by APRN #1 on 3/30/26 at 10:15 AM identified Resident #2 was seen for a fall with left ankle pain and swelling. The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #1 on 3/31/26 at 9:30 AM identified Resident #2 was seen for follow-up after a fall. The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #1 on 4/1/26 at 10:00 AM identified Resident #2 was seen for review of lab work. The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #1 on 4/6/26 at 8:00 PM identified Resident #2 was seen for review and renewal of Oxycodone. The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #1 on 4/9/26 at 12:45 PM identified Resident #2 was seen for loose stools related to Metformin use. The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #1 on 4/10/26 at 10:45 AM identified Resident #2 was seen for discontinuation of his/her wound treatment. The note identified Resident #2 had a dental referral pending.An in-house dental provider schedule list for the service date of 4/10/26 identified the provider was scheduled to see 14 residents for dental related services. Resident #2 was not identified on this list.An APRN progress note written by APRN #3 on 4/17/26 at 10:00 AM identified Resident #2 was seen for bilateral knee swelling and pain. The note identified Resident #2 had a history of cellulitis of the face (3/12/26 ED visit). The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #3 on 4/20/26 at 9:15 AM identified Resident #2 was seen for follow-up of a lower extremity doppler. The note identified Resident #2 had a dental referral pending.An APRN progress note written by APRN #3 on 4/21/26 at 8:30 AM identified Resident #2 was seen for bilateral lower extremity pain. The note identified Resident #2 had a dental referral pending.Interview with Resident #2 on 4/21/26 at 12:52 PM identified he/she had tooth pain and swelling and had told the staff but they did not offer or assist for him/her to see a dentist. Interview with Social Worker(SW) #1 on 4/22/26 at 1:45 PM identified she was responsible for submitting the Request for Services documents to the ancillary services provider which included dental services. She identified that she was not responsible for scheduling appointments, but she was the point of contact between the provider and the facility to ensure the facility was aware of when each service visit was scheduled and which residents were scheduled to be seen at that visit. SW #1 identified she did not automatically sign residents up for services because not everyone was eligible for services and so she relied on the nursing staff and/or the residents to notify her when a resident needed to have the Request for Services form submitted for them. She further identified that she had not been requested to sign Resident #2 up for dental services, but that she would check with Resident #2 to determine if she required dental services.Interview, clinical record review, and facility documentation review with Registered Nurse (RN) #1 on 4/22/26 at 2:30 PM identified she was responsible for making dental appointments for residents. She identified that the nurse who confirmed a physician/APRN order for a dental appointment was supposed to print the referral out and leave it for her so that she would know an appointment was needed. She identified she had not been aware of the order by APRN #1 that directed to make a dental appointment for Resident #2. Additionally, when looking through her paperwork she was unable to locate a dental referral had been printed for Resident #2. She identified when she received a referral she would send the referral to a dental provider in the community used by the facility unless the resident had a provider of their own, she indicated she usually documented her progress on the printed referral sheet and that she did not always document the progress in a nursing note. She further identified she was unable to identify why she had not received the referral, but now that she was aware of the need for Resident #2 to have a dental appointment she would print the referral and make an appointment.Subsequent to surveyor inquiry a Request for Services form dated 4/22/26 was faxed to the in-house ancillary dental service provider to request services including dental.Interview with APRN #1 on 4/22/26 at 3:28 PM identified she had written multiple progress notes regarding Resident #2 obtaining a dental appointment including prior to Resident #2 being sent to the ED for evaluation related to facial swelling. APRN #1 identified when she put in an order for a dental appointment referral, she always alerted the nursing supervisor so they were aware. She identified she had verbally reminded the nursing staff more than once that Resident #2 had not seen a dentist and had an order requesting a dental appointment be made. Additionally, she indicated that considering the referral had been made due to Resident #2 having dental pain her expectation was that an appointment would have been made within 2-3 weeks. APRN #1 further identified that while Resident #2 didn't have active dental pain when she last saw him/her on 4/10/26, she couldn't rule out that the improvement wasn't related to the antibiotic treatment initiated by the hospital, and that over time without a dental consult and management of the dental caries, that Resident #2's dental pain could return.Subsequent to surveyor inquiry, interview with RN #1 on 4/24/26 at 11:00 AM identified she had made a dental appointment for Resident #2 for the beginning of May 2026.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 12:01 PM identified that all new physician/APRN orders were reviewed within 24-72 hours by the interdisciplinary team and so the order for a dental appointment for Resident #2 should have been identified. She identified that a month or more without making an appointment was too long, and she would have expected that when Resident #2 had been on antibiotics for a dental/mouth infection, the appointment should have been made immediately. She was unable to identify why the appointment had not been made sooner. 2.Resident #14's diagnoses included heart failure, diabetes and chronic kidney disease.Physician orders dated 1/13/25 and currently in effect directed to vision, dental, podiatry, audiology and psychiatric services as needed.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, independent for dressing toileting, showering, eating and transfers. Also, no dental concerns were identified.A Dental consult dated 9/25/25 identified Resident #14's teeth were badly broken down, and most were reduced to nubbins. Also, identifying Resident #14 should have all her/his teeth removed.The annual MDS assessment dated [DATE] identified Resident #14 was cognitively intact, independent for dressing toileting, showering, eating and transfers. Also, no dental concerns were identified.A Dental consult dated 1/21/26 directed for Resident #14 to be referred to an oral surgeon as soon as possible, Resident #14's dentition was in dreadful condition, and has had some dental infections. Also, identifying Resident #14 needed 18 teeth to be removed.Physician orders dated 4/8/26 directed to schedule a dental appointment in 6 months.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #14 was at risk for cardiac issues. Interventions included to monitor vital signs, obtain weights as ordered, and encourage Resident #14 to elevate legs when out of bed as needed.Observation and interview on 4/20/26 at 12:13 PM with Resident #14 identified she/he had broken front teeth, had seen the dentist in the past and was waiting for a follow up appointment to have teeth removed but had not heard of any appointments from the facility.Interview on 4/22/26 at 1:26 PM with Registered Nurse (RN) #7 identified an appointment/referral for an oral surgeon should have been scheduled within 2-3 months of the original dentist visit on 9/25/25.Interview and review of the dental record on 4/22/26 at 1:29 PM with the Director of Nursing Services (DNS) identified that she was unsure if a follow-up appointment had been made for Resident #14. Also, identifying 7 months was too long to wait if teeth were infected and to have the teeth extracted.Interview on 4/22/26 at 3:25 PM with Licensed Practice Nurse (LPN) #5 identified she had made a follow-up appointment for Resident #14 today, subsequent to surveyor inquiry and that she usually does not make appointments for the residents.Interview on 4/23/26 at 9:57 AM with the DNS identified the Social Worker was responsible for making appointments for the residents.Interview on 4/23/26 at 10:13 AM with Advance Practice Registered Nurse (APRN) #3 identified if Resident #14's teeth were infected and needed to be removed, she would expect the appointment to be made with an oral surgeon within a few weeks. Also, identifying if a resident had an oral infection left unattended, it could lead to sepsis and could cause cardiac issues to worsen. Further, identifying waiting 7 months for teeth to be removed was too long.Interview on 4/23/26 at 10:20 AM with SW #1 identified the nursing supervisor was responsible for making the appointments and the receptionist books the transportation needed for the appointment. 3.Resident #43 was admitted to the facility in August 2023 with diagnoses that included chronic systolic congestive heart failure, chronic embolism and thrombosis of bilateral femoral veins and schizoaffective disorder. Review of the Dental providers Do Not Treat list provided to the facility on 3/12/26 identified Resident #43 was listed as active at the facility but was not receiving services due to reason stated (Request for Service form was not signed by patient/RP). The dental provider's document further directed if the resident should be seen, please submit a new Request for Services form or an Attending Physician Request for Services form. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was cognitively intact and dependent with transfers, toileting and bed mobility. The MDS indicated Resident #43 required supervision or touching assistance with oral hygiene. The Resident Care Plan (RCP) dated 4/2/26 identified Resident #43 needed staff assistance with activities of daily living and was at risk for malnutrition. Interventions included assisting the resident as needed and providing diet as ordered. Interview and review of facility documents and the clinical record with Social Worker (SW) #1 and the Director of Nurses (DNS) on 4/22/26 at 11:32 AM identified Resident #43 was listed as do not treat on the dental provider's service form because a request for service had not been signed by the resident or the resident's responsible party. SW #1 indicated although Resident #43 was admitted to the facility on [DATE], review of the clinical record failed to indicate a consent to treat had been completed/signed or that dental services had been provided to the resident since admission. Review of the clinical record with the DNS identified Resident #43 was responsible for self, could have signed the consent to treat form and was unsure why that was not done. SW #1 then indicated the dental providers consent to treat should have been addressed and completed by the charge nurse or supervisor who admitted the resident to the facility and it must have been an oversight. SW #1 further stated she should address if residents need ancillary services (podiatry, dental, audiology and ophthalmology) at quarterly care conferences so residents would not fail to receive needed services going forward. Although requested SW #1 and the DNS were unable to provide documentation that Resident #43 had received dental services since admission to the facility on 8/21/23. Subsequent to surveyor inquiry, on 4/22/26 at 1:27 PM the DNS identified Resident #43 signed the consent for treatment form and she was going to fax it to and call the dental provider to have them come to the facility to evaluate and treat the resident as soon as possible. The DNS indicated she was still unable to locate a dental provider consent form for the resident since admission (on 8/21/23), was unsure why it was not done and dental services were not offered or provided to the resident since admission. The DNS indicated the resident had teeth and should have received routine dental services. Interview with the dental providers Senior Operations Manager (Vendor #2) on 4/23/26 at 2:53 PM identified Resident #43 was not an active patient and the facility contact (SW #1) had failed to respond or follow-up with correcting or completing the Request for Service form for the resident. Vendor #2 indicated the facility was repeatedly notified via the dental providers monthly Do Not Treat list (which directed a consent to treat form needed to be signed and submitted before dental services could be provided). Additionally, Vendor #2 identified the facility should have utilized the attending physician order form (can be completed/signed by a physician or nurse at the facility) if the resident or responsible party were unable to sign the initial consent to treat form. Vendor #2 further indicated a completed consent to treat form for the resident was received from the facility on 4/22/26 (subsequent to surveyor inquiry) and dental services would be provided to Resident #43 during their next visit to the facility. Another interview with SW #1 on 4/24/26 at 11:00 AM identified she had reviewed the dental providers records of services provided and Resident #43 was not on any record which indicated dental care had been provided since admission [DATE]). SW #1 stated Resident #43 had teeth and should have received routine dental services and although she did recall sending paperwork to the dental provider, she failed to follow-up and get the consent to treat corrected/signed by Resident #43 or the responsible party. SW #1 further indicated she was not aware the dental provider had an alternative form (Attending Physician Request for Services) which could be signed by a facility physician/nurse (when a resident or responsible party were unable to sign) and she would begin using that form for residents when needed. Review of the facility policy, Ancillary Services, undated, directed ancillary services including dental care would be provided and residents ancillary services needs would be evaluated during admission and as part of ongoing assessments. Ancillary services would be provided by the facility or through coordination with qualified external providers and residents or their representatives would be informed of available services and assisted with scheduling appointments as needed.Review of the Oral Hygiene policy directed, in part, residents are provided with regular and emergency dental care. This care is provided by the facility Consultant Dentist, who provides consultation, and may be available in case of an emergency. Arrangement for emergency dental care will be made when the Consultant Dentist is unavailable.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only resident (Resident #43) reviewed for activities of daily living and for 1 of 2 residents (Resident #67) reviewed for pressure ulcer/injury the facility failed to ensure podiatry services were provided. The findings include: 1.Resident #43 was admitted to the facility in August 2023 with diagnoses that included chronic systolic congestive heart failure, chronic embolism and thrombosis of bilateral femoral veins and schizoaffective disorder. The Resident Care Plan (RCP) dated 1/13/26 identified Resident #43 needed staff assistance with activities of daily living and was at risk for malnutrition. Interventions included assisting the resident as needed and providing diet as ordered. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was cognitively intact and dependent with transfers, toileting, bed mobility and personal hygiene. On 4/20/26 at 10:48 AM, Resident #43 was observed lying in bed with his/her bilateral feet toenails extremely lengthy and thickened and Nurse Aide (NA) #3 was observed putting socks on the resident's feet. Observation and interview with NA #3 on 4/22/26 at 10:55 AM identified she had observed Resident #43's toenails very lengthy and thickened for a long time, had told the charge nurse and asked if the residents could be put on the podiatry list. NA #3 indicated Resident #43 should not have toenails so very lengthy, but she was told she could not trim resident's toenails. Observation of Resident #43's toenails and interview with Licensed Practical Nurse (LPN) #2 on 4/22/26 at 10:55 AM identified she had been working at the facility for 4 months and when she first observed Resident #43's extremely lengthy toenails she reported it to the Nursing Supervisor, asked if there was a podiatry book and was told to report it to the Social Worker (SW #1). LPN # 2 indicated she had spoken to SW #1 and was told next time the podiatrist came to the facility the resident would be seen. LPN #2 stated she worked full time at the facility but had not seen the podiatrist on her unit since working there. Observation and interview with the DNS on 4/22/26 at 11:25 AM identified Resident #43's toenails on both feet were extremely long and thickened and should not be that way. The DNS indicated she would need to check to see if the resident was seen by podiatry and when. The DNS stated although NAs cannot trim toenails, the NA should have informed the charge nurse or nursing supervisor about the resident's lengthy toenails. The DNS further identified it was SW #1 that worked with the podiatry provider and SW #1 should have obtained the paperwork, communicated with the provider and ensured the podiatry services were scheduled. The DNS indicated Resident #43 should have been provided with routine podiatry services either at the facility or by an outside provider. Interview and review of facility documents and the clinical record with SW #1 and the DNS on 4/22/26 at 11:32 AM identified Resident #43 was listed as do not treat on the podiatry provider form because a request for service had not been signed by the resident or the resident/resident representative. SW #1 indicated although Resident #43 was admitted to the facility on [DATE], review of the clinical record failed to indicate a consent to treat had been completed/signed or that podiatry services had ever been provided to the resident. Review of the clinical record with the DNS identified Resident #43 was responsible for self, could have signed the consent to treat form and she was unsure why that was not done. SW #1 then indicated the podiatry providers consent to treat should have been addressed and completed by the charge nurse or supervisor who admitted the resident to the facility and it must have been an oversight. SW #1 further stated she would need to address residents, staff and families at quarterly care conferences if residents need ancillary services (podiatry, dental, audiology and ophthalmology) so residents would not fail to receive the needed services going forward. Although requested SW #1 and the DNS were unable to provide documentation that Resident #43 had received podiatry services since admission to the facility on 8/21/23. Subsequent to surveyor inquiry, on 4/22/26 at 1:27 PM the DNS identified Resident #43 signed the consent for treatment form, she was going to fax it to and call the podiatry provider to have them come to the facility to evaluate and treat the resident as soon as possible. The DNS indicated she was still unable to locate a podiatry provider consent form for the resident since admission (on 8/21/23) and she was unsure why it was not done and podiatry services were not offered or provided to the resident since admission. The DNS indicated the resident should have received routine podiatry services. Interview with the podiatry providers Senior Operations Manager (Vendor #2) on 4/23/26 at 2:53 PM identified Resident #43 was not an active patient, and the facility contact (SW #1) had failed to respond or follow-up with correcting or completing the Request for Service forms for the resident. Vendor #2 indicated the facility was repeatedly notified via the podiatry providers monthly do not treat list, which indicated a Request for Service form needed to be signed and submitted before podiatry services could be provided to Resident #43. Additionally, Vendor #2 identified the facility should have utilized the Attending Physician Request for Service form (can be completed/signed by a physician or nurse at the facility) if the resident or responsible party were unable to sign the other consent to treat form. Vendor #2 further indicated a completed Request for Service form for Resident #43 was received from the facility on 4/22/26 (subsequent to surveyor inquiry) and podiatry services would be provided to Resident #43 during their next visit to the facility. Another interview with SW #1 on 4/24/26 at 11:00 AM identified she reviewed the records of services provided by the podiatry provider and Resident #43 was not on any record which indicated podiatry care had been provided since admission. SW #1 stated Resident #43 should have received routine podiatry services and although she did recall sending paperwork to the podiatry provider, she failed to follow-up and get the consent to treat corrected/signed by the resident or the responsible party. SW #1 further indicated she was not aware the podiatry provider had an alternative form (Attending Physician Request for Services) which could be signed by a facility physician/nurse (when a resident or responsible party were unable to sign) and she would begin using that form for residents when needed. Observation with the Infection Preventionist (RN #2) on 4/27/26 at 2:40 PM identified Resident #43's right great toe toenail measured 5.2 cm from the nailbed to the end of the nail and the left great toe toenail measured 4.2 cm from the nailbed to the end of the nail. RN #2 indicated that the resident's great toenails were very lengthy, curved, thickened, and dark in color and should be evaluated by the podiatrist as soon as possible. 2. Resident #67 was admitted to the facility in July 2024 with diagnoses that included dementia, chronic obstructive pulmonary disease and unspecified severe protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #67 was severely cognitively impaired and was dependent with transfers, toileting, bed mobility and personal hygiene. The Resident Care Plan (RCP) dated 2/20/26 identified Resident #67 required staff assistance with activities of daily living with interventions that included assisting the resident as needed and report any changes to the interdisciplinary team. Observation of Resident #67's toenails and interview with Nurse Aide (NA) #3 on 4/22/26 at 10:55 AM identified she had observed Resident #67's toenails very lengthy for a long time, had told the charge nurse and asked if the resident could be put on the podiatry list. NA #3 indicated Resident #67 should not have his/her toenails so very lengthy, but she was told she could not trim resident's toenails. Observation and interview with LPN #2 on 4/22/26 at 10:55 AM identified she had been working at the facility for 4 months and when she first observed Resident #67's extremely lengthy toenails she reported it to the Nursing Supervisor and asked if there was a podiatry book and was told to report to social worker (SW #1). LPN # 2 indicated she spoke to SW #1 and was told next time the podiatrist came to the facility the resident would be seen. LPN #2 stated she worked full time at the facility but had not seen the podiatrist on her unit since working there. Observation and interview with the DNS on 4/22/26 at 11:25 AM identified Resident #67's toenails on both feet were extremely long and should not be that way. The DNS indicated she would need to check to see if the resident was seen by podiatry and when. The DNS stated although NAs cannot trim toenails, the NA should have informed the charge nurse or nursing supervisor about Resident #67's lengthy toenails. The DNS further identified it was SW #1 that worked with the podiatry provider and SW #1 should have obtained the paperwork, communicated with the provider and ensured the podiatry services were scheduled. The DNS indicated Resident #67 should have been provided routine podiatry services either at the facility or by an outside provider. Interview and review of facility documents and the clinical record with SW #1 and the DNS on 4/22/26 at 11:32 AM identified Resident #67 was listed as do not treat on the podiatry provider form because a request for service had not been signed by the resident or the resident's responsible party. SW #1 indicated although Resident #67 was admitted to the facility on [DATE], review of the clinical record failed to indicate a consent to treat had been completed/signed or that podiatry services had been provided to the resident. SW #1 indicated the podiatry providers Request for Services form should have been addressed and completed by the charge nurse or supervisor who admitted the resident to the facility and it must have been an oversight. SW #1 further stated she would begin to address the residents need for ancillary services (podiatry, dental, audiology and ophthalmology) at the quarterly care conferences so residents would not fail to receive needed services going forward. Although requested SW #1 and the DNS were unable to provide documentation that Resident #67 had received podiatry services since admission to the facility on 7/30/24. Interview with Person #1 on 4/22/26 at 1:40 PM identified he/she was the resident representative for Resident #67 and recalled having signed the paperwork for the resident to receive podiatry services shortly after the resident's admission (on 7/30/24). Person #1 indicated although he/she again signed the request for services paperwork for podiatry services a few months ago, the resident had still not received podiatry care. Person #1 stated when he/she last visited Resident #67 he/she became concerned because the resident's toenails looked like talons and feared the resident or the staff caring for Resident #67 could become injured because of the length and sharpness of his/her toenails. Person #1 indicated he/she brought the concern to the charge nurse during a visit and was told Resident #67 would be put on the podiatry list. Person #1 felt there continued to be a breakdown in communication at the facility and was going to call SW #1 to address it. Interview with the podiatry providers Senior Operations Manager (Vendor #2) on 4/23/26 at 2:53 PM identified Resident #67 was not an active patient, and the facility contact (SW #1) had failed to respond or follow-up with correcting or completing the Request for Service forms for the resident. Vendor #2 indicated the facility was repeatedly notified via the podiatry providers monthly do not treat list, which indicated a Request for Service form needed to be signed and submitted before podiatry services could be provided to Resident #67. Additionally, Vendor #2 identified the facility should have utilized the Attending Physician Request for Service form (can be completed/signed by a physician or nurse at the facility) if the resident or responsible party were unable to sign the other consent to treat form. Vendor #2 stated she had not yet received a completed Request for Service form for Resident #67. Another interview with SW #1 on 4/24/26 at 11:00 AM identified she reviewed the services provided by the podiatry provider and Resident #67 was not on any record which indicated podiatry care had been provided since admission. SW #1 stated Resident #67 should have received routine podiatry services and although she did recall sending paperwork to the podiatry provider, she failed to follow-up and get the consent to treat corrected/signed by the resident or the responsible party. SW #1 further indicated she was not aware the podiatry provider had an alternative form (Attending Physician Request for Services) which could be signed by a facility physician/nurse (when a resident or responsible party were unable to sign) and she would begin using that form for residents when needed. Review of the facility policy, Ancillary Services, undated, directed ancillary services including podiatry care would be provided and residents ancillary services needs would be evaluated during admission and as part of ongoing assessments. Ancillary services would be provided by the facility or through coordination with qualified external providers and residents or their representatives would be informed of available services and assisted with scheduling appointments as needed.

Based on interviews, observations, review of the clinical record, facility documentation, and facility policy for 1 of 4 residents (Resident #73) reviewed for dining, the facility failed to ensure a dignified dining experience by feeding Resident #73 while standing and not sitting at eye level with Resident #73 during feeding. The findings include: Resident #73 had diagnoses that included diabetes, vascular dementia, and dysphagia.The Resident Care Plan (RCP) dated 1/6/26 identified Resident #73 was at risk for inadequate intake related to impaired cognition, dysphagia, and an altered texture diet. Interventions included to provide the diet as ordered, offer routine between meal snacks, and obtain speech therapy services as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #73 was moderately cognitively impaired, was on a therapeutic diet, required setup or clean-up assistance with eating, and was dependent with bed mobility, and transfers. The MDS failed to identify Resident #73 was on a mechanically altered diet.A physician order signed 4/5/26 (original order date 9/7/23) directed to provide a carbohydrate controlled, no added salt, fat and cholesterol restricted dysphagia level 2 textured diet with thin liquids.Observation of dining in the Main dining room on 4/20/26 at 12:15 PM identified Nurse Aide (NA) #2 standing at a table located at the far end of the dining room away from the steam table. NA #2 was observed standing between Resident #73 and another resident while feeding Resident #73. While standing next to Resident #73, NA #2's head was observed to be above the head of Resident #73 and out of the eyesight line of Resident #73. NA #2 was observed feeding Resident #73 the last 4 bites of the meal.Interview with NA #2 on 4/20/26 at 12:25 PM identified she was feeding Resident #73 because he/she cannot feed themselves and did not sit in a chair at eye level to feed Resident #73 but that sometimes she does. She indicated that there were not always chairs available to sit on to feed residents that required assistance, so she stood when there wasn't a chair available. She indicated that she could have asked for someone to get another chair, but she hadn't done that. She further indicated that she had received education from the facility about feeding residents, that the education directed for her to sit when feeding a resident but she was unaware of the rationale for needing to sit and not stand.Interview with the Director of Nursing (DNS) on 4/23/26 at 9:50 AM identified NAs should be seated when feeding a resident and the NA should be interacting with the resident during the feeding time period. The DNS indicated when a chair was unavailable for a NA to sit when feeding a resident, they should request someone to bring them a chair and then sit down and begin feeding the resident.Review of the Feeding policy directed, in part, to ensure assistance was provided in a dignified, respectful manner, and to speak with the resident while feeding. The policy further directed not to stand when feeding the resident.

Based on interviews, observation, review of the clinical record, facility documentation, and facility policy for 1 of 2 residents (Resident #3) reviewed for skin conditions, the facility failed to ensure that Resident #3 was properly assessed for the ability to self administer a treatment prior to allowing self administration of a prescribed antibacterial ointment. Resident #3's diagnoses included diabetes with a related foot ulcer, a local infection of the skin and subcutaneous tissue, and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #3 had intact cognition, independently propelled a wheelchair, and was independent with toilet transfers; however, the resident required supervision or touching assistance for toilet hygiene and was frequently incontinent. A physician order dated 4/18/26 directed that Gentamycin ointment be applied to Resident #3's bilateral lower extremities and right lower abdomen once daily. The physician orders failed to direct self-administration of medications or treatments. Observation and interview with Resident #3 on 4/20/26 at 12:07 PM identified Gentamicin ointment was observed on his/her bed in his/her room and within reach. Resident #3 picked up the ointment and stated that the nurses apply it after providing care; however, he/she would reapply it throughout the day when he/she felt it had rubbed off from the incontinent brief. Interview with LPN #2 indicated that she applies the Gentamicin ointment for Resident #3 but was aware that the resident was reapplying the ointment independently throughout the day when he/she became itchy or felt it had rubbed off. LPN #2 further stated that Resident #3 had not been assessed or cleared to self administer medications and should not be applying Gentamicin ointment independently, but she allowed it because the resident was alert and oriented. Interview with RN #6 (Regional Director of Nursing Leadership) indicated that Resident #3 should not have been administering Gentamicin ointment on his/her own because he/she had not been assessed to self administer medications. RN #6 further stated that, following the surveyor's inquiry, the medication was removed from the resident's room. Review of the facility policy titled Self Administration of Medications, undated, indicated that residents may self administer medications if it is determined to be safe and appropriate based on an individual assessment conducted by a licensed nurse. The policy further directs that the assessment must be documented in the resident's medical record and that medications must be stored securely to prevent misuse or accidental exposure.

Based on review of the clinical record, facility policy and interviews for the only sampled resident (Resident #42) reviewed for the availability of medication , the facility failed to ensure the provider was notified timely of a medication not being available for administration. The findings include: Resident #42 had diagnoses that included osteomyelitis of the right ankle/foot, post-traumatic stress disorder, attention deficit hyperactivity disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 was cognitively intact, used a walker and wheelchair, and was independent with eating, bed mobility and bed/chair transfers. A physician order dated 12/8/25 and currently in effect directed to administer Ramelteon 8 milligrams (mg) by mouth at bedtime for sleep.The Resident Care Plan (RCP) dated 12/18/25 identified Resident #42 was at risk for pain/discomfort which may impact his/her sleep. Interventions included administering medications as ordered, observe Resident #42 for non-verbal signs of pain such as restlessness, changes in usual pattern of sleep, and change in mood.a. Review of Medication Administration Record (MAR) identified Ramelteon 8 mg was not administered on 2/4/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/15/26, 2/18/26, 2/25/26, and 2/28/26 (10 out of 28 opportunities (35.7%)) for reason code 12 (medication unavailable-see progress notes). Additionally, the MAR identified Resident #42 went 5 consecutive days without the medication being administered (2/7/26 through 2/11/26).Nursing notes from 2/1/26 through 2/28/26 failed to identify the physician or responsible party were notified of Ramelteon not being available or actions taken to ensure Resident #42 received the medication ordered by the physician. Additionally, the notes failed to identify nursing notes had been written on 2/4/26, 2/7/26, 2/8/26, 2/10/26, 2/11/26, 2/15/26, 2/18/26, and 2/25/26 (the MAR identified a note would be written when Ramelteon was not administered on those dates).Nursing notes located in the electronic medical record (EMR) identified 8 out of 10 dates when Ramelteon 8 mg was not administered (2/4/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/15/26, and 2/18/26) the nurse documented they were waiting on pharmacy/delivery, and 2 out of 10 dates when Ramelteon was not administered (2/25/26 and 2/28/26) the nurse documented Ramelteon was unavailable. The EMR nursing notes failed to identify the MD/APRN had been notified that Ramelteon 8mg was unavailable and not administered.Physician and Advanced Practice Registered Nurse (APRN) progress notes for February 2026 failed to identify a note which referenced they were notified Ramelteon was unavailable for administration and any action taken.b. The MAR for 3/1/26 through 3/31/26 identified Ramelteon 8 mg was not administered on 3/2/26 and 3/8/26 for reason code 3 (hold-see progress note), and not administered on 3/5/26, 3/6/26, 3/7/26, 3/9/26, 3/13/26, and 3/14/26 for reason code 12 which indicated the medication was not administered a total of 8 out of 31 opportunities (25.8%). Additionally, the MAR identified Resident #42 went 5 consecutive days without the medication being administered (3/5/26 through 3/9/26).Nursing notes from 3/1/26 through 3/10/26 failed to identify the MD/APRN was notified that Ramelteon 8mg was not available or actions taken to ensure Resident #42 received the medication ordered by the physician. The nursing notes failed to identify Resident #42 had an order in place to hold Ramelteon 8mg. Additionally, the notes failed to identify a nursing note had been written on 3/2/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, and 3/9/26 as the MAR identified when the medication was not administered.Nursing notes located in the EMR identified 6 out of 8 dates when Ramelteon was not administered (3/2/26, 3/5/26, 3/6/26, 3/7/26, 3/9/26, and 3/14/26) and the nurse documented on order/waiting on pharmacy/delivery, 1 out of 8 dates when Ramelteon was not administered (3/8/26) the nurse documented Ramelteon was discontinued (this was a discrepancy as no MD/APRN order was identified in the chart to discontinue Ramelteon), and 1 out of 8 dates (3/13/26) the nurse documented Ramelteon was unavailable. The EMR nursing notes failed to identify the MD/APRN had been notified that Ramelteon was unavailable and not administered.Physician and APRN progress notes from 3/1/26 through 3/10/26 failed to identify a note which referenced they were notified Ramelteon was unavailable for administration and any action taken.An APRN progress note written by APRN #1 on 3/11/26 at 2:15 PM identified Resident #42 was seen for submission of prior authorization forms for Ramelteon, complaints of dental pain, and review of blood work. The note identified Resident #42 had a diagnosis of chronic primary insomnia and had been trialed on multiple other medications (melatonin, trazodone, and zolpidem) for 30 days or more without any impact on his/her sleep. The note identified Resident #42 was unable to obtain therapeutic levels of sleep with the trialed medications, and that Resident #42 had trouble with falling asleep and staying asleep even with appropriate sleep hygiene habits. The note identified Resident #42 was followed by the psychiatric team who had determined that Ramelteon was the most appropriate medication at this time for Resident #42's insomnia. The note further identified that a prior authorization for this medication was required by Resident #42's insurance company, and that the necessary forms had been completed and faxed per guidelines and a response was pending. The note identified Resident #42's chronic insomnia affected his ability to function on a day-to-day basis and caused (chronic fatigue, decreased appetite, poor activity tolerance, mood disturbances). The note indicated a new prescription for Ramelteon 8mg was E-faxed to the pharmacy, and prior authorization forms were completed and refaxed to get the medication covered. The note further identified staff were to encourage appropriate sleep hygiene habits and to notify the provider for any changes in condition.Interview with Licensed Practical Nurse (LPN) #6 on 4/23/26 at 12:19 PM identified she typically worked the evening (3:00 PM-11:00 PM) shift and when a medication was unavailable, she would notify the nursing supervisor and then would do whatever the supervisor directed her to do. Interview with Registered Nurse (RN) #4 on 4/23/26 at 1:04 PM identified she worked as the nursing supervisor on the evening shift. She identified LPN #6 had not notified her that Resident #42 did not have Ramelteon available as ordered. She identified when a medication was unavailable, the MD/APRN would need to be notified even if the medication would be unavailable for a single day so that the MD/APRN would have the opportunity to order an alternative medication if warranted. She further identified if she had been made aware the medication was unavailable, she would have notified the MD/APRN and she would have written a note of the outcome.Interview with APRN #1 on 4/24/26 at 11:30 AM identified she had eventually been told by the nursing staff that Resident #42's Ramelteon 8mg was unavailable for administration. She identified she was unaware of how long the medication had not been available when she was notified, but that she had instructed the nursing staff to call the pharmacy to find out why the medication was unavailable. She identified the pharmacy had informed staff that a prior authorization was required for the medication, and that after filling out the prior authorization she had not heard of any further issues related to the Ramelteon supply.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 12:01 PM identified that when medications were unavailable the nurse should notify the nursing supervisor to determine if the medication was available in the emergency supply. She further identified the MD/APRN should be notified of any medication that was unavailable to be administered within that order timeframe (within 1 hour after the ordered administration time) so that an alternative order could be provided if warranted.Review of the Medication Administration policy directed, in part, if a medication is unavailable at the time of administration the physician must be notified immediately to request guidance and/or an alternative order, and the responsible party should be informed of the situation. Additionally, the policy directed to check with the pharmacy to expedite delivery of the medication and notify the nursing supervisor and document all actions taken in the medical record.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #64) reviewed for mistreatment, the facility failed to report an allegation of abuse to the state agency timely. The findings include: Resident #64 had diagnoses that included end stage renal disease, hyperglycemia, and frontal lobe and executive functioning deficit.The Resident Care Plan (RCP) dated 1/3/26 identified Resident #64 was at risk for mood changes related to anxiety and depression. Interventions included be aware of and report any changes in mental status, and if Resident #64 appears upset or angry, offer to discuss his/her feelings of anger and options of appropriate channeling of these feelings.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was moderately cognitively impaired, had no physical or verbal behavioral symptoms directed towards people, and had end stage renal disease. The MDS assessment further indicated Resident #64 used a wheelchair, required setup or clean-up assistance with eating, and was dependent with bed mobility and transfers.a. Interview with Registered Nurse (RN) #1 on 4/27/26 at 9:20 AM identified on the morning of 4/2/26 (approximately 9:00 AM to 10:00 AM according to facility investigation statements) Resident #64 had told her, That girl beat me up., offered a description that matched Nurse Aide (NA) #2, and stated he/she didn't want to go to dialysis. RN #1 identified that she had told Resident #64 that he/she knew that didn't really happen and that she had then brought Resident #64 back to his/her room. RN #1 identified she had thought Resident #64 was just angry and therefore making up an accusation. RN #1 verbalized that NA #2 had also told her that Resident #64 was saying that she (NA #2) had hit him/her, and RN #1 indicated she had told NA #2 to ensure she had another staff member with her during all care for Resident #64. RN #1 identified she had not reported the allegation of abuse to the DNS. Review of the State Agency reportable event portal identified the allegation of abuse was reported to the State Agency on 4/3/26 at 9:39 AM by the DNS (approximately 24 hours after the allegation was first reported to RN #1), was reported as staff to resident abuse without injury and that skin and pain assessments had been conducted. Additionally, the report indicated Resident #64 reported being hit by NA #2 on his/her back, arms, and stomach.Interview with the DNS on 4/27/26 at 4:30 PM identified she should have been notified of the allegation of abuse by Resident #64 on 4/2/26 when it had first been reported to RN #1 and identified that RN #1 had received disciplinary action for not reporting the allegation of abuse to her immediately. b. Review of a facility initiated Reportable Event form signed by Registered Nurse (RN) #9 dated 4/3/26 at 1:30 AM identified that Resident #64 reported being punched by a nurse aide while care was provided prior to his/her dialysis appointment on 4/2/26. Review of the State Agency reportable event portal identified the allegation of abuse for Resident #64 was reported to the State Agency on 4/3/26 at 9:39 AM, approximately 8 hours after the allegation was reported to RN #9 (the second opportunity for the facility to report timely to the State Agency).Interview with the DNS on 4/27/26 at 10:10 AM identified she had been notified of the allegation of abuse via text message from RN #9 after 1:30 AM on 4/3/26 which she didn't read until later in the morning of 4/3/26 (greater than 2 hours after the message was sent) when she woke up for work. The DNS further identified she had provided education to RN #9 after the event, about calling her phone when there was an allegation of abuse and not sending a text message so she can provide guidance and ensure the allegation was reported timely within 2 hours.Although attempted, an interview with RN #9 was not obtained.Review of the Abuse policy directed, in part, any allegation of abuse by a staff member must be reported immediately to the nursing supervisor and the nursing supervisor should immediately notify the DNS and Administrator of any allegation of abuse. The policy further directed the Administrator/DNS will initiate an investigation and submit an online report to the State Agency within 2 hours of notification of the allegation.

Based on review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #64) reviewed for mistreatment, the facility failed to follow their policy regarding an allegation of mistreatment by allowing an alleged perpetrator to continue working and failed to remove the alleged perpetrator after becoming aware of an allegation of mistreatment and the facility failed to complete a thorough investigation of an allegation of abuse. The findings include: Resident #64 had diagnoses that included end stage renal disease, hyperglycemia, and frontal lobe and executive functioning deficit. The Resident Care Plan (RCP) dated 1/3/26 identified Resident #64 was at risk for mood changes related to anxiety and depression. Interventions included being aware of and report any changes in mental status, and if Resident #64 appears upset or angry, offer to discuss his/her feelings of anger and options of appropriate channeling of these feelings. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was moderately cognitively impaired, had no physical or verbal behavioral symptoms directed towards people, and had end stage renal disease. The MDS assessment further indicated Resident #64 used a wheelchair, required setup or clean-up assistance with eating, and was dependent with bed mobility and transfers. a. Reportable Event form signed by Registered Nurse (RN) #9 and dated 4/3/26 at 1:30 AM identified that Resident #64 reported being punched by a nurse aide (NA #2) while care was provided prior to his/her dialysis appointment on 4/2/26. Review of NA #2's time sheet report identified on 4/2/26 she was scheduled to work 7:00 AM to 3:00 PM, then 3:00 PM to 9:00 PM, and she clocked in for her shift at 7:00 AM and clocked out at 8:30 PM. The report identified on 4/3/26 she was scheduled to work 7:00 AM to 3:00 PM, clocked in at 6:54 AM and clocked out at 9:27 AM (NA #2 the alleged perpetrator continued working on 4/2/26 and then returned to work on 4/3/26). Review of the Daily Attendance Report dated 4/2/26 identified NA #2 was assigned to work on the Ambrosia/Empire unit(s) for both of her shifts on 4/2/26 (Resident #64 resided on the Empire unit). Interview with Registered Nurse (RN) #1 on 4/27/26 at 9:20 AM identified on the morning of 4/2/26 Resident #64 had told her, That girl beat me up., offered a description that matched Nurse Aide (NA) #2, and stated he/she didn't want to go to dialysis. RN #1 identified that she had told Resident #64 that he/she knew that didn't really happen and that she had then brought Resident #64 back to his/her room. RN #1 identified she had thought Resident #64 was just angry and therefore making up an accusation. RN #1 verbalized that NA #2 had also told her that Resident #64 was saying that she (NA #2) had hit him/her, and RN #1 indicated she had told NA #2 to ensure she had another staff member with her during all care for Resident #64. RN #1 identified she had not told the DNS of the allegation of abuse, nor had she requested NA #2 to write a statement and NA #2 continued to work the shift. Interview with Licensed Practical Nurse (LPN) #4 on 4/27/26 at 9:30 AM identified he had not been told by the NA #2, RN #1 or Resident #64 of any allegation of abuse. Interview with the Director of Nursing Services (DNS) on 4/27/26 at 10:10 AM identified she had been notified of the allegation of abuse via text message from RN #9 after 1:30 AM on 4/3/26 which she didn't read until the morning of 4/3/26 when she woke up for work. Interview with the DNS on 4/27/26 at 4:30 PM identified she should have been notified of the allegation of abuse by Resident #64 on 4/2/26 when it had first been reported to RN #1, so that she could have ensured NA #2 was sent home per the facility policy. (please refer to F 609). Although requested, the facility was unable to provide the NA assignment (list of residents NA #2 was responsible for during her shift(s) for the 2 shifts she worked on 4/2/26. Review of the Abuse policy directed, in part, any allegation of abuse by a staff member must be reported immediately to the nursing supervisor. The policy directed hitting was a form of physical abuse and all allegations will be thoroughly investigated with appropriate action taken. The policy directed the nursing supervisor should immediately notify the DNS and Administrator of any allegation of abuse and the accused individual will be immediately suspended pending the outcome of the investigation. b. Review of a facility initiated Reportable Event (RE) form signed by RN #9 and dated 4/3/26 at 1:30 AM identified that Resident #64 reported being punched by a nurse aide (NA) while care was provided prior to his/her dialysis appointment on 4/2/26. The RE form identified Resident #64 had no new physical injury assessed. Review of the facility-initiated investigation documentation for the RE dated 4/3/26 at 1:30 AM (which occurred on 4/2/26 at approximately 9:00 AM to 10:00 AM) failed to identify that the facility completed a thorough and timely investigation of Resident #64's allegation of mistreatment from NA #2. Although the facility interviewed and obtained statements from NA #2, Resident #64 and 2 NAs that assisted NA #2 with morning care, however the investigation lacked interviews/statements from licensed staff (Nursing Supervisor and Charge Nurse) from when the allegation first occurred. A nursing note written by RN #9 on 4/3/26 at 2:52 AM identified Resident #64 denied new onset of pain from the reported incident and no new injuries were assessed. Review of Inservice/Education dated 4/3/26 identified education had been presented by the DNS on the policy for abuse and that abuse was to be reported and an investigation was to be conducted immediately. Interview with Registered Nurse (RN) #1 on 4/27/26 at 9:20 AM identified on the morning of 4/2/26 (approximately 9:00 AM to 10:00 AM according to facility obtained investigation statements) Resident #64 had told her, That girl beat me up., offered a description that matched NA #2, and stated he/she didn't want to go to dialysis. RN #1 identified that she had told Resident #64 that he/she knew that didn't really happen and that she had then brought Resident #64 back to his/her room. RN #1 identified she had thought Resident #64 was just angry and therefore making up an accusation. RN #1 verbalized that NA #2 had also told her that Resident #64 was saying that she (NA #2) had hit him/her, and RN #1 indicated she had told NA #2 to ensure she had another staff member with her during all care for Resident #64. RN #1 identified she had not told the DNS of the allegation of abuse, nor had she requested NA #2 to write a statement. Although attempted, an interview with RN #9 was not obtained. Review of the Abuse policy directed, in part, any allegation of abuse by a staff member must be reported immediately to the nursing supervisor and the nursing supervisor should immediately notify the DNS and Administrator of any allegation of abuse. The policy directed the Administrator/DNS will initiate an investigation and submit an online report to the State Agency within 2 hours of notification of the allegation. The policy directed the outcome of the investigation and any corrective actions will be documented within the investigation report. Additionally, the policy directed a follow-up report with conclusions and actions taken will be submitted online to the State Agency within 5 days of the incident.

Based on observations, review of the clinical record, facility documentation and interviews for 1 of 3 residents (Resident #67) reviewed for pressure ulcer/injuries, the facility failed to implement padded side rails per the plan of care. The findings include: Resident #67's diagnoses included dementia, chronic obstructive pulmonary disease, and severe protein calorie malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was significantly cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #58 was at risk of developing pressure ulcers/injuries based on formal and clinical assessments. The Resident Care Plan (RCP) dated 2/20/26 identified Resident #67 was at risk for skin breakdown due to decreased mobility, incontinence, altered sensation and mechanical forces. Interventions included keep the side rails padded at all times to help prevent bruising and gentle handling during all transfers and care procedures. Review of the Nurse Aide (NA) care card for Resident #67 directed padded side rails at all times. Observations on 4/22/26 at 12:30 PM and 4/23/26 at 11:08 AM noted Resident #67 lying in bed, 1/2 side rails were raised, without the benefit of being padded. Observation, interview and review of the clinical record with NA #3 and NA #6 on 4/23/26 at 12:17 PM identified Resident #67 was in bed and without the benefit of padded siderails. NA #3 and NA #6 indicated they were not aware the resident needed padded side rails and that the resident has never had them on the bed since he/she transferred to the unit months ago. Although review of the NA care card with NA #3 and NA #6 directed padded side rails at all times, NA #3 and NA #6 stated they had not reviewed the NA care card before providing care to Resident #67. NA #3 and NA #6 indicated they would need to inform LPN #4 that Resident #67 needed padded side rails applied to the bed. Observation, interview and review of the clinical record with Licensed Practical Nurse (LPN #4) on 4/23/26 at 12:24 PM identified Resident #67 was in bed, 1/2 side rails were in the raised position and not padded. LPN #4 indicated he was not aware the resident needed padded side rails. Although review of the RCP and the NA care card for Resident #67 with LPN #4 directed padded side rails at all times to help prevent bruising, LPN #4 stated he had not reviewed the RCP or the NA care card before providing care to Resident #67. Additionally, LPN #4 indicated it would have been the responsibility of the charge nurse or nursing supervisor to obtain and apply the padded side rails to the resident's bed and he was unsure why that was not done. LPN #4 indicated he would obtain and the padded side rails from maintenance and ensure they were applied today. Interview and review of the clinical record with the Director of Nurses (DNS) on 4/23/26 at 1:00 PM identified if padded side rails were on the care plan and on the NA care card for Resident #67, they should have been in place on the resident's bed. The DNS indicated it would have been the responsibility of the charge nurse or nursing supervisor to ensure the padded side rails were on the resident's bed. The DNS was unsure why the padded side rails were not there and stated she would check with maintenance to get them put in place for Resident #67 today. Subsequent to surveyor inquiry, an observation on 4/27/26 at 2:40 PM found Resident #67 in bed with bilateral padded side rails in place. Although requested, a policy on padded side rails was not provided by the facility.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #6) reviewed for activities of daily living (ADLs), the facility failed to provide fingernail care for a resident who was dependent for personal hygiene. The findings include: Resident #6's diagnoses included dementia, functional quadriplegia, muscle weakness, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was severely cognitively impaired and was dependent on staff for showering and personal hygiene. The Resident Care Plan (RCP) dated 3/26/26 identified Resident #6 may present as alert and verbal with impaired cognition but was able to verbalize basic needs and wants. The RCP indicated that Resident #6 required assistance with activities of daily living (ADLs), including toileting needs and mouth care. The RCP did not reflect that the resident refused care. Interview with Person #3 on 4/21/26 at 11:33 AM indicated that they had visited Resident #6 the previous day and were concerned about how long and dirty Resident #6's fingernails were. Person #3 stated that they did not inform staff at that time but had intended to do so and did not get the opportunity. On 4/21/26 (Tuesday) at 11:40 AM, Resident #6 was observed lying in bed, the left 5th (pinky) fingernail extended significantly beyond the nail bed and had a brown substance underneath. The remaining fingernails on the left hand appeared jagged but short. The right hand could not be observed because it was under the blanket. Observation and interview with Resident #6 on 4/22/26 (Wednesday) at 12:20 PM, while the resident was seated in a wheelchair at the nurse's station, identified that the left 5th fingernail remained significantly longer than the nail bed with a brown substance underneath. Although nonverbal at times, Resident #6 clearly nodded in response to questions and followed directions to move his/her hand to allow observation of both sides and indicated that the nail bothered him/her and that he/she wanted it to be cut. The resident denied refusing to have the left 5th nail trimmed but was unable to verbalize why it had not been cut. Additional questions were attempted to gather more specific information; however, at that time Resident #6 was only able to respond to yes or no questions. Although attempted, an interview with the Nurse Aide (NA) caring for Resident #6 on 4/22/26 was not obtained. Interview with NA #9, who was assigned to Resident #6's unit but not to the resident on 4/22/26 at 12:35 PM, indicated that fingernails were not necessarily cleaned every day during morning care but rather twice a week. NA #9 stated that nurses were responsible for cutting residents' nails and that NAs would usually notify the nurse when nail care was needed. Interview with Licensed Practical Nurse (LPN) #2 on 4/22/26 at 12:55 PM indicated that nurses were responsible for cutting residents' nails; however, there was no set schedule for when that occurred. LPN #2 stated that nail trimming usually happens on shower days but may occur at any time if a resident needs their nails cut. She was unaware of who last trimmed Resident #6's nails and did not know why the 5th left nail had not been cut, noting that the resident follows directions well and had good mobility in the left hand. Interview with the Recreation Director on 4/24/26 indicated that Resident #6 was capable of comprehending verbal communication; however, the resident sometimes does not feel comfortable responding verbally. The Recreation Director stated that despite this, Resident #6 was able to make his/her needs known. Review of Resident #6's Resident Care Card identified that the resident required total assistance with activities of daily living (ADLs), including bathing, and that his/her scheduled shower day was Wednesday during the morning shift (7:00 AM-3:00 PM) but did not specifically identify when and how to cut Resident #6's nails. Interview with the Director of Nursing Services (DNS) on 4/27/26 at 9:32 AM indicated that although there was no set schedule for nail care, nail trimming should be completed whenever a resident required it, regardless of the scheduled shower day. The DNS further stated that if a resident's nails were dirty, they can and should be cleaned at any time. Review of the facility policy titled AM Care/ADLs, dated 12/9/14, directed staff to assist residents with morning care daily as needed, including but not limited to washing residents' hands and providing fingernail care, including trimming if necessary. The policy further directed staff to document any refusal of care in the care plan and, if a resident refuses care, to re approach and notify the nurse.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #3) reviewed for skin conditions, the facility failed to ensure weekly wound documentation was completed to describe Resident #3's wounds in order to identify worsening or improvement of wounds, and for 1 of 2 residents observed for edema (Resident #14) the facility failed to ensure weights were completed and documented per physician order and for the only sampled resident (Resident #42) reviewed for difficulty sleeping, the facility failed to ensure medication was administered for insomnia. Additionally, for 1 of 2 residents (Resident #57) reviewed for edema, the facility failed to ensure compression stockings were applied according to physician orders. 1. Resident #3's diagnoses included diabetes with a related foot wound, a local skin and subcutaneous tissue infection, and a history of a pressure ulcer to the buttocks.A physician's order dated 2/9/26 directed staff to monitor the superficial wounds on the right fourth and fifth toes every shift for changes and for signs and symptoms of infection, and to have the wounds evaluated by the inhouse wound team.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #3 was cognitively intact, required supervision or touching assistance for showering and toileting hygiene, and required moderate assistance for lower body dressing. The Resident Care Plan (RCP) dated 3/9/26 identified that Resident #3 had venous ulcers and a rash on the abdomen, with interventions that included following physician ordered treatments, monitoring for signs of infection, and reporting any such findings to the provider. A physician's order dated 3/9/26 directed wound care for Resident #3's right venous stasis wound, including cleansing, covering with an absorbent pad, and applying specialty treatment wraps weekly to be removed on the scheduled day. The physician's order also included wound treatment instructions for bilateral upper arm wounds, directing staff to cleanse the areas, apply a silver wound treatment, and wrap them. A physician's order dated 3/30/26 directed to complete a weekly body audit on resident's shower day, evening shift on Mondays and to ensure the nursing aid documentation reflects care given. A physician's order dated 4/4/26 directed the house wound team to evaluate the abdominal rash on the right lower abdomen, the inner buttocks and groin areas, and the superficial wounds on the fourth and fifth toes. The order also directed staff to monitor these areas for changes and for signs and symptoms of infection. Review of the outpatient wound care clinic after visit summary dated 4/17/26 documented Resident #3's first encounter of open abdominal wound and rash and prescribed Gentamycin ointment (topical antibacterial) treatment for the area. The after-visit summary also identified other wounds evaluated at the visit included wounds on the left upper arm, left calf, and right ankle. The instructions stated the dressings to the abdomen and arm may be removed for the shower and the dressings to the wounds on both legs were not to be removed for the shower and should only be changed by the wound care clinic at the resident's next appointment. Although attempted, an interview with outpatient wound care clinic staff was not obtained. A physician's order dated 4/17/26 reflected the new prescription from the wound care clinic of Gentamycin ointment to be applied to the abdomen and bilateral legs once a day. Observation and interview with Resident #3 on 4/20/26 at 12:07 PM identified a large red area on the right lower abdomen with three small, scabbed areas. Resident #3 stated that the area had been open for a few weeks prior to the outpatient wound care clinic appointment and that the clinic's nursing staff were aware of it because they assist him/her with incontinence care and applied Gentamicin ointment to the area. Resident #3 reported that the area was sometimes itchy and believed the wounds were caused by the facility provided incontinent brief rubbing against the skin. Resident #3 further reported that during his/her most recent outpatient wound care clinic visit, the abdominal area was very itchy, prompting the wound care nurse to assess it and was prescribed Gentamicin ointment, a topical antibacterial medication. Review of the Treatment Administration Record (TAR) from 4/1/26 through 4/23/26 showed that nurses documented monitoring of Resident #3's rash on the lower abdomen, inner buttocks, and groin, as well as the wounds on the right fourth and fifth toes and right ankle, every shift (three times daily); however, no descriptive details were provided, and staff only checked off that the task was completed. The TAR also indicated that weekly body audits were documented as completed on Monday evening shifts (4/6/26, 4/13/26, and 4/20/26) but did not provide details or have a corresponding nursing note regarding the description of the wounds. Review of nursing notes from 4/1/26 through 4/23/26 failed to identify any documentation of Resident #3's wounds, including the abdominal rash, inner buttocks and groin wounds, right toe wounds, and right ankle wound, including on the resident's scheduled shower days. Interview with LPN #2 on 4/22/26 at 12:59 PM indicated that she was aware of Resident #3's abdominal rash but was not aware that any open areas were present. LPN #2 further stated that if any wounds or rashes were identified during a body audit, a corresponding nursing note should be completed to document the findings. Interview with RN #6 (Regional Director of Nursing Leadership) on 4/23/26 at 3:15 PM indicated that even residents who were independent should receive a weekly body audit on their scheduled shower day, as ordered. RN #6 stated that although the weekly body audits were checked off on the Treatment Administration Record (TAR), any skin irregularities such as wounds or rashes should also be documented in a corresponding nursing note to describe the findings. RN #6 further stated that a nursing note corresponding to each body audit detailing the resident's wounds and rashes should have been written, and that when the abdominal rash opened, the provider should have been notified of the worsening condition. Interview with RN #2 (Infection Preventionist) on 4/24/26 at 9:30 AM indicated that during body audits, all wounds, rashes, and other skin irregularities should be identified and documented in a nursing note. RN #2 stated that she maintains a wound book for residents whose wounds are evaluated in the facility; however, Resident #3's wounds were not included because the resident is followed by an outpatient wound clinic. RN #2 further acknowledged that there were no corresponding nursing notes to the completed body audits documenting Resident #3's known wounds and rashes, including the abdominal rash and wounds on the bilateral legs and bilateral arms, and stated that such documentation should exist even when wounds are already known to staff. Interview with the Director of Nursing (DNS) on 4/27/26 at 9:30 AM indicated that checking off the body audit on the TAR only confirmed that the task had been completed. The DNS stated that a body audit was considered negative unless a corresponding nursing note documented any skin irregularities, such as wounds or rashes. Review of the facility policy titled, Wound and Skin Care Protocol, undated, directed licensed nursing staff to conduct a weekly body audit, with weekly documentation of all skin areas until healed. An attempt was made to obtain a more specific skin documentation or body audit policy; however, the facility did not have one. 2. Resident 14's diagnoses included heart failure, diabetes and chronic kidney disease.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, independent for dressing toileting, showering, eating and transfers.The Resident Care Plan (RCP) dated 2/12/26 identified Resident #14 was at risk for cardiac issues with interventions that included monitoring vital signs, obtaining weights as ordered, and encourage Resident #14 to elevate legs when out of bed as needed.A physician order dated 3/18/26 directed for Resident #14 to be weighed prior to breakfast every day, if the resident refused may collect weight later in the day and note the time in the nurse's note for cardiac monitoring.Review of the Resident's #14 weight monitoring record on 4/22/26 at 12:16 PM with Registered Nurse (RN) #1 identified Resident #14 failed to be weighed on 3/20/26, 3/21/26, 3/22/26, 3/27/26, 4/4/26, 4/5/26, 4/9/26, 4/10/26, 4/13/26, 4/14/26, 4/15/26, 4/16/26, 4/17/26, 4/18/26 and 4/19/26. (missing 15 opportunities of 35 opportunities). There was a nursing note dated 4/16/26 referencing Resident #14's weight not being completed. RN #1 identified the nurses were responsible for the documentation of daily weights and she was responsible for the oversight. RN #1 further noted she was unsure of the reason the weights were not completed, stating the policy was to follow the physician orders and document refusals of why it wasn't completed.Review of the facility weight monitoring policy directed, in part to establish a reference for resident's body weight that is realistic, individually appropriate, to effectively monitor and communicate weight changes. Also, residents will be weighed weekly for 4 weeks and then monthly unless otherwise indicated by the physician order. 3. Resident #42 had diagnoses that included osteomyelitis of right ankle/foot, post-traumatic stress disorder, attention deficit hyperactivity disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 was cognitively intact, used a walker and wheelchair, and was independent with eating, bed mobility and bed/chair transfers. A physician order dated 12/8/25 directed to administer Ramelteon 8 milligrams (mg) by mouth at bedtime for sleep.The Resident Care Plan (RCP) dated 12/18/25 identified Resident #42 was at risk for pain/discomfort which may impact his/her sleep. Interventions included administering medications as ordered, observe Resident #42 for non-verbal signs of pain such as restlessness, changes in usual pattern of sleep, and change in mood. The RCP failed to identify a focus and interventions related to Resident #42 had a diagnosis of chronic primary insomnia.Review of Medication Administration Record (MAR) for 2/1/26 through 2/28/26 identified Ramelteon 8 mg was not administered as ordered by the physician 10 out of 28 opportunities (35.7%) on 2/4/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/15/26, 2/18/26, 2/25/26, and 2/28/26. Additionally, the MAR identified Resident #42 went 5 consecutive days without the medication being administered (2/7/26 through 2/11/26).Nursing notes for dated 2/1/26 through 2/28/26 failed to identify any measures taken to ensure Resident #42 received the medication ordered by the physician. Additionally, the notes failed to identify a nursing note had been written on 2/4/26, 2/7/26, 2/8/26, 2/10/26, 2/11/26, 2/15/26, 2/18/26, and 2/25/26 regarding the reasons/interventions/resident response to Ramelteon not being administered.Physician and Advanced Practice Registered Nurse (APRN) progress notes for February 2026 failed to identify a note which referenced they were notified Ramelteon was unavailable for administration and any action taken. (Please refer to F 580).Review of MAR for 3/1/26 through 3/31/26 identified Ramelteon 8 mg was not administered as ordered by the physician 8 out of 31 opportunities (25.8%) on 3/2/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/13/26, and 3/14/26. Additionally, the MAR identified Resident #42 went 5 consecutive days without the medication being administered (3/5/26-3/9/26).Nursing notes for 3/1/26 through 3/10/26 failed to identify measures taken to ensure Resident #42 received the medication ordered by the physician. Additionally, the notes failed to identify a nursing note had been written on 3/2/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, and 3/9/26, regarding the reasons/interventions/resident response to Ramelteon not being administered.Physician and APRN progress notes for 3/1/26 through 3/10/26 failed to identify a note which referenced they were notified Ramelteon was unavailable for administration and any action taken.An APRN progress note written by APRN #1 on 3/11/26 at 2:15 PM identified Resident #42 was seen for submission of prior authorization forms for Ramelteon. The note identified Resident #42 had a diagnosis of chronic primary insomnia and had been trialed on multiple other medications (Melatonin, Trazodone, and Zolpidem) for 30 days or more without any impact on his/her sleep. The note identified Resident #42 was unable to obtain therapeutic levels of sleep with the trialed medications, and that Resident #42 had trouble with falling asleep and staying asleep even with appropriate sleep hygiene habits. The note identified Resident #42 was followed by the psychiatric team who had determined that Ramelteon was the most appropriate medication at this time for Resident #42's insomnia. The note further identified that a prior authorization for this medication was required by Resident #42's insurance company, and that the necessary forms had been completed and faxed per guidelines and a response was pending. The note identified Resident #42's chronic insomnia affected his/her ability to function on a day-to-day basis and caused (chronic fatigue, decreased appetite, poor activity tolerance, mood disturbances). The note indicated a new prescription for Ramelteon 8mg was E-faxed to the pharmacy, and prior authorization forms were completed and refaxed to get the medication covered.Interview with Resident #42 on 4/20/26 at 10:38 AM identified that the facility ran out of his/her medication(s) often, and that the nurses would indicate that it was a pharmacy problem causing the medication(s) to be unavailable. Resident #42 identified medication(s) not being available was frustrating and he/she didn't know what needed to be done to prevent the medication(s) from running out and affecting his/her routine.Interview with Licensed Practical Nurse (LPN) #6 on 4/23/26 at 12:19 PM identified she typically worked the evening (3:00 PM shift to 11:00 PM) and when a medication was unavailable, she would notify the nursing supervisor and then would do whatever the supervisor directed her to do. She identified that she would check the electronic medical record (EMR) to see if the EMR showed the medication was reordered. She identified that she didn't typically write a nursing note when medication was unavailable. She identified that if she called the pharmacy and was told the medication was on order she didn't need to write a nursing note because the medication was expected to be in the facility in a couple of days. She further identified she tried to order medications before they ran out so that the medications would be available in time for administration.Interview with Registered Nurse (RN) #4 on 4/23/26 at 1:04 PM identified she worked as the nursing supervisor on the evening shift. She identified LPN #6 had not notified her that Resident #42 did not have Ramelteon available as ordered. She identified at any time when told by the charge nurse that medication was unavailable, she would instruct them to call the pharmacy to see when the medication was expected to arrive. She identified when a medication was unavailable, the MD/APRN would need to be notified even if the medication would be unavailable for a single day so that the MD/APRN would have the opportunity to order an alternative medication if warranted. She further identified if she had been made aware the medication was unavailable; she would have notified the MD/APRN and she would have written a note of the outcome.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 12:01 PM identified that when medications were unavailable the nurse should notify the nursing supervisor to determine if the medication was available in the emergency supply. She indicated the pharmacy should then be contacted to find out if the medication has been reordered and when the expected delivery would be. She further identified the MD/APRN should be notified of any medication that was unavailable to be administered within that order timeframe (within 1 hour after the ordered administration time) so that an alternative order could be provided if warranted.Interview with Vendor #3 on 4/27/26 at 1:30 PM identified the Ramelteon medication required prior authorization before the medication could be sent to the facility. She identified on 12/14/25, 12/23/25, 1/22/26, 2/2/26, and 3/10/26 prior authorization requests were sent to the DNS at the facility. She identified on 12/22/26 RN #1 had notified the pharmacy that a 14-day supply could be sent and billed to the facility. She further identified that the facility received a 14-day supply on 12/22/25, a 30-day supply on 3/17/26, and a 30-day supply on 4/14/26, and that no other supplies of Ramelteon had been sent to the facility.Review of the Medication Administration policy directed, in part, if medication is unavailable at the time of administration the physician must be notified immediately to request guidance and/or an alternative order, and the responsible party should be informed of the situation. Additionally, the policy directed to check with the pharmacy to expedite delivery of the medication and notify the nursing supervisor and document all actions taken in the medical record. 4. Resident #57's diagnoses included heart failure, acute kidney failure, and chronic obstructive pulmonary disease.The Resident Care Plan (RCP) dated 2/13/26 identified Resident #57 was at risk for cardiac/respiratory distress related to complication due to congestive heart failure. Interventions included watching for any increase in edema and report to the physician/advanced practice registered nurse, compression stockings as ordered, assist with donning and doffing as needed.The admission MDS assessment dated [DATE] identified Resident #57 was moderately cognitively impaired, required substantial/moderate assistance for toileting hygiene and showering/bathing self, dressing, and transfers. The MDS also, identified Resident #57 was independent for eating and required set up assistance with oral hygiene.An Advanced Practice Registered Nurse (APRN) note dated 4/17/26 at 8:30 AM identified Resident #57 had bilateral lower extremity edema and compression stockings were ordered to be applied in the morning/removed in the evening.A physician's order dated 4/17/26 directed to apply compression stocking on in the morning (AM) and off in evening (PM).Observation on 4/20/26 at 11:00 AM, 4/21/26 at 11:04 AM and 4/22/26 at 10:33 AM noted Resident #57 out of bed, seated in a chair without the benefit of wearing compression stockings.Interview and review of the Nurse Aide (NA) care card with NA #5 on 4/22/26 at 11:44 AM identified she worked with Resident #57 on a regular basis and Resident #57 had already received morning care. NA #5 also identified she was not aware that Resident #57 required compression stockings because the NA care card failed to identify the need for compression stockings.Interview on 4/22/26 at 11:49 AM with Licensed Practical Nurse (LPN) #3 identified she had worked on Resident #57's unit that week but was unsure if Resident #57 required compression stockings.Interview and review of the clinical record on 4/22/26 at 11:53 AM with LPN #1 identified Resident #57 was to have compression stockings on in the AM and off in the PM. LPN #1 reviewed the physician's order and identified the NAs were responsible for applying compression stocking for residents. LPN #1 attempted looking in Resident #57's room for compression stockings but could not locate any.Interview and record review on 4/22/26 at 12:10 PM with Registered Nurse (RN) #1 identified the physician's order dated 4/17/26 for the use of compression stocking to be placed on in the AM and off in the PM. Also, identifying the staff member who transcribed the order was responsible for updating the NA care card. RN #1 further identified the policy for the NA care card was to be updated as orders were reviewed by the nursing RN and identified it was an oversight.Although a policy was requested for compression stockings one was not provided, the facility identified the orders for the Residents must be followed as per standards of practice.Subsequent to this surveyor's inquiry the care card was updated for compression stockings.

Based on interviews, review of the clinical record, and facility policy for 2 of 2 resident rooms observed with cleaning solutions (Resident #14 and Resident #77), the facility failed to ensure cleaning solutions were secured and for 1 of 4 smokers (Resident #20), the facility failed to provide supervision when Resident #20 was provided smoking material and went outside to smoke. The findings include: 1.Resident #14's diagnoses included heart failure, diabetes and chronic kidney disease.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, independent for dressing toileting, showering, eating and transfers.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #14 was at risk for respiratory distress, ineffective breathing patterns and activity intolerance. Interventions included watching for signs of fungal infection in mouth, report findings to the physician, encouraging rest periods as needed and pacing activities.An observation and interview with Resident #14 on 4/20/26 at 12:23 PM identified Resident #14 had a 28-ounce bottle of Lysol that was almost empty and a 33.8-ounce bottle of bleach that was 3/4 empty located in his/her bathroom. Located on Resident #14's refrigerate was also noted a 600-milliliter bottle of Fabulosa all-purpose cleaner that was 3/4 full. A bottle of Virex (a facility cleaning product) was 3/4 full and Resident #14 stated the housekeeper left it in his/her room. Resident #14 stated she/he orders cleaning products online, and Resident #14's family member takes the resident out where she/he was able to purchase the cleaning products to clean her/his own room. Further, identifying she/he has been doing this for a long period of time.An interview with the Administrator on 4/20/26 at 1:57 PM identified he was not aware Resident #14 had chemicals in the bathroom, the resident should not have had, nursing staff on the unit should have brought it to someone's attention, and the chemicals should have been removed.Interview on 4/21/26 at 2:54 PM with Licensed Practice Nurse (LPN ) #3 identified she had noticed cleaning products in Resident #14's room before and the resident had a habit of hiding the items.A second interview on 4/22/26 at 11:38 AM with LPN #3 identified she had reported finding cleaning products before in Resident #14's room and had reported it to the Director of Nursing Services and RN #1. Also, identifying the products have been in the resident's room for a couple of months on/off and when she discovers the items she will remove them from the resident's room.Interview on 4/23/26 at11:15 AM with Housekeeper #2 identified that she had seen the cleaning products in Resident #14's room, told the resident she could not have them but failed to report finding the cleaning products in the room to her supervisor.An interview on 4/24/26 at 1:30 PM with the Maintenance Director who identified the cleaning product Virex solution was supposed to be locked in the cleaning cart when not in use and he was unsure how Resident #14 gained access to the item.Review of the Housekeeping Services Overview policy directed, in part, sufficient housekeeping and Maintenance personnel are employed to maintain the interior and exterior of the residence in a safe, clean, orderly, and attractive manner. Also, identified all cleaning equipment will be cleaned, stored, properly maintained, according to policy, procedures, housekeeping carts properly cleaned and stored with chemicals cabinets locked. All spray bottles properly labeled, facing the wall or locked in a cabinet.Subsequent to this surveyor's inquiry all cleaning products (chemicals) were removed from the resident's room.2. Resident #20's diagnoses included generalized muscle weakness, nicotine dependence, and age-related physical debility. The admission Minimum Data Set assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Additionally, the MDS identified Resident #20 required set-up assistance with eating, oral hygiene and required supervision with toilet hygiene and upper body dressing. The MDS further identified Resident #20 used tobacco.The Resident Care Plan dated 2/18/26 identified Resident #20 as a current smoker who required supervision in designated facility areas. Interventions included staff directing the resident to designated smoking areas, as well as having the Resident #20 wear a smoking apron while smoking.A smoking assessment dated [DATE] indicated Resident #20 was a current smoker, wanted to smoke, and was able to smoke with supervision. Observation of Resident #20 on 4/23/26 at 6:25 AM identified he/she made a request to Licensed Practical Nurse (LPN) #7 that he/she wanted to smoke a cigarette, while he/she was waiting to receive their morning medication. At 6:28 AM, Resident #20 was then assisted by LPN #7 in his/her wheelchair outside the front door of the facility for Resident #20 to smoke. After letting Resident #20 outside, and lighting his/her cigarette, LPN#7 instructed Resident #20 to press the doorbell at the front entrance when he/she was done smoking when he/she wanted to be let back into the building. LPN #7 also failed to provide Resident #20 with a smoking apron per the care plan. LPN #7 then walked back into the facility, leaving Resident #20 outside by themselves and unsupervised. The surveyor maintained constant observation on Resident #20 while they were left outside unattended by staff.Observation on 4/23/26 at 6:35 AM identified Resident #20 outside the front door of the facility, facing the entrance door waiting to be let in, as he/she was unable to reach the doorbell secondary to being in a wheelchair. At 6:36 AM two incoming staff members let Resident #20 into the building. Interview with LPN #7 on 4/23/26 at 6:45 AM identified that he was aware of where the regular smoking area was located at the facility, but he let Resident #20 smoke in the front of the building (unsupervised) due to the circumstances of trying to assist the charge nurse with opening the locked Methadone cabinet to obtain Resident #20's Methadone prior to his/her transportation arriving.Interview with the DNS and Regional Clinical Nurse (RN #7) on 4/23/26 at 9:06 AM identified that a resident who was assessed as requiring supervision to smoke, should not have been left alone while smoking. The DNS also indicated that she would follow up with LPN #7 regarding him leaving Resident #20 unsupervised outside of the facility.Interview with LPN #7 on 4/27/26 at 12:25 PM identified it did not occur to him that he should not have left Resident #20 alone outside of the facility to smoke, stating he had never done supervised smoking at the facility before. LPN #7 indicated he knew how to review if a resident required supervision while smoking, stating there was a list in the supervisor's office. LPN #7 also identified that he did not follow that protocol prior to letting Resident #20 outside the building alone to smoke and not in the designated smoking area of the facility, stating it was hectic that morning, I was busy helping the RN Supervisor. Review of the Smoking Policy directs in part that an MD/APRN order will be obtained for the resident to participate in the facility's supervised smoking program, and that smoking will occur outside only in designated areas within view of a facility staff member.3. Resident #77's diagnoses included chronic obstructive pulmonary disease, bipolar disorder, and anemia. The Annual Minimum Data Set (MDS) assessment dated [DATE], identified Resident #77 was cognitively intact and independent with toileting, bed mobility and transfers. The Resident Care Plan (RCP) dated 3/10/26 identified Resident #77 had a mental health illness that could impact the resident's mood and the resident could be impulsive, unable to control behavior and have angry outbursts. Interventions included encouraging the resident to call staff for assistance, to monitor mood changes and to offer the resident clear simple explanations. Additional interventions included providing face to face psych services and following up with psych as recommended/needed. An observation on 4/20/26 at 11:29 AM with Housekeeper #1 identified several bottles of cleaning chemicals unsecured and on the floor in Resident #77's bathroom which consisted of:One 21-ounce container of Comet powder, 1/4 fullTwo 64-ounce bottles of Bleach, both 1/4 fullOne 64-ounce bottle of Cleaner/Degreaser, 1/8 fullInterview with Housekeeper #1 at that time identified he was aware the cleaning chemicals were unsecured and on the floor in the resident's bathroom and the resident would frequently use them to clean his/her room and bathroom. Housekeeper #1 indicated Resident #77 had the cleaning chemicals in the bathroom for a long time and would often offer to help him/her clean the room and bathroom with his/her cleaning chemicals. Housekeeper #1 further identified he had not told anyone that Resident #77 had the cleaning chemicals unsecured in the bathroom and did not know he should have. Interview with Resident #77 on 4/20/26 at 12:00 PM identified a family member took him/her to the store and he/she purchased the cleaning chemicals there. Resident #77 indicated he/she would clean the toilet, and the sink of the bathroom and staff were aware she had the unsecured cleaning chemicals and nothing was said to him/her about them. Resident #77 further identified he/she had the cleaning chemicals unsecured and on the bathroom floor for months. Subsequent to surveyor inquiry, an interview and observation with Housekeeper #1 on 4/20/26 at 12:32 PM identified all the unsecured cleaning chemicals had been removed from Resident #77's bathroom. Housekeeper #1 indicated he should have told someone about the unsecured cleaning chemicals and ensured they were removed from the resident's bathroom. Housekeeper #1 further identified he had made a mistake and would not let it happen again. Interview with Licensed Practical Nurse (LPN #2) on 4/20/26 at 12:45 PM identified she was aware Resident #77 went out of the facility and often made purchases in the community. LPN #2 indicated although she was aware the resident had unsecured cleaning chemicals on the floor in the bathroom and would frequently clean the room with them, she did not tell anyone about it but should have. Interview with the DNS on 4/20/26 at 12:56 PM identified she was not informed Resident #77 had unsecured cleaning chemicals on the floor in his/her bathroom and had just become DNS last month. The DNS indicated Resident #77 should not have had unsecured cleaning chemicals in his/her bathroom and the nursing staff on the unit should have brought it to someone's attention and the chemicals should have been removed. Interview with the Administrator on 4/20/26 at 1:57 PM identified she was not informed Resident #77 had unsecured cleaning chemicals on the floor in his/her bathroom. The DNS indicated Resident #77 should not have had unsecured cleaning chemicals in his/her bathroom and the nursing staff on the unit should have brought it to someone's attention and the chemicals should have been removed. Interview with NA #3 on 4/21/26 at 10:39 AM identified she was aware Resident #77 was independent and often made purchases in the community. NA #3 indicated although she was aware the resident had unsecured cleaning chemicals on the floor in the bathroom and would frequently clean the room with them, she did not tell anyone about it but should have. Review of the facility policy, Housekeeping Services Overview, undated, identified sufficient housekeeping and Maintenance personnel are employed to maintain the interior and exterior of the residence in a safe, clean, orderly, and attractive manner. The policy directed all cleaning equipment will be stored and properly maintained according to policy and procedures, and all chemical bottles would be secured. Unsafe conditions were to be reported to the Director of Maintenance and equipment was never to be left unattended.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #110) reviewed for bowel/bladder incontinence, the facility failed to ensure a 3-day voiding diary was initiated as per nursing notes and identify a change in bladder continence in order to ascertain the cause for the change to help improve bladder function. The findings include: Resident #110 had diagnoses that included fusion of lumbar spine, chronic kidney disease, and epilepsy.A Nursing admission Assessment completed by Registered Nurse (RN) #3 on 4/14/26 at 6:32 PM identified Resident #110 was cognitively intact, had a lower back surgical incision (no measurement), was independent for eating, required assistance with personal hygiene/grooming, required the assistance of 2 staff members for positioning, and required a mechanical lift for transfers. The assessment further identified Resident #110 took a diuretic medication, was continent with complete bowel and bladder control and used a urinal and bedpan. The assessment identified Resident #110 did not use incontinent products/garments (as indicated by the box was left unchecked under interventions within the assessment).The Resident Care Plan (RCP) dated 4/14/26 identified Resident #110 was admitted for a short term stay following surgery. Interventions included providing care to the surgical site, monitoring for signs and symptoms of infection and conducting pain assessments as needed. The RCP further identified on 4/18/26 Resident #110 required staff assistance with activities of daily living (ADLs). Interventions included assisting as needed to meet toileting needs and incontinent care per policy.An admission Checklist dated 4/14/26 identified item #23 3 day Bowel and Bladder diary initiated in PCC (electronic medical record platform)-to be completed by day 5 was crossed off with a line through the task description. A nursing note dated 4/20/26 at 7:44 AM identified Resident #110 had an unwitnessed fall in the bathroom after attempting to self-transfer from the toilet. The note identified Resident #110 had no changes in urine or genitourinary system. The note failed to identify whether Resident #110 was continent or incontinent of bowel and bladder.Review of the Resident Care Card for Resident #110 (not dated) identified Resident #110 required the assistance of 2 staff members for toileting, positioning needs, mobility, and required a mechanical lift for transfers. The reverse side of the care card identified an entry dated 4/20/26 which directed not to leave Resident #110 unattended in the restroom. The care card failed to identify if Resident #110 was continent or incontinent, or that he did or did not use incontinence products/garments.A nursing note written by Licensed Practical Nurse (LPN) #1 on 4/22/26 at 2:49 PM identified Resident #110 was both continent and incontinent of bowel and bladder (a discrepancy from the Nursing admission Assessment which identified Resident #110 as having complete continence of bladder/bowel).Review of the clinical record failed to identify completion of a bladder assessment or initiation of a 3-day bladder diary by LPN #1 on 4/22/26 after documentation of Resident #110 being both continent and incontinent of bowel and bladder.A nursing note written by LPN #1 on 4/23/26 at 12:56 PM and 4/24/26 at 1:26 PM identified Resident #110 was continent of both bowel and bladder.A nursing note dated 4/25/26 at 2:30 PM identified Resident #110 was continent of bowel and bladder.A nursing note written by Registered Nurse (RN) #4 on 4/26/26 at 4:30 PM identified Resident #110 had an unwitnessed fall in the bathroom after attempting to self-transfer from the toilet. The note identified Resident #110 had no changes in urine or genitourinary system. The note failed to identify whether Resident #110 was continent or incontinent of bowel and bladder.Review of the Documentation Survey Report for April 2026 identified for bladder elimination 39 out of 44 opportunities for bladder elimination were documented. 5 out of 44 opportunities failed to identify documentation for that shift. Of the 39 documented bladder elimination opportunities, the nursing staff member documented Resident #110 was continent 17 out of 39 (43.5%) opportunities, and incontinent 20 out of 39 (51.2%) opportunities, and did not void 2 out of 39 (5.1%) opportunities. This documentation identified Resident #110 was incontinent more often than he/she was continent which did not correlate with his/her nursing admission assessment of continent of bladder on 4/14/26.Review of the Documentation Survey Report for April 2026 identified for bowels 34 out of 40 opportunities for bowel (elimination) were documented. 22 out of the 34 documented opportunities identified Resident #110 did not have a bowel movement and 12 out of 34 opportunities identified Resident #110 did have a bowel movement. Of the 12 documented bowel movements, the nursing staff member documented Resident #110 was continent 6 out of 12 (50%) opportunities, and incontinent 6 out of 12 (50%) opportunities. This documentation identified Resident #110 was incontinent 50% of the time which did not correlate with his/her nursing admission assessment of continent of bowel on 4/14/26.Review of the clinical record failed to identify completion of a 3-day or 4-day bladder diary since admission, failed to identify any further assessment of bowel and bladder after the nursing admission assessment, failed to identify a completed Continence Product Screening form, and failed to identify the RCP was updated to reflect Resident #110 was both continent and incontinent of bowel and bladder and used an incontinent garment (pull-up).Interview and observation with Resident #110 on 4/20/26 at 11:08 AM identified 1.5 packages of pull-ups on top of the dresser. Resident #110 identified that he/she did not wear pull-ups or use any other incontinence product/garment at home because it wasn't needed due to being continent of bowel and bladder at home. He/she identified at the facility the toilet was not always adequately clean and he/she wore pull-ups due to an inability to hold it until staff were available to assist him/her. Additionally, indicated that it was easier to wear the pull-up so staff could just wipe me clean and put a new pull-up on instead of waiting for staff to answer the call bell, then clean up the bathroom, and then help him/her into the bathroom. Observation on 4/20/26 at 11:34 AM in the in-room bathroom shared by Resident #110 and his/her roommate identified the area of the toilet seat closest to the tank was visibly soiled with a light brown substance, the toilet was unflushed and contained a clear yellow liquid, and the outside of the toilet had 8 visible dried yellowish-brown lines running from just beneath the toilet bowl to the floor and a dark yellowish-brown stripe was on the tile of the floor proximal to the base of the toilet where it sat on the floor. (Please refer to F 584).Interview with Nurse Aide (NA) #2 on 4/23/26 at 9:45 AM identified Resident #110 was able to use the bathroom with assistance of 2 staff members, rang his/her call light when he/she needed to go to the bathroom. She identified Resident #110 used either incontinence briefs or pull-ups every day which were supplied by the facility. She identified that although Resident #110 always rang when needing to go to the bathroom he/she couldn't always hold his/her urine/stool until staff responded to the bell, but that since admission he/she was getting better control. She further identified sometimes Resident #110 soiled the toilet when he/she used it, but that staff would clean it off.Interview with LPN #5 on 4/24/26 at 3:00 PM identified she was responsible for the RCPs and would enter a specific continence related focus in the RCP if it was talked about in the team meetings so that she was aware there was a need for the RCP to be updated. She was unable to recall if Resident #110's continence was discussed in the team meetings.Interview with RN #3 on 4/24/26 at 11:35 AM identified she had been the nursing supervisor who completed the Nursing admission Assessment for Resident #110 and it showed Resident #110 was continent. RN #3 identified it was the responsibility of the admitting nurse and the nursing supervisors for the next few shifts to ensure everything on the admission Checklist was completed. She indicated that she completed what she could on her shift and then it was up to the next nurse to continue. She identified she did not know the reason Item #23 on the checklist was crossed off, that the 3-day bladder diary was part of a batch order in the electronic medical record and she usually initiated them. She was unable to identify why she hadn't completed the batch order for the 3-day bladder diary and thought it might be because he/she was continent.Interview with the Director of Nursing Services (DNS) on 4/24/26 at 12:01 PM identified the 3-day bowel and bladder diaries were not being consistently done. She identified the nursing supervisor did an initial assessment and writes a note, the 3-day bowel and bladder diary should follow and any changes identified should be followed up on to see what interventions were needed. She identified the charge nurses should be monitoring the nurse aide documentation and when there was a change in a resident's continence a new 3-day bladder diary should be initiated by the nurse. She further identified that the nurses should be documenting on new admissions every shift for at least the first 3 days and any change in the resident's continence would be identified with that documentation. She was unable to identify why the 3-day bladder diaries were not being consistently done and indicated that education was needed for the nursing staff.Review of the Bladder Assessment and Rehabilitation policy directed, in part, each resident will have a comprehensive bladder assessment on admission and with any significant change in condition. The policy directed a 3-day bladder diary is completed on admission beginning at midnight for new admissions, and a 4-day bladder diary is completed when sufficient information was not collected. The policy directed to determine if the resident is continent based on the diary information, and if the resident is determined incontinent, proceed with a full assessment, and determine what type of incontinence the resident has. The policy directed the nurse will complete a Continence Product Screening form to determine the products needed for day and evening. The policy further directed the licensed nurse would initiate the resident in a bladder retraining program or restorative toileting plan and interventions would be added into the resident care card and into the RCP.Review of the Nursing Documentation policy directed, in part, for timeliness: documentation should be completed as soon as possible, preferably within the same shift, and if entered at a later time it must be clearly indicated for transparency. The policy directed for resident changes: document any changes in a resident's condition, new symptoms, and any actions taken (notification of physician/family).

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 resident (Resident #101) reviewed for medical appointments, the facility failed to continue an endocrinology follow up with the specialty provider of choice and not a facility-initiated change of medical specialist. The findings include: Resident #101's was admitted to the facility in November of 2023 with diagnoses that included anoxic brain damage, diabetes, and contracture.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #101 was cognitively intact, dependent on bathing, required substantial maximal assistance for personal hygiene, dressing, toileting and oral hygiene. The MDS further identified Resident #101 required set-up assistance for eating.Nursing notes dated 3/27/26 at 11:46 AM and written by the previous Director of Nurses (DNS) identified a conversation with Person #2 on 3/26/26 regarding the follow up appointment with Resident #101's Endocrinologist related to Resident #101 thyroid levels being abnormal in November 2025. The nursing notes further identified the DNS had a conversation with Advance Practice Registered Nurse (APRN) #1 who felt it was unnecessary for Resident #101 to be seen by the Endocrinologist at that time as Resident #101 labs were within normal range and Person #2 was made aware of the conversation between the APRN and DNS. The nursing notes further identified the call became disconnected and the DNS did not call Person #2 back.The Resident Care Plan (RCP) dated 4/21/26 identified Resident #101 may choose to be resistive to care at times. Interventions included allowing Resident #101 to make decisions about treatment regime, to provide a sense of control, provide Resident #101 with opportunities for a choice during care and educate resident/family of the possible outcomes of not complying with treatment of care.On 4/21/26 at 10:16 AM during initial tour of the facility, Person #2 identified Resident #101 was to see the Endocrinologist on 3/26/26 for a yearly follow up, had been to that Endocrinologist's office 2 times before, but Resident #101 never went because the DNS told him/her the physician's office was too far from the facility and therefore the resident never went to the appointment scheduled for 3/26/26 (on 3/26/25 the appointment was made by the Endocrinology office for a yearly follow up scheduled for 3/26/26).Review of the transportation log on 4/23/2026 at 1:43 PM failed to identify transportation was ever scheduled for the 3/26/26 Endocrinology appointment.Nursing notes dated 4/23/26 at 9:39 AM and written by Licensed Practice Nurse (LPN) #5 identified on 4/22/26 she had made the appointment for another Endocrinology group for 5/28/26 (but not the Endocrinology group that Resident #101 was a patient of) but failed to identify if Person #2 was notified that the facility changed Resident #101's Endocrinologist.Interview on 4/23/26 at 1:33 PM with LPN #5 identified she was asked by administration to make an appointment with an Endocrinologist (after this surveyor's inquiry) but not a specific Endocrinologist and LPN#5 was not aware Resident #101 had an established history with a different provider. LPN #5 further noted she did not inform Person #2 or Resident #101 of the appointment for 5/28/26 with a new provider group and not the one Resident #101 had seen in the past. Further, identifying she meant to call Person #2 but had yet to done so.An interview on 4/24/26 at 11:00 AM with the DNS identified she had spoken to the APRN who felt the resident did not require a follow up with the Endocrinologist, but she did not know who cancelled the appointment previously scheduled for 3/26/26.Interview on 4/24/26 at 11:13 AM with APRN #1 identified she did not have a conversation on 3/26/26 with the DNS regarding Resident #101's appointment with the Endocrinologist. Also, identifying the DNS made APRN #1 aware of the thyroid issue Resident #101 had, identifying Person #2 wanted to have Resident #101 be seen by the Endocrinologist and APRN#1 had lab work completed but no issues were identified. After having a conversation with Person #2, APRN #1 realized it was for a follow up appointment from last year. Further, identifying she was not aware of why Resident #101 did not go to the appointment scheduled for 3/26/26.Interview on 4/24/26 at 12:20 PM with Resident #101's prior Endocrinology office (MD Office Employee #1) who identified in reviewing the office electronic medical record, noted the appointment for 3/26/26 was cancelled. Also, identifying the appointment was rescheduled for 3/30/26 and the resident was a no show. Further, identifying she was unable to identify who cancelled the appointment on 3/26/26 and the office did not have an appointment scheduled for Resident #101 on 5/28/26.On 4/24/26 at 12:45 PM interview with Person #2 identified the facility had not informed her/him an appointment had been made with a different Endocrinologist and not the same endocrinologist Resident #101 had a previous history with. Also, identifying this would be something Person #2 would have liked to have been informed of because the first choice would have been for Resident #101 to see the same Endocrinologist.Review of the Resident Rights Policy directed, in part, the resident has the right to receive quality of care and service with reasonable accommodation of the residents' individual needs and preferences, except when your health or the safety of others would be endangered by such accommodation. The residents have the right to make choices about aspects of their life that are significant to the residents. The residents have the right to participate in planning their care and treatment and be fully informed in advance about changes in their care and treatment.

Based on observations, interviews and facility policy review, the facility failed to ensure the medication cart was secured prior to licensed staff leaving the cart unattended. Resident #71's diagnosis included traumatic brain injury, mental disorder, and mild cognitive impairment.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 was severely, cognitively impaired and independent with eating, showering, dressing, toileting, and transfers.The Resident Care Plan (RCP) dated 4/7/26 identified Resident #71 had a cognitive impairment. Interventions included to monitor for changes in mood/mental status, report changes to the physician, check the resident's room daily for other resident's belongings and return the belongings to the correct resident.Observation on 4/23/26 at 2:12 PM noted the medication cart was unlocked, unattended in the hallway of the Empire Unit, the surveyor was able to open the drawers to the cart that contained blister packs and house stock bottles of medications and the nurse was not in sight.Observation on 4/23/26 at 2:15 PM identified a staff member walking by the unlocked medication cart and an alert/oriented resident was standing in the hallway. Another staff member came down the hall, went into a resident's room, and then transferred the resident via a wheelchair past the medication cart. Resident #71 was observed unattended and walked by the medication cart. The medication cart was left unlocked and unattended for 15 minutes.Observation and interview on 4/23/26 at 2:26 PM with Licensed Practical Nurse (LPN) #1 who walked by the unlocked, unattended medication cart while transferring a resident further down the hall to his/her room identified she did not know she left the medication cart unlocked but identified it was within her eye site as she was in the office behind the nurse's station (36 feet away around a corner). Also, identifying the policy was for medication to be locked when a nurse was not near it. Further, identifying she just forgot.Interview on 4/23/26 at 2:5PM with the Director of Nursing Services (DNS) identified all medication carts were to be locked when unattended. Also, identifying she needed to read the policy on locking medication carts. Further, identifying the nurse on the unit was responsible for locking the medication cart and the nursing supervisor provides oversight.Review of the facility policy for Medication Administration directed, in part to ensure safe, accurate, and effective administration of medications to residents, promoting optimal health outcomes while minimizing medication errors. Medication storage and handling: All medications should be stored in a secure, locked area accessible only by authorized personnel. Narcotics and controlled substances must be locked and counted per the facility policy.

Based on facility policy and staff interviews for 1 of 1 resident reviewed (Resident #1) for access to medical records, the facility failed to provide timely access to the resident's medical records upon request. The findings include: Resident #1's diagnoses included end stage renal disease with dialysis dependence, a Stage 4 pressure ulcer of the sacral region, sepsis (a life-threatening whole body infection), and immunodeficiency. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and was dependent for toileting, showering, and transferring between bed and chair. The Resident Care Plan dated 3/29/26 identified Resident #1 required enhanced barrier precautions for a chronic wound. Interventions included staff wearing gowns and gloves for high contact resident care activities such as bathing, assistance with toileting, and wound care, with the goal of establishing and maintaining infection control to help prevent the transmission of communicable diseases and infections. An interview with Resident #1 on 4/21/26 at 11:58 AM identified that the resident had been asking multiple staff members (but could not identify specific staff member names) from various roles and shifts for several weeks (including nursing supervisors, nurses, and nurse aides on all three shifts) for a copy of his/her medication list and lab work. Resident #1 stated that it was frustrating because he/she was immunocompromised, had multiple high risk health issues such as a sacral pressure ulcer, dialysis dependence, and was recently hospitalized with sepsis. Resident #1 identified a desire to participate in his/her care by keeping track of lab results and medications while at the facility. A subsequent interview with Resident #1 on 4/23/26 at 9:00 AM identified that he/she had requested a medication list and lab results from LPN #3 several weeks prior but was unable to recall the exact date of the request. The resident stated that he/she had not received the documents requested. An interview with the Nursing Supervisor (RN #1) on 4/23/26 at 9:15 AM identified that when a resident requests medical records, she would notify either the Social Worker or the Director of Nursing Services (DNS) so they could initiate the formal process for obtaining medical records, after which the medical records department would provide the requested documents. An interview with the Director of Nursing Services (DNS) on 4/23/26 at 9:30 AM identified that when a resident requests medical records, Social Worker #1 should be notified so she can begin processing the request and ensure the records were provided. Interview with LPN #3 on 4/23/26 at 12:15 identified that Resident #1 did previously ask her for a copy of his/her medication list and lab work either at the end of March 2026, or early April 2026, but was unable to identify the specific date of the request. LPN #3 stated that she can print certain parts of the medical records such as labs for residents however it was not her role at the facility. LPN #3 stated that she would normally let the nursing supervisor know of the request and they would then complete the request. LPN #3 identified that upon Resident #1's request for a copy of his/her medication list and labs, she let the nursing supervisor know, however she was unsure which nursing supervisor she let know as she did not work with her often. An interview with Social Worker #1 on 4/23/26 at 1:15 PM identified that any nurse, including the nursing supervisor and the unit nurse, had the capability to print a medication list and lab results for residents directly from the electronic health record. Social Worker #1 further explained that if a resident requested other types of medical records that nurses were unable to print directly from the electronic health record, a request would be forwarded to the medical records department. She added that if a resident no longer resided in the facility, a written request was required to release medical records; however, residents currently residing in the facility may request a medication list and lab results from any nurse, and the nurse should be able to print those documents directly. Social Worker #1 also identified that she had access to print medication lists and lab results and would do so upon request. Subsequent to surveyor inquiry, an interview with Social Worker #1 on 4/23/26 at 2:15 PM identified that she met with Resident #1 to discuss the request for a medication list and lab results. She stated that she was able to print and provide the requested documents to the resident immediately but had already done so. Social Worker #1 further stated that she provided education to RN #1, clarifying that all nurses have the ability to print and provide residents with medical documents such as medication lists and lab results and should do so when requested. Review of the facility policy titled, Resident Rights, undated, directed that residents or their legal representative have the right to access all facility records pertaining to that resident within 24 hours of such request.

Based on observation, facility documentation, facility policy, and interviews, the facility failed to provide a clean, homelike environment for the bathrooms utilized by Resident #2, Resident #3, Resident #13, Resident #42 and Resident #110. The findings include: 1a. Observation of the bathroom for Resident #2 on 4/20/26 at 12:10 PM identified a commode placed over the toilet seat with multiple small spots of a dark brown substance on the back edge of the toilet seat. Additionally, on the floor proximal to the base of the toilet where the toilet meets the floor was a brown ring of accumulated buildup of debris. Further identified on the floor between the base of the toilet and next to the wall were numerous clumps of a dark brown substance on the floor.b. Observation of the bathroom for Resident #2 on 4/21/26 at 12:24 PM identified a commode placed over the toilet seat with multiple small spots of a dark brown substance on the back edge of the toilet seat which appeared unchanged from the previous day. Further identified was on the floor proximal to the base of the toilet, where the toilet meets the floor, was a brown ring of accumulated buildup of debris. Further identified on the floor between the base of the toilet and next to the wall were numerous clumps of a dark brown substance on the floor which remained unchanged from the previous day.c. Observation of the bathroom for Resident #2 and interview with RN #2 and RN #6 on 4/23/26 at 11:40 PM identified a commode placed over the toilet seat which appeared to have been cleaned with no visible brown spots. Additionally, the floor at the base of the toilet and between the toilet and the wall appeared to have been cleaned with a smaller less prominent accumulation of debris and further identified on the floor between the base of the toilet and next to the wall less clumps of a dark brown substance on the floor. RN #2 identified the floor around the toilet should have been thoroughly cleaned.2. Observation on 4/20/26 at 11:55 AM of Resident #3's shared bathroom identified a missing and broken tile on the wall next to the toilet and below the sink immediately above the floor level. The tile space was damaged, exposing a dark, deteriorated backing material with visible discoloration and staining, as well as dark/black particles/specs on adjacent tiles and on the floor. The observation also identified a sign posted on the bathroom mirror above the sink stating Do not use.Interview with Resident #3 at 12:04 PM revealed that the resident believed the dark particles on the floor and tile were bugs, which was distressing to him/her. The resident stated that the tile had been missing since admission, the sink had been out of order for at least four days, and the sink and toilet frequently required repair. Resident #3 reported being unable to use the bathroom for two of those days and had to use another resident's bathroom. After the sink was repaired, the water was inadvertently left off, resulting in an additional two days without bathroom access because it was the weekend and no one was available to turn the water back on.Interview with the Maintenance Director on 4/22/26 at 12:25 PM revealed that he had been aware of the missing tile for approximately one week and had ordered replacement tiles; however, the specific tile needed was on backorder and therefore could not yet be replaced. He also stated that he was aware the sink had not been working for a few days but reported that it had been repaired prior to the interview.Observation and interview with Resident #3 on 4/24/26 at 9:05 AM continued to identify the missing tile with dark deterioration and discoloration present, along with dark particles on the adjacent tiles; however, particles were no longer noted on the floor. Resident #3 stated that the floor had been cleaned and was usually cleaned daily, but the walls were not cleaned as often, resulting in residue buildup. The resident pointed out residue on the wall under the grab bar above the toilet paper holder, stating it had been present for a few days and was unpleasant to him/her. A basin next to the toilet was filled with water and contained a toilet plunger and toilet brush. Water was observed dripping from a valve on the toilet into the basin. Resident #3 stated he/she had not noticed the basin filling with water but reported that the toilet leaked at times.Interview with Housekeeper #1 on 4/24/26 at 9:30 AM indicated that bathrooms were cleaned every day, including the floors, walls, sink, and toilet, and additionally upon request from residents or staff. He was unable to identify why there were particles on the wall but stated he would clean the area immediately following the surveyor's inquiry.Interview and review of the Maintenance Communication Binder with the Director of Maintenance on 4/24/26 at 12:10 PM did not identify any reported issues related to Resident #3's bathroom for the months of April, March, or February, including the missing tile, leaking toilet, or clogged sink. The Director of Maintenance stated that he discovered the missing tile himself during periodic rounds the previous week and that Resident #3 often approached him or other maintenance staff directly to report issues which included the clogged sink and leaking toilet. He stated that because he was already aware of the repairs needed, he did not document them in the maintenance binder. The Director of Maintenance also stated that the missing tile had subsequently been replaced.3a. Observation of the shared bathroom for Resident #13 and Resident #110 on 4/20/26 at 11:34 AM identified the area of the toilet seat closest to the tank was visibly soiled with a light brown substance, the toilet was unflushed with multiple visible yellowish-brown lines running from under the rim of the toilet to the edge of the water inside the toilet which contained a clear yellow liquid, and the outside of the toilet had 8 visible dried yellowish-brown lines running from just beneath the toilet bowl to the floor and a dark yellowish-brown stripe along the edge of the tile on the floor proximal to the base of the toilet where it sat on the floor.b. Observation of the shared bathroom for Resident #13 and Resident #110 on 4/21/26 at 12:18 PM identified the toilet seat appeared to have been cleaned with no visible light brown substance remaining, and the toilet bowl no longer contained a clear yellow liquid. Additionally, the multiple yellowish-brown lines running from under the rim of the toilet to the edge of the water were lighter in color appearing more yellow. Further identified was the outside of the toilet and floor proximal to the toilet appeared unchanged with 8 visible dried yellowish-brown lines running from just beneath the toilet bowl to the floor and a dark yellowish-brown stripe along the edge of the tile on the floor proximal to the base of the toilet where it sat on the floor.c. Observation of the shared bathroom for Resident #13 and Resident #110 on 4/22/26 at 2:29 PM identified multiple yellowish-brown lines running from under the rim of the toilet to the edge of the water which appeared darker from the previous observation. Further identified was the outside of the toilet and floor proximal to the toilet with 8 visible dried yellowish-brown lines running from just beneath the toilet bowl to the floor and a dark yellowish-brown stripe along the edge of the tile on the floor proximal to the base of the toilet where it sat on the floor which appeared unchanged from the previous 2 observations.d. Observation of the shared bathroom for Resident #13 and Resident #110 and interview with Registered Nurse (RN) #2 and RN #6 on 4/23/26 at 11:35 AM identified the toilet seat and inside surface of the toilet bowl above the water line was heavy soiled with a thick layer of a brown substance. The outside of the toilet and floor proximal to the toilet with 8 visible dried yellowish-brown lines running from just beneath the toilet bowl to the floor and a dark yellowish-brown stripe along the edge of the tile on the floor proximal to the base of the toilet where it sat on the floor appeared improved from the previous observations with the lines on the outside of the toilet bowl appearing very light yellow and the yellowish-brown stripe along the edge of the tile proximal to the base of the toilet appearing thinner and lighter in color. While RN #6 flushed the toilet and went to request the staff clean the toilet, RN #2 identified the toilet seat should not have been left in that condition and indicated although the outside of the toilet was improved it should have been thoroughly cleaned and not left for multiple days in the same condition. 4. Observation and interview on 4/21/26 at 12:53 PM with Resident #42 identified his/her bathroom had multiple small screw holes in the wall next to the mirror from a soap dispenser that had been pulled off the wall by a previous roommate. Resident #42 stated that he/she had told staff more than once about the holes in the wall, but they still had not been fixed. Also, Resident #42 identified he/she uses the bathroom.Observation and tour on 4/24/26 at 10:30 AM with the Maintenance Director identified room [ROOM NUMBER] had holes in the tile by the grab bar and where the toilet paper holder used to be. Also, identifying room [ROOM NUMBER] had holes in the bathroom mirror from the old soap dispenser. Further identifying he was aware of the holes in the wall/tile for room [ROOM NUMBER]/57, he was responsible for repairing the wall/tile, the bathrooms were not home like, and he just did not get to it yet.Interview and observation on 4/27/26 at 11:22 AM with Resident #42 identified the holes by the mirror have been there for at least 4 months and he/she had reported it to the Maintenance Director because he was the one who replaced the soap dispenser months ago5. An observation and interview on 4/27/26 at 11:24 AM with Resident #13, (room [ROOM NUMBER]) reported the holes in tile was where the old toilet paper holder used to be and had been like that since Resident #13 was admitted 2 weeks ago. Also, reporting the bathroom does not contain a toilet paper holder and the resident had been placing the toilet paper roll on the top of the toilet tank when he/she used the toilet.Interview on 4/27/26 at 11:28 AM with Registered Nurse (RN) #5 identified the units have a maintenance log for reporting broken items and repairs that were needed. Review of the maintenance log for the past year failed to identify holes in tiles or walls of any resident's room.Subsequent to surveyor inquiry holes being repaired. Review of the Housekeeping Services Overview policy directed, in part, sufficient housekeeping staff are employed to maintain the interior resident areas in a clean and attractive manner. The policy directed thoroughly vacuum main floors and all traffic areas, spot clean all floors and corridors and removed spots and spills where appropriate. The policy failed to identify directives to maintain and clean the bathroom floors, toilets and sinks.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #11) reviewed for Pre-admission Screening and Resident Review (PASRR), the facility failed to notify the state contracted agency of a post-admission diagnosis of major depression, to ensure a PASRR level 2 evaluation was completed. The findings include: Resident #11 was admitted to the facility in May 2024 with diagnoses that included post-traumatic stress disorder (PTSD), Type 2 diabetes mellitus, and peripheral vascular disease. A post admission diagnosis of major depression was identified on 5/5/25. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had diagnoses of PTSD and unspecified mood (affective) disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was cognitively intact and dependent with toileting, bed mobility, and transfers. Review of Resident #11's MDS indicated a diagnosis of PTSD and unspecified mood (affective) disorder. The MDS failed to indicate Resident #11's diagnosis of major depression. The Resident Care Plan (RCP) dated 3/30/26 identified Resident #11 could be physically and/or verbally aggressive toward staff members or other residents, had increased agitation and anxiety, had past trauma and a diagnosis of depression. Interventions included consulting with psychiatric services, provide treatment and monitor medication as prescribed, and to watch the resident for signs of distress or changes in cognition, mood and behaviors and to report to the physician. Interview and review of the clinical record with Social Worker (SW) #1 on 4/23/26 at 12:04 PM indicated Resident #11 had a negative Level 1 PASRR completed on 5/6/24 which identified a Level 2 PASRR was not needed as Resident #11 did not have a serious mental illness. Additionally, while a resident at the facility, the resident was diagnosed with major depression on 5/5/25. SW #1 identified that although Resident #11 should have been referred for the completion of Level 2 PASRR after being diagnosed with major depression, the referral was not made, and she was unsure why it was not done. SW #1 indicated it would have been her department's responsibility to ensure the Level 2 PASRR was requested and completed and that she would make the referral. Subsequent to surveyor inquiry, an additional interview and review of the clinical record with SW #1 indicated a referral was made on 4/23/26 for the completion of a Level 2 PASRR screening for Resident #11. The referral identified the resident had never had a Level 2 PASRR evaluation and shows signs and symptoms that indicated he/she may have a PASRR condition with mental health diagnoses of current major depression and PTSD. Review of the facility policy, Preadmission Screening and Resident Review Policy, undated, directed that the facility would ensure that residents admitted to the facility meet federal PASRR requirements and are appropriately screened for serious mental illness and receive necessary services. Requirements would ensure a Level 2 evaluation would be completed when required and social services was responsible for PASRR coordination, tracking and compliance.

Based on clinical record review, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was at risk for falls, the facility failed to ensure a staff member did not leave Resident #1 unattended while ambulating without an assistive device to prevent a fall that resulted with Resident #1 sustaining a fracture of the right humerus and laceration to the right eyebrow. The findings include: Resident #1's diagnoses included dementia, difficulty walking, weakness, osteoporosis and chronic pain. A physician's order dated 9/30/24 directed assist of one (1) with transfers and ambulate with a rolling walker. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status score of six (6) indicating Resident #1 had poor memory recall, required extensive assistance with transfers, supervision or touching assistance when ambulating, utilized a walker for mobility, and had two (2) falls with no injuries in the past ninety (90) days. The Resident Care Plan dated 10/22/24 identified Resident #1 was a fall risk and preferred to push his/her wheelchair for stability. Interventions directed to encourage the resident to ask and wait for staff for assistance, encourage proper and non-skid footwear, redirect to use wheelchair by sitting on for ambulation and not use it as a walker, re-enforce the need to call for assistance, and remind of transfer/ambulation status of assist of one with rolling walker frequently. The Advanced Practice Registered Nurse (APRN) note dated 12/31/24 at 9:45 AM identified Resident #1 had a witnessed fall, sustained a laceration, and was transferred to the hospital. The nurse's note dated 1/1/25 at 8:02 PM identified Resident #1 returned from the hospital at 5:45 PM after receiving treatment for a fall that resulted in a closed fracture of the right proximal humerus and a right eyebrow laceration. The note indicated Resident #1 complained of mild pain in the shoulder and was medicated to manage the discomfort. Review of the investigation identified Resident #1 was observed pushing the wheelchair in the hallway, then Resident #1 walked away from the wheelchair and was ambulating without a device and as a nurse aide, Nurse Aide (NA) #1, was getting the wheelchair, Resident #1 fell. The report indicated another staff member witnessed Resident #1 walking in the hallway and instructed NA #1 to get Resident #1's wheelchair. The report identified NA #1 turned her back on Resident #1 to get the wheelchair, the other staff member went into her office, therefore Resident #1 was not in eyesight of either staff member. Interview with NA #1 on 1/14/25 at 11:34 AM identified on 12/31/24 she observed Resident #1 in the hallway, passed by and walked away from Resident #1 at which time the secretary asked her if Resident #1 was supposed to be walking by him/herself. NA #1 identified she went to obtain Resident #1's wheelchair which was behind Resident #1 and while she was getting the wheelchair, Resident #1 sustained a fall. NA #1 identified she was within reach of Resident #1 but did not have eyes on Resident #1 at the time of the fall. NA #1 identified she was aware Resident #1 required assistance when ambulating and Resident should not have been ambulating alone. NA #1 did not give a reason as to why she did not assist Resident #1 over to the wheelchair. Interview with the Infection Control Nurse, Registered Nurse (RN) #1, on 1/14/25 at 12:05 PM identified on 12/31/24 she observed Resident #1 in the hallway in his/her wheelchair, then observed Resident #1 get up from the wheelchair and begin ambulating without assistance. RN #1 identified although she did not assist NA #1 with Resident #1, she did instruct NA #1 to get Resident #1's wheelchair, which was behind Resident #1, and then she went into her office. RN #1 identified when she was in her office, she heard a thud and went out to find Resident #1 on the floor. Interview and clinical record review with the Director of Nursing (DON) on 1/14/25 at 12:39 PM identified Resident #1's ambulation status on 12/31/24 was assistance of one (1) staff member with a rolling walker. The DON indicated at the time of the fall, although NA #1 was near Resident #1, Resident #1 was not within NA #1's eyesight. The DON identified it was reported that Resident #1 had gotten up and was walking rapidly when the receptionist alerted the staff. The DON identified that when NA #1 went to get Resident #1's wheelchair there was some distance between NA #1 and Resident #1. The DON identified Resident #1 should have been directed towards the wheelchair with the staff member instead of leaving Resident #1 in the process of getting the wheelchair. Review of the facility policy titled Ambulation, directed, in part, all residents will be evaluated for ambulatory capabilities and for appropriate therapeutic equipment and services as needed, assistive devices as ordered to assist the residents in achieving and maintaining the highest practicable level of ambulation. Additionally, the policy directed to ambulate the resident according to his/her plan of care and tolerance.

Based on a review of clinical records, facility documentation, and interviews for one (1) of two (2) residents (Resident #1) reviewed for accidents, the facility failed to ensure that skin protective measures were implemented in accordance with physician orders, and failed to ensure that the residents wheelchair was free from accident hazards, as a result, the resident sustained a laceration that required sixteen (16) sutures. The finding includes: Resident #1 had diagnoses that included speech disorder following a stroke, dementia and thrombocytopenic purpura. An occupational therapist note dated 6/1/23 identified Resident #1 was assessed seated in his/her tilt in space wheelchair that noted continued right lower extremity hip external rotation and knee flexion. After three hours of sitting in the wheelchair, redness/skin indentation was noted on Resident #1's right lateral aspect of his/her shin. The right leg rest was removed, and foam padding was placed to the proximal aspect of the area where the leg rest was removed to maintain skin integrity. Staff were updated on the changes to the wheelchair. A physician's order dated 6/22/23 directed geri-legs on at all times, off for care only. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, required total dependence of two staff for bed mobility and transfers, had impairments in range of motion on both sides of upper extremities and lower extremities, and used a wheelchair for mobility. The care plan dated 8/10/23 identified Resident #1 was prone to bruising due to senile purpura with interventions that included geri-legs on at all times ( a sleeve applied to the leg to protect the skin from injury), off for care only and to replace as needed, caution while providing care due to fragile skin, and while providing care be mindful of placement and positioning of all extremities due to extremely fragile skin. A nursing note dated 8/12/23 at 1:24 PM identified that Resident #1 had obtained a skin tear measuring 15 cm x 2.0 centimeter flap. The area was cleaned with normal saline, steri-strips applied (small bandages) and covered with an abdominal pad (ABD dressing is an extra thick gauze dressing) and cling wrap. The physician was notified, prescribed a normal saline rinse, steri-strips and ABD dressing until seen by the in-house wound physician. On 8/14/23 the wound nurse and the Director of Nurses assessed the skin tear and identified moderate bleeding with the wound edges not approximated (the edges of wound could not be brought together). The bleeding continued and strike through bleeding was noted on the dressing, an order was obtained to send Resident #1 to the emergency department. The hospital Discharge summary dated [DATE] identified Resident #1 received sixteen (16) sutures to the laceration on his/her right calf and an order for Keflex (an antibiotic) 500 mg every 8 hours for ten (10) days. The accident and incident (A & I) form dated 8/12/23 identified at 11:30 AM Resident #1 sustained a skin tear to his/her right calf while sitting in the wheelchair. The investigative summary identified Resident #1 was placed in the wheelchair without geri-legs on and a pillow underneath his/her shin with no padding on the leg rest. A skin tear was observed on Resident #1's right calf. Presumably when the pillow fell off, Resident #1's shin rubbed against the joint where the leg rest was removed (the area that should have been padded) causing the skin tear. Interview with NA #3 on 8/20/24 at 3:53 PM (assigned to Resident #1 on 8/12/23) stated while providing care on 8/12/23, she noted that the resident's geri-legs needed to be laundered, so she put them in the laundry, however, failed to apply another pair. NA #3 identified she observed that Resident #1's wheelchair had exposed metal from where the footrests were removed, so she placed a pillow to the area where the footrest was removed, the resident kicked the pillow off and obtained the skin tear. Interview with the DNS on 8/20/24 at 4:46 PM identified Resident #1 had extremely fragile skin. It was noted that metal was exposed on his/her wheelchair where the leg rest was removed, NA#3 should have gone to the therapy department to have the padding replaced prior to placing the resident in the wheelchair. She further identified Resident #1's geri-legs should be in place at all times, and when NA #1 removed them to be laundered the NA should have obtained a second pair as geri-legs are stocked by the facility.

Based on clinical record reviews, facility documentation review, and interviews for one of four sampled residents (Resident #5) who were reviewed for accidents, the facility failed to ensure Resident #5 was not struck by a meal cart causing the resident to fall wand sustain a fracture of the right humerus. The finding includes: Resident #5's diagnoses included normal pressure hydrocephalus, dementia, anxiety, depression, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had moderate cognitive impairment and was independent with bed mobility, transfers, and ambulation. The Resident Care Plan dated 8/29/23 identified Resident #5 as a risk for falls. Interventions directed to place the call bell within reach, physical therapy and occupational therapy to increase strength and endurance, place commonly used articles within easy reach, and transfer per physician orders. A physician's order dated 11/1/23 directed Resident #5 was independent without assistive device with transfers and ambulating. The nurse's note dated 11/13/23 at 6:45 PM identified Resident #5 had expressed severe pain to the right arm after injuring the area on the meal cart during the dinner meal. The note identified Resident #5 complained of a pain level of seven (7) out of ten (10) with difficulty performing movement and activity on the affected arm. The note identified the physician was notified and an x-ray was ordered of the right arm. The nurse's note dated 11/13/23 at 9:17 PM identified Resident #5 had an acute fracture of the proximal humerus (upper arm). Review of the x-ray report dated 11/13/23 identified an acute fracture of the proximal humerus, osteoarthritic changes were seen, and the bones were osteoporotic. The Facility Reported Incident form dated 11/13/23 identified Resident #5 sustained an injury on the right humerus after Resident #5 collided with a food service cart causing Resident #5 to fall on the right side with complaints of severe pain/discomfort. The report indicated an x-ray was ordered and Resident #5 was given pain medication. Interview with Dietary Aide #1 on 12/7/23 at 12:55 PM identified on 11/13/23 she was pushing the meal cart and hit Resident #5. Dietary Aide #1 indicated she looked on both sides of the cart and did not see Resident #5 in front of the meal cart. Dietary Aide #1 identified Resident #5 fell after being hit by the meal cart. Dietary Aide #1 identified at the time of the incident the meal cart was taller than her and she could not see over the cart. Interview with the Director of Nursing (DON) on 12/8/23 at 10:10 AM identified after the incident on 11/13/23, she watched the video and observed Resident #5 at the nursing station facing one direction, the Dietary Aide was pushing the meal cart, looked to the right but Resident #5 was to the left and while pushing the meal cart it collided with Resident #5 causing Resident #5 to fall and sustain the injury to his/her right arm. Interview with the Food Service Director (FSD) on 12/8/23 at 10:36 AM identified after watching the video surveillance of the 11/13/23 incident, he observed Dietary Aide #1 look to both the left and right of the cart, however Resident #5 was in front of the meal cart and Dietary Aide #1 was not able to see Resident #5.

Based on review of facility documentation and facility policies, observations, and interviews, the facility failed to implement an effective water management plan to mitigate the risk of Legionella (originally identified in 2019) and other water borne pathogens and implement immediate control measures for a presumptive Legionella infection identified on 4/5/21 as recommended to protect residents, staff and visitors from potential exposure to Legionella which resulted in Immediate Jeopardy. The findings include: 1. The facility water management plan, email communications with the facility water management contractor and water testing logs were reviewed for the period from July 2019 through March 2021 indicated a continuing proliferation of Legionella Pneumophila in multiple locations throughout the facility. The facility sampled (8) and ten (10) locations every test. On 7/15/19 and 7/16/19 the facility installed point of use Nephros .005-micron water filters on all showerheads. Additionally, the facility removed aerators from all faucets and instituted a heat and flush program that failed to eradicate Legionella Pneumophila from the water system. No other mitigation measures were initiated. The facility was advised from its water management contractor Facility Compliance Services that the heat and flush program wasn't working due to the age of the facility, the condition of the water piping system and recommended a supplemental disinfection water treatment system in August of 2020. The facility received a quote for a treatment system on 10/16/20 but failed to institute or act on the quote for the treatment system as of the day of survey (4/5/21). On 4/5/21 the facility transferred Resident #57 to the hospital and was subsequently notified on 4/5/21 that Resident #57 had a positive urine [MEDICATION(S)] test for Legionella. On 4/5/21 the facility failed to provide logs on when the micron filters were changed for the point of use water filters for showers and ice machines upon surveyor request. Interview with the Director of Maintenance on 4/6/21 identified that he did not have formal logs, and only had notes on paper. Subsequent to surveyor inquiry, the Director of Maintenance transcribed his notes onto an official log. The Maintenance Director and the Administrator failed to produce invoices for the filters that would confirm that the point of use filters had been ordered and replace on 90-day intervals for the Nephros SSU-H filter and 180-day intervals for the Nephros DSU-H filters in accordance with the manufactures recommendations. On 4/8/21 at 8:00 AM and times throughout the day, a review of the facilities Water Management Plan and subsequent staff interview identified the Administrator was advised by the Department of Public Health Legionella Surveillance Coordinator & Waterborne Disease Coordinator on 4/7/21 at approximately 5:04 PM, to place the facility on water restrictions and to use bottled water due to a presumptive healthcare associated case of Legionella identified on 4/5/21, following the guidance and the recommendations of the Centers of Disease Control. The facility had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/8/21 at approximately 10:00 AM the facility was still utilizing tap water for drinking and medication administration and was not following the CDC guidance recommended by the State Department of Public Health, risking further cases of a presumptive healthcare associated case Legionella. Subsequent to those observations, the facility started utilizing bottled water and following the CDC recommendations. On 4/9/21 at 4:00 PM, observation and tour of the facility with the facility contractor for Facility Compliance Services had installed .005 micron point of use Nephros SSU-H water filters and Nephros DSU-H water filters on all potable water sources within the facility and corrected the immediate jeopardy situation and could start utilizing potable water, ice and showers in the facility 2. Resident #57 was admitted to facility from an acute care hospital on 3/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) dated [DATE] identified that Resident #57 was alert and oriented and required extensive assistance of 2 for bed mobility and limited assistance of 1 for transfers. A nurse's note dated 4/3/21 at 5:57 PM identified Resident #57 complained of hand tremors, not eating much, dizziness and requested to be put back into bed. Resident #57 also requested to be administered [MEDICATION(S)] for generalized pain, which was administered with positive outcome. A nurse's note dated 4/4/21 at 1:35 PM identified that at approximately 11:30 PM Resident #57 received as needed (PRN) Tylenol due to a complaint of a headache and that continuous pulse oximetry holster was in place and identified an oxygen saturation level of 83% to 85% with oxygen at 2 Liters per minute via nasal cannula. Resident #57s oxygen flow was increased to 3 liters per minute (per physician titration orders to increase oxygen to 3 Liters per minute to maintain oxygen saturation to 90%) and Resident #57s oxygen saturation increased to 90% with no acute respiratory distress. A nurse's note dated 4/4/21 at 2:59 PM identified Resident #57's family member was visiting and requested Resident #57 be sent to the emergency room (ER) for evaluation due to Resident #57's low oxygen saturation level and Resident #57 was sent to the ER. A microbiology report from the acute care hospital identified that Resident #57's urine sample collected on 4/5/21 identified Resident #57 was presumptive positive for Legionella [MEDICATION(S)]. Additionally, a chest xray report from the acute care hospital dated 4/4/21 identified new patchy airspace opacities in the right upper lobe and right lower lobe concerning for multifocal infection. According to the State Department of Health Epidemiology, a urine sample with a presumptive positive Legionella [MEDICATION(S)] coupled with an abnormal chest xray consistent with pneumonia meets the clinical criteria in the Council of State and Territorial Epidemiologists (CSTE) case definition as a confirmed case of Legionella disease. Additionally, the State Department of Health's Epidemiology Department has classified Resident #57 as a confirmed case of Legionella. On 4/6/21 at 10:30 AM during the facility's re-certification survey, Corporate Nurse #2 stated that Resident #57 had tested positive for Legionella at the acute care hospital. An email dated 4/7/21 at 5:04 PM addressed to the Administrator from the Connecticut Department of Public Health Epidemiology (DPH) identified that Resident #57 was in the facility during the entire incubation period (Resident #57 had not left the facility) and reported onset on 4/2/21, fitting the Center for Disease Control and Prevention (CDC) for a presumptive healthcare associated case and that in the interest of protecting patients, staff and visitors, Centers for Disease Control (CDC) recommendations included restricting water in the facility, using bottle water and placement of 0.2 micron biological point-of-use filters on all showerheads, sink and tub faucets as an immediate control measure. An observation of a medication pass and interview with the Infection Control Nurse (RN #1) on 4/8/21 at 10:10 AM identified RN #1 pouring a cup of water from a water pitcher located on the top of the medication cart. RN #1 identified that he had filled the water pitcher from the sink in the nourishment room in order for the resident's morning medication pass. RN #1 identified that 5 residents (Resident #23, Resident #215, Resident #216, Resident #315, and Resident #316) had already been provided their medications using the tap water he had poured from the water pitcher. RN #1 stated that he was unaware that he needed to use bottled water and not the tap water from the nourishment room. Interview with the Director of Nurses (DNS) on 4/8/21 at 10:28 AM identified that the Infection Control Nurse (ICN) was responsible to educate the nursing staff to restrict use of unfiltered tap water and utilize bottle water as recommended by the Connecticut Department of Public Health Epidemiology (DPH) and the CDC and she had not yet checked in with the ICN. An interview with LPN #2 on 4/8/21 at 10:30 AM identified that she had provided 8 residents (Resident #19, Resident #28, Resident #29, Resident #43, Resident #46, Resident #48, Resident #56, and Resident #61) their morning medications utilizing the tap water from the nourishment room so the residents could take their medications. She further identified that she was unaware that she needed to use bottled water identifying that the residents also have water pitchers at their bedsides that are filled by the 11:00 PM to 7:00 AM shift nursing assistants who used tap water. LPN #2 indicated she gave medications with water to 8 residents and 17 residents were given water pitchers. LPN #2 noted there was no bottled water available at the nurse's station. Observation on 4/8/21 at 10:35 AM identified Resident #43 had 2 water pitchers in front of her/him and was drinking from one water pitcher and Resident # 43 indicated he/she had just finished the first one. An interview with LPN #3 on 4/8/21 at 10:45 AM identified that he was not educated or aware to use bottled water instead of tap water when providing resident care on the unit. LPN #3 indicated he had already given medication pouring the tap water into cups for 8 residents prior to the Administrator informing him of a resident with positive Legionella and then provided him with a gallon of bottled water. LPN #3 noted 23 residents on his unit that had water pitchers distributed by the 11:00 PM to 7:00 AM shift at their bedsides. On 4/8/21 at 10:50 AM, surveyor observation identified 156 gallon containers of potable water located in the emergency supply closet. Interview with the DNS on 4/8/21 at 11:00 AM identified that she had left the faciity on [DATE] at approximately 5:00 PM and was not informed of the email on 4/7/21 at 5:04 PM from the Connecticut Department of Public Health Epidemiology (DPH) recommending the CDC guidelines to use bottle water instead of tap water to ensure safety due to the report of the positive resident case of Legionella and did not instruct the ICN to provide education to staff on 4/7/21. Interview with NA #2 and NA #4 on 4/8/21 at 11:08 AM identified that they worked the 11:00 PM to 7:00 AM shift on 4/7/21 and they filled the water pitchers for the facility at approximately 3:00 AM on 4/8/21 with ice and tap water from the sink in the nourishment room on the units. NA #2 and NA #4 continued by indicating that no one during their shift informed or educated them to use bottled water instead of the unfiltered tap water due to Legionella. Interview with the Administrator on 4/8/21 at 11:10 AM identified that he had a phone conference with DPH at approximately 5:30 PM on 4/7/21 that reviewed the contents of the email dated 4/7/21 at 5:04 PM addressed to him from DPH that identified that Resident #57 was in the facility during the entire incubation period and reported onset on 4/2/21 fitting the Center for Disease Control and Prevention (CDC) for a presumptive healthcare associated case. In the interest of protecting patients, staff and visitors, CDC recommended activities included restricting water in the facility and using bottle water and placement of 0.2 micron biological point-of-use filters on all showerheads, sink and tub faucets as an immediate control measure. The Administrator further identified that he immediately put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not implement the recommended activities overnight and stated he was waiting for clarification of water restrictions as he was unclear if it would include bathing. He further stated that he was aware that the facility had a 3 day emergency supply of water but did not consider using it as it was designated for food emergencies only. He further stated that he personally distributed water to the units this morning subsequent to the surveyor's observations and was now placing 0.005 micron filters (which are greater than the CDC recommendations) on the required water sources as they had just arrived that morning. He continued by stating for those sinks that they did not have a filter, the maintenance team was now directed to shut off the water to that particular sink and post a sign to not use. 3. On 4/5/21 at 9:45 AM documentation review of the facilities Water Management Plan, identified the facility's water management committee members were not identified or listed on the provided documentation. The Water Management Plan also failed to provide documentation to verify the monthly test results that the facility had been doing as part of a plan of correction for Legionella that was previously present in the facility. The only documentation that was available was testing from 9/1/20, 12/1/20, and 1/15/21 from all the same rooms within the facility. The water samples from the three tests showed positive results. Additionally, there were no meeting minutes provided regarding Legionella issues within the facility. The only meeting minutes that were presented at time of survey were in reference to the 1/12/21 water samples. Further review of the Water Management Plan failed to identify documentation to indicate when the filters for Legionella have been replaced in the facility.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #52 and Resident #323) reviewed for accidents, the facility failed to prevent a fall with injury (Resident #52), and for 1 of 4 residents (Resident #51) reviewed for medication administration, the facility failed to ensure medications were properly secured and failed to assess Resident #323 for multiple falls to determine the root cause to ensure appropriate interventions and adequate supervision was in place to prevent a fall with injury. The findings include: 1. Resident #52's diagnoses included Schizo-affective disorder, diabetes, and anxiety. The quarterly Minimum Data Set, dated dated dated [DATE] identified Resident #52 had moderately impaired cognition, was occasionally incontinent of bladder, always continent of bowel, was independent for transfers and ambulation without an assistive device, and required supervision for toileting with set up help only. The Resident Care Plan (RCP) dated 4/1/20 identified Resident #52 fluctuated in frequency with bowel and/or bladder continent status. Interventions included to assist him/her with toileting and incontinent care as needed (there was not an intervention that Resident #52 required or utilized a raised toilet seat). A physician's order dated 4/14/20 directed to transfer and ambulate independently. A Social Service note dated 4/30/20 identified Resident #52's room was changed due to COVID-19 positive results and Resident #52 was placed on droplet precautions. A nurse's note dated 5/4/20 at 2:46 PM identified that Resident #52 was yelling for help. RN #4 responded to the room, observed Resident #52 on the floor with his/her head down, and resting against the wall with a large amount of blood noted on the bathroom floor. Resident #52 was alert and verbal, and reported that when he/she attempted to get off the toilet, he/she fell forward onto the floor. Resident #52 sustained a laceration to the forehead, scrapes to both knees, his/her nose was bruised and appeared to be deformed (question of a fracture). Resident #52 complained of pain to his/her head, nose, and knees. 911 was called, Resident #52 was transferred to the emergency room for evaluation, and the responsible party and MD were notified. A facility Accident and Incident Report dated 5/4/20 at 1:15 PM identified Resident #52 had an unwitnessed fall in the bathroom, was lying on his/her right side with a laceration to his/her face and bruising to both knees. Resident #52's description of the event was that he/she was sitting on the toilet and fell forward onto the floor; Resident #52 fell off the raised toilet seat when he/she was on the toilet. The investigation concluded Resident #52 accidentally fell off the toilet and the adaptive raised toilet seat was lowered to accommodate Resident #52's height for safety. The hospital Discharge Summary dated 5/4/20 at 6:19 PM identified Resident #52 was treated in the emergency room for a 5 centimeter (cm) by 5 cm forehead laceration, with eight (8) sutures applied. A CT scan of the head was negative, and Resident #52 was discharged from the hospital back to the facility with directions for removal of the sutures in seven (7) days. A nurse's note dated 5/4/20 at 9:42 PM identified that Resident #52 returned from the hospital at 9:30 PM with stitches to the right side of the forehead and scrapes to bilateral knees. Review of the clinical record failed to identify Resident #52 required the use of a raised toilet seat or adaptive equipment for toileting prior to Resident #52 falling off of the toilet which had a raised toilet seat in place. An interview and clinical record review with the Director of Rehabilitation/Physical Therapist (PT) #1 on 4/13/21 at 10:00 AM identified Resident #52 was independent with ambulation without an assistive device. PT #1 further indicated that Resident #52 was independent using the bathroom and did not require any adaptive equipment (railed toilet seat) to use the toilet. Interview, clinical record review and facility documentation review with RN #4 on 4/13/21 at 1:44 PM identified Resident #52 had a recent room change, and the roommate was tall and required the adaptive equipment (raised toilet seat) to use the toilet. She indicated that Resident #52 was independent with toileting, and she completed an assessment after Resident #52's fall on 5/4/20. She observed a commode over the toilet with one handle at the time of the fall. She identified that Resident #52 did not need the adaptive equipment, as it was required for the roommate. She indicated that if Resident #52 sat on the adaptive equipment/raised toilet seat, his/her feet could not reach the floor, the equipment should have been removed after the roommate last used the bathroom and she did not know the reason it was not removed. An interview with NA #8 on 4/13/21 at 2:15 PM identified Resident #52 did not require adaptive equipment over his/her toilet seat, but the roommate did require use of the equipment. She noted Resident #52 was independent at the time of the fall 5/4/20. The roommate required staff assistance to use the bathroom and the NA assigned would bring the adaptive equipment into the bathroom for the roommate and then they should remove it when roommate was done in the bathroom. Although NA #8 was unable to identify when the roommate was last toileted, she indicated that the adaptive equipment should have been removed from the toilet after the roommate was done in the bathroom and she indicated she did not know the reason it was not removed. NA #8 indicated the adaptive equipment had to be removed, because Resident #52 did not need it and it was too high for Resident #52 to sit on the toilet safely. An interview with the DNS on 4/13/21 at 2:30 PM identified that the equipment was not required for Resident #52 to use the bathroom, and the equipment should have been removed to prevent Resident #52 from falling when trying to get off the toilet. The DNS was unable to provide a reason why the adaptive equipment had not been removed after the roommate last used the toilet and identified that the NA who last toileted the roommate should have removed the adaptive equipment. Although attempted, an interview with DNS #2 was not obtained. Although requested, a facility policy on adaptive equipment such as the use of high rise/raised toilet seats, or commodes over toilets was not provided. 2. Resident #51's diagnoses included Type 2 Diabetes Mellitus with ketoacidosis, metabolic [CONDITION(S)]. An admission Minimum Data Set, dated dated dated [DATE] identified Resident #51 had severe cognitive impairment and required extensive assist with activities of daily living care, total locomotion, and was independent with eating. A physician's order dated 4/5/21 directed finger stick for blood sugars three times daily. An observation on 4/5/21 at 10:55 AM identified RN #1 entered Resident #51's room with a point of care device. Upon further observation, a medication cup was noted on top of the medication cart with medications that included 1 tablet of Aspirin 81mg, one Multivitamin tablet, 1 tablet of [MEDICATION(S)] (a calcium channel blocker to treat hypertension) 10mg tablet, one tablet [MEDICATION(S)] (an anti-diabetic medication) 1000mg tablet and one tablet of [MEDICATION(S)] (an antidepressant medication) 12. 5mg tablet. Additionally, a blister pack of [MEDICATION(S)] 12. 5mg tablets, Aspirin 81mg bottle, and a Multivitamin bottle were also observed on top of the medication cart. The medication cart was placed outside in the hallway and out of RN #1's visual field upon entering into the room. RN #1 returned to the medication cart subsequent to surveyor intervention and properly stored all medications. An interview with RN #1 identified the medication cart should not be left unattended with medications on top. RN #1 indicated he had not intended to leave medication on top of the cart. The facility policy dated 1/1/13 for General Dose Preparation and Medication Administration directed that facility staff should not leave medications or chemicals unattended. 3. Resident #323's diagnoses included femur and clavicle fractures, history of falling, muscle weakness, and difficulty walking. An Admission Fall Risk assessment dated [DATE] identified Resident #323 had no prior history of falls and received a fall risk score of 16 indicating Resident #323 was at risk for falls. A physician's order dated 3/5/20 directed to provide the assistance of one staff member for transfers and gait with the utilization of a roller walker. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #323 was moderately cognitively impaired and required limited assistance with transfers, ambulation and toileting. The Resident Care Plan (RCP) dated 3/18/20 identified being at risk for falls. Interventions directed: to analyze the resident's previous falls to determine whether a pattern/trend could be addressed, to keep the call bell within reach, to encourage to the resident to ask and wait for staff assistance for transfers and/or toileting, to encourage the resident to transfer and change positions slowly, to keep personal items within reach, to use assistive devices properly, and to transfer the resident per physician's order. a. The nurse's note dated 5/22/21 at 1:56 P.M. identified the nurse was called to Resident #323's room at 11:40 A.M. and Resident #323 was noted to be sitting on the bathroom floor with the roller walker in front of him/her. Resident #323 indicated that she/he lost his/her balance while trying to use the bathroom. The Reportable Event Form and investigation dated 5/22/20 identified an unwitnessed fall and that Resident #323 had open back slippers. The care plan was updated to include wearing proper footwear when ambulating. Interview and review of the facility investigation and interdisciplinary fall assessment with RN #6 on 4/14/21 at 1:51 P.M. identified Resident #323 required assistance to ambulate. b. The nurse's note dated 6/7/20 at 9:39 A.M. identified Resident #323 was found on the floor next to the bed. The Reportable Event Form and investigation dated 6/7/21 identified Resident #323 had an unwitnessed fall and had slid off a pillow that had been on the chair. The Care Plan was updated to include removing pillows from the chair. Interview and review of the facility investigation and interdisciplinary fall assessment with RN #6 on 4/14/21 at 1:51 P.M. identified the investigation failed to include the last time that Resident #323 had been toileted and that the interdisciplinary fall assessment was incomplete and lacked the time of Resident #323's last void. c. The nurse's note dated 6/25/20 at 8:20 A.M. identified Resident #323 was sitting on the bathroom floor with the walker and was at the sink. Resident #323 verbalized that he /she fell . The Reportable Event investigation dated 6/25/20 at 6:00 A.M. identified Resident #323 had an unwitnessed fall and had slid off the toilet. The care plan was updated and repeated the intervention to call staff for assistance. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 P.M. failed to identify the last time Resident #323 was toileted and failed to identify a new revision in the care plan with an intervention to prevent future falls. The care plan intervention continued with a previous intervention for Resident #323 to continue to use his/her call bell. Interview with Corporate Nurse #1 on 4/15/21 at 1:48 P.M. identified Resident #323 had been assessed by an RN, but that an Interdisciplinary Fall Assessment Form had not been completed according to facility policy. d. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #323 was moderately cognitively impaired and had declined to require extensive assistance with toileting and indicated the resident was subsequently placed on the rehabilitation case load. The nurse's note dated 9/18/20 at 4:19 P.M. identified that Resident #323 was found on the bathroom floor. The Reportable Event investigation dated 9/18/20 identified Resident #323 had an unwitnessed fall at 12:00 P.M. and was last toileted after breakfast by the Nurse Aide (NA). The Care Plan was updated to encourage Resident #323 to use the urinal at the side of the bed. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 P.M. failed to identify Resident #323 had been toileted from the time breakfast ended, approximately 9:00 A.M., until the fall occurred at 12:00 P.M. RN #6 identified Resident #323 should have been toileted prior to lunch. Review of the care plan intervention for the fall identified Resident #323 should be encouraged to use the urinal. RN #6 indicated this was an inappropriate intervention as Resident #323 required assistance with transfers, standing, ambulation, and toilet use. RN #6 was unable to find any appropriate new fall interventions. Interview with Corporate Nurse #1 on 4/15/21 at 1:48 P.M. identified Resident #323 had been assessed by an RN, but that an Interdisciplinary Fall Assessment Form had not been completed according to facility policy. e. The nurse's note dated 9/20/20 at 2:19 A.M. identified Resident #323 had an unwitnessed fall and was found on the floor, next to his/her bed, and indicated that she/he had lost his/her balance after standing. The Reportable Event investigation dated 9/20/20 identified that she/he was walking and slipped. The Care Plan was updated and repeated the same intervention to use the walker with transfers and ambulation and reinforce the need to call for assistance. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 P.M. failed to identify where Resident #323 had been going. RN #6 indicated that the care plan repeated the intervention to use his/her call bell and repeated the intervention Resident #323 should rise slowly from lying to sitting position. RN #6 was unable to identify a new fall prevention intervention to prevent future falls. f. The nurse's note dated 9/27/20 at 2:52 P.M. identified Resident #323 had an unwitnessed fall and was on the bathroom floor and unable to state what happened. Resident #323 was noted to be having difficulty standing. The physician was notified and staff was directed to obtain an x-ray of the left hip and knee. The Reportable Event investigation dated 9/27/21 identified Resident #323 was unable to bear weight on his/her left foot. The care plan was updated to include the use of non-skid strips near the bed and in the bathroom. Review of the radiology report dated 9/27/20 identified a right femoral neck fracture with modest angulation and displacement. The physician's order dated 9/27/20 directed the facility to send Resident #323 to the hospital for further evaluation. Review of the Hospital Discharge Summary dated 10/1/20 identified Resident #323 had his/her required right femoral hemiarthroplasty surgical repair. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 PM with RN #6 identified that upon Resident #323 return to the facility s/he required a full mechanical lift to transfer and the use non-skid strips was never changed to reflect his/her current transfer status. Additionally, new interventions were either inappropriate or repeated and did not address Resident #323's need to use the bathroom. RN #6 was unable to identify that Resident #323's initial admission full care plan dated 3/18/20 to review and analyze the root cause of the resident's falls had never been completed as Resident #323's need to use the bathroom had not been addressed. g. A readmission Fall Risk assessment dated [DATE] identified Resident #323 had fallen 1 to 2 times over the past six months and received a score of 17 indicating Resident #323 was at risk to fall. The readmission physician's orders directed to medicate Resident #323 for pain with [MEDICATION(S)] 50 Milligrams (MG) for severe pain and 25 MG for moderate pain every 6 hours as needed. A physician's order dated 10/2/20 directed to use a mechanical lift with two staff members for transfers. The nurse's note dated 10/5/20 at 6:14 A.M. identified Resident #323 was restless with periodic attempts to climb out of bed and was redirected with success. The nurse's note dated 10/7/21 at 12:11 A.M. identified Resident #323 was found on the floor next to his/her bed at 9:45 A.M. and indicated Resident # 323 was complaining of bilateral hip pain. Additionally, Resident #323 continued to attempt to get out of bed throughout the shift, even with constant reminders. The Reportable Event investigation dated 10/7/20 identified Resident #323 had an unwitnessed fall and was attempting to use the bathroom. The care plan was updated to keep Resident #323 at the nurse's station when out of bed. A physician's order dated 10/7/21 directed to obtain a two-view bilateral hip x-ray which was subsequently negative. h. The nurse's note dated 10/8/20 at 3:24 P.M. identified Resident #323 had an unwitnessed fall and was found sitting on the floor in front of his/her wheelchair next to his/her bed. Resident #323 was noted with an abrasion to the right lateral wrist. Resident #323 was placed back into his/her wheelchair. The resident made multiple attempts to get up unassisted. The Reportable Event investigation dated 10/8/20 identified that Resident #323 had an unwitnessed fall and was trying to walk to the bathroom. Additionally, a staff statement dated 10/8/20 at 12:50 P.M. identified Resident #323 was provided the assistance of three staff members and a gait belt to be transferred back to bed. The care plan was updated and repeated the intervention to keep Resident #323 near the nurse's station. A physician's order dated 10/8/21 directed to obtain a bilateral hip x-ray which was subsequently negative. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 P.M. indicated the intervention from the previous day, 10/7/20, to keep Resident #323 near the nurse's station when out of bed, had not been followed as Resident #323 had an unwitnessed fall in his/her room. Additionally, the investigation into Resident 323's fall identified the facility staff had not transferred Resident #323 according to the physician's order dated 10/2/20, via mechanical lift, but used three staff and a gait belt to stand him/her and place him/her back to bed. RN #6 identified the facility has a mechanical lift that goes to the floor and the mechanical lift should have been used for Resident #323's transfer. A physician's order dated 10/15/20 directed the assistance of two staff with a roller walker for ambulation. i. The nurse's note dated 10/24/20 at 10:36 P.M. identified Resident #323 had an unwitnessed fall and was found on the floor next to the bed in front of his/her recliner. The resident was assisted back to bed and reminded to use the call bell. The Reportable Event investigation dated 10/24/20 identified that Resident #323 had an unwitnessed fall and was found sitting on the floor and the Care Plan was updated with the repeat interventions to encourage the resident to call for assistance with all transfers. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 P.M. indicated the previous intervention to call for assistance had been repeated. Interview with Corporate Nurse #1 on 4/15/21 at 1:48 P.M. identified Resident #323 had been assessed by an RN, but that an Interdisciplinary Fall Assessment form had not been completed according to facility policy. j. The nurse's note dated 11/1/20 at 9:25 P.M. identified Resident #323 had an unwitnessed fall, was found on the floor at 2:55 P.M., and was assisted back onto the wheelchair. The Reportable Event investigation dated 11/1/20 identified Resident #323 had voided last on 11/1/20 and had not walked in months. The Care Plan was updated to offer toileting after lunch. A physician's order dated 11/1/21 directed to obtain a bilateral hip x-ray which was subsequently negative on 11/2/20. Review of the nurse's note dated 11/21/20 at 9:07 A.M. identified Resident #323's right shoulder with a lump, was warm to touch, not painful and noted with discoloration of the skin. The area under Resident #323's right armpit had discoloration but was not painful to touch and did not have increased warmth. The physician was notified and directed an x-ray of the right shoulder. Review of the nurse's note dated 11/21/20 at 10:14 A.M. identified that the right shoulder X-ray was performed at 10:00 A.M. and a finding of an acute fracture was present in the distal aspect of the right clavicle with minimal displacement and soft tissue swelling. Review of the nurse's note dated 11/21/20 at 2:46 P.M. identified Resident #323 was sent out to the hospital around 11:45 A.M. Review of the Reportable Event and investigation dated 11/21/20 identified that the event occurred on 11/20/20. Interview with Physician #2 on 4/15/20 at 1:18 P.M. identified that clavicle fractures are resultant from some sort of trauma to the area. Physician #2 identified that she/he disagreed with the original report that Resident #323's fracture was acute and that it could have occurred 2 to 3 weeks to months ago. Physician #2 identified that the disruption of the AC joint implied torn ligaments, an indication of an old injury, possibly chronic sub-union. Interview and review of the facility investigation and Resident Care Plan with RN #6 on 4/14/21 at 1:51 P.M. identified it was never determined what time Resident #323 was last toileted on 11/1/20. RN #6 indicated that of the ten falls that Resident #323 had in six months, most falls had occurred as a result of Resident #323 needing to use the bathroom. RN #6 indicated that Resident #323's toileting needs had not been addressed until 11/1/20 when she/he was offered toileting after lunch. Review of the facility Fall Minimizing Risk policy identified, in part, that Residents who experience a fall will be evaluated following the occurrence using the interdisciplinary assessment tool to identify the potential causes of the fall. An individualized care plan will be developed and updated as needed to identify interventions to prevent falls and minimize injuries. All falls will be reviewed monthly and as needed to identify trends and any common causes.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 8 residents (Resident #55) reviewed for accidents, the facility failed to implement interventions to ensure the resident's lower extremities were protected from repeated injury and/or for 2 of 5 nursing units reviewed for environment, the facility failed to maintain safe water temperatures. The findings include: 1. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/27/17 identified Resident #55 was at risk for falls due to weakness, preferred not to wear socks at all, refused to wear proper footwear during transfers and utilized a power wheelchair. Interventions included to encourage Resident #55 to wear proper footwear during transfers, educate the resident on importance of wearing slipper socks or proper footwear, remind the resident to be mindful and more aware of surroundings when going through doorways when using the power wheelchair. The quarterly MDS dated [DATE] identified Resident #55 had moderately impaired cognition, required supervision with locomotion on unit and was independent with locomotion off unit. A reportable event form dated 3/15/18 identified that Resident #55 reported he/she hit his/her left 5th toe while attempting to get out of the friendship room while in the power wheelchair. The facility investigation dated 3/15/18 identified that Resident #55 was observed going through doorway of friendship room, and hitting his/her left foot against doorway. The investigation indicated that the physical therapist adjusted the residents left lower extremity on the leg rest to protect the leg. Additionally, the investigation identified Resident #55 was independent in the power wheelchair, and wore no footwear per his/her request and preference. Interventions included to remind Resident #55 to be more aware of his/her surroundings when going through doorways when in power wheelchair. A nurse's note dated 3/15/18 at 9:21 PM identified that at 3:30 PM a physical therapist reported that Resident #55 hit his/her foot while attempting to get out of the friendship room in his/her electric wheelchair. Resident #55 stated that he/she hit left foot fifth toe on the doorway. Resident #55 had no socks or shoes on at the time of incident. Resident #55 stated I do not wear shoes or socks. Review of facility documentation identified that on 3/19/18 modifications were made to Resident #55's foot plate and his/her feet were repositioned on the plate. physician's orders [REDACTED]. A reportable event form dated 5/18/18 identified Resident #55 was maneuvering his/her power wheelchair in a doorway and bumped his/her left foot into the wall. A statement by OT #1 dated 5/18/18 at 1:00 PM identified Resident #55's left foot was completely off the extended footplate while Resident #55 was maneuvering in the power wheelchair, and the resident hit his/her foot into the wall near bathroom door. Review of the facility investigation identified that Resident #55 was independent with using power wheelchair in room and/or hallways and needed frequent reminders to position feet on footrest. Intervention included to remind Resident #55 to be mindful when using power wheelchair. Review of facility documentation identified that on 6/20/18, the speed of Resident #55's power wheelchair adjusted by the vendor. A reportable event form dated 6/26/18 identified that Resident #55 sustained a skin tear to left second toe when entering room in the power wheelchair. Review of the facility investigation identified that Resident #55 reported that he/she bumped his/her left foot while entering his/her room while in the power wheelchair which resulted in an injury to left second toe. Resident #55 had no footwear on at the time while using the power wheelchair per Resident #55's request. Intervention included to apply gripper socks to bilateral lower extremities when in power wheelchair out of room, and continued education regarding awareness of surroundings, foot placement and asking for assistance. A nurse's note dated 6/26/18 at 4:22 PM identified that Resident #55 bumped his/her foot while entering his/her room while in the power wheelchair. A scant amount of blood noted to left second toe with small hairline opening. The area was approximated with steri strips and covered with a band aid. Review of facility documentation identified that on 7/20/18, a new back was placed on Resident #55's power wheelchair due to the residents increased leaning toward the right side, however, Resident #55 was unable to tolerate it due to discomfort. A reportable event form dated 7/23/18 at 2:15 PM identified that a large amount of blood was found on the floor and on Resident #55's right lower leg with the unna boot in place while the resident was seated in the power wheelchair. A statement by NA #5 dated 7/23/18 identified that NA #5 was noticed a pool of blood under Resident #55's chair, and that the resident was wearing non-skid socks. Review of the facility investigation identified that Resident #55 was unaware his/her leg was bleeding, and was unable to recall what had happened. When the unna boot was removed, Resident #55 was noted with 4.0cm laceration to the side of the right foot. The nurse's note dated 7/23/18 at 3:09 PM identified Resident #55 was found with blood on the right ankle area of the unna boot, and on the floor. The area was cleaned and upon assessment, measured approximately 4.0cm in length. The depth could not be determined, and the area could not be approximated with sutures. Subsequent to physician notification, 911 was called and Resident #55 was transported to the hospital. Nurse's note dated 7/23/18 at 8:08 PM identified that Resident #55 returned from hospital at approximately 8:00 PM via ambulance. Review of the discharge summary dated 7/23/18 identified that Resident #55 presented to the hospital after sustaining a laceration to his/her right foot, which the resident was not aware how he/she sustained the injury. Resident #55 indicated he/she did not feel any pain to area due to [MEDICAL CONDITION] from [MEDICAL CONDITION]. Resident #55 received 7 sutures to the medial aspect of the right foot, and was prescribed Keflex 500 mg 4 times daily for 5 days. Additionally, the dressing was to be changed daily, along with topical [MEDICATION NAME] for 3 days then stop [MEDICATION NAME]. A reportable event form dated 12/2/18 identified that Resident #55 was noted with abrasion measuring 3.0cm to right great toe. The investigation identified that interventions to prevent a reoccurrence included to encourage Resident #55 to wear footwear. A Nurse's note dated 12/2/18 at 3:37 PM identified that Resident #55 was noted with abrasion to right great toe measuring 3.0cm in diameter. Resident #55 was unaware how the injury occurred and indicated the resident was non-compliant with footwear and/or non-skid socks. Education was provided to Resident #55 and Resident #55 agreed to try. Observation on 12/11/18 at 11:07 AM identified a nurse aide positioned Resident #55 in the power wheelchair with the foot on the platform. Resident #55 was observed to move his/her legs which caused his/her back of his/her feet/heel to rest directly on the edge of the platform. Interview with Resident #55 at the time of observation identified he/she was comfortable in the power wheelchair and the staff positioned his/her feet on the foot platform, but the feet come off. Observation of Resident #55's lower extremities identified his/her legs were wrapped with ace wraps, his/her feet were purple, and there was a scab on right large toe. Interview with NA #5 on 12/17/18 at 11:55 AM identified that although Resident #55 can move his/her foot of off the wheelchair leg rest, the resident cannot place his/her legs back on the wheelchair leg rest. Interview with LPN #4 on 12/17/18 at 3:17 PM identified that when asked, Resident #55 was unable to lift his/her foot. Interview with NA #7 on 12/18/18 at 12:30 PM identified that Resident #55 was unable to move and/or lift his/her feet by him/herself while in the power wheelchair. NA #7 indicated that Resident #55/s feet slide out sometimes when he/she repositions and/or moves him/herself in the power wheelchair. Interview with MD #2 on 12/18/18 at 12:35 PM identified that the facility staff should implement measures to try and protect Resident #55's feet. MD #2 identified that he/she was approached regarding the issue of Resident #55 injuring his/her feet and/or asked what should have been done to prevent Resident #55 from hitting and/or bumping into things. Interview with the DNS on 12/18/18 at 11:30 AM identified that although staff properly position Resident #55 in the power wheelchair, within 30 minutes, his/her foot would be of off the wheelchair foot plate. The DNS identified that Resident #55 was educated multiple times, however, the issue is positional. Subsequently, Resident #55 had a large platform placed on his/her power wheelchair which seemed to be working. Interview with PT #1 on 12/18/18 at 1:30 PM identified that Resident #55 was encouraged to wear socks, and the power wheelchair speed was lowered twice, the power wheelchair foot plate was extended and padding was added. Also, a new back was placed on the power wheelchair, however it was removed due to Resident #55's refusal. Although the facility was aware that Resident #55 had sustained injuries to the lower extremities on 3/15, 5/18 and 6/26/18 while in the power wheelchair because he/she would mover his/her feet off the protective footrests/footplate, and accidently bump the power wheelchair into the walls/doorways, the facility failed to protect Resident #55 from continued injury to his/her lower extremities. Subsequently, on 7/23/18, while in the power wheelchair, Resident #55 sustained a 4.0cm laceration to the right foot that required 7 sutures to close and Keflex 500 mg 4 times daily for 5 days for infection prevention. 2. Observation on 12/11/18 at 3:12 PM with the Corporate Electrician the following hot water temperatures in resident rooms; room [ROOM NUMBER] 136.1 F. room [ROOM NUMBER] 136.2 F. Subsequent to surveyor observation, on 12/11/18 at 3:15 PM, the Administrator and Corporate Nurse, RN # 5 were notified of the high hot water temperature. Observation on 12/11/18 at 3:50 PM identified the hot water temperature in the bathroom of room [ROOM NUMBER] was noted to be 146.3 F. Observation on 12/11/18 at 3:55 PM identified the hot water temperature in the bathroom of room [ROOM NUMBER] was noted to be 136.1 F. Subsequent to surveyor inquiry, the facility placed signs at all water faucets warning of high hot water temperatures, resident showers were put on hold, staff and residents were educated to use caution when using hot water. Additionally, the facility monitored hot water temperatures hourly from 12/11/18 at 5:00 PM through 12:00 PM on 12/12/18. Observation on 12/12/18 at 8:55 AM identified a hot water temperature of 112.2 F in room [ROOM NUMBER]. Interview with the Director of Maintenance on 12/17/18 at 4:10 PM identified he/she checks the water temperature in the morning when staff are providing showers and adjust the temperature to make sure it's the correct temperature. The Director of Maintenance indicated he/she does not check the water temperatures any other time of the day. Additionally, the hot water system was serviced on 12/13/18 and 12/14/18 to include replacement and cleaning of valves and tempering valve.

Based on a review of clinical records and interviews, for one of three residents reviewed with abnormal laboratory results (Resident #1), the facility failed to accurately report a critical laboratory result to the physician and/or practitioner resulting in a delay in treatment. The finding included: Resident #1's [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition, required extensive assistance with mobility and ADL's and was non ambulatory. Review of a care plan dated 2/26/18 identified that the resident was at risk for cardiac issues related to [MEDICAL CONDITIONS], and hypertension. Interventions included to be aware of symptoms of heart failure (including) crackles, abnormal heart sounds, obtain labs as ordered and report abnormal results, and check blood pressure (BP) daily prior to administering cardiac medications. A laboratory report dated 2/27/18 identified that on 2/27/18 at 1:56 PM, RN #1 was informed that the resident's potassium level was 6.3 mmol/L (Normal 3.5-5.1 mmol/L). Review of the short peripheral catheter physician's orders [REDACTED].#1 directed in part, to administer intravenous (IV) D5NS at 100 ml/hour for 3 Liters. APRN #1 further directed to administer [MEDICATION NAME] 30 grams orally one time STAT noted on the physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of a laboratory report dated 2/27/18 identified that the resident's Potassium level was 7.0 mmol/L. The report identified that the results were verified, called to, and read back to RN#2 at 10:40 PM. Review of the resident's clinical record identified a fax cover letter from RN#2 to MD#1 dated 2/27/18 and timed at 10:45 PM. The fax identified that Resident #1's STAT potassium result was 6.0 mmol/L. Review of RN#2's progress notes dated 2/27/18 initiated at 10:56 PM and completed at 11:56 PM, identified that MD#1 called the facility with an order to hold the previous order to give [MEDICATION NAME] and IV D5 NS order and do a stat lab BUN, result is 6.0, lab to fax hard copy to facility, MD#1 updated, waiting call back. A linked nurse's note identified that STAT lab potassium of 6.0 was called to APRN#2 with an order to continue orders of IV D5NS and [MEDICATION NAME]. The note failed to identify the specific times and/or accurate account of the events that occurred and/or the accurate results of the resident's potassium. Review of a physician's orders [REDACTED].#2 to RN #2 that directed to give [MEDICATION NAME] 30 grams and start IV D5 hydration. A nurse's note dated 2/27/18 identified that at approximately 11:30 PM, RN#3 was called to assess Resident #1. RN#3 identified that the resident had no apical pulse, no blood pressure and no respirations. Pupils were fixed and dilated. The resident was pronounced at 11:36 PM. Interview with RN #2 on 3/20/18 at 4:30 PM identified that on 2/27/18 at 4:15 PM, when she arrived to supervise for the 3 PM-11PM shift, she was informed that Resident #1 was waiting for an IV start and [MEDICATION NAME]. RN #2 indicated that although she was unable to recall the exact time, sometime later, MD#1 called and said to get a STAT potassium level and do not start the IV or [MEDICATION NAME] until the results were in. RN #2 stated that when the results of the potassium level were called in, she called MD #1 but there was no answer so she called the on call APRN and reported the results. Review of the resident's record and initial interview with RN#2 identified that she reported the resident's potassium of 6.0 to APRN #2 as soon as she was informed. Subsequent to surveyor inquiry and review of the laboratory report dated 2/27/18 at 10:40 PM identified that the resident's potassium was 7.0 (not 6.0) as RN #2 initially stated. RN #2 stated she must have made a documentation error in the record as she reported the results that were printed on the laboratory slip. Interview with APRN #1 on 3/21/18 at 2:30 PM and review of APRN #2's on call report from 2/27/18 identified that at 11:16 PM, APRN #2 was informed that Resident #1's repeat potassium level was 6.0 and APRN #2 directed to give [MEDICATION NAME] 30 grams and start IVF D5 as previously ordered. During the interview, APRN #1 indicated that if RN #2 reported that the resident's potassium was 7.0 rather than 6.0, she would expect an EKG to be performed and the resident would have been sent to the emergency room . Interview with MD #1 on 3/21/18 at 11:45 AM stated he was notifed that the resident's critical potassium level of 7 was erroneously reported on 2/27/18, however, did not feel this contributed to the resident's death.

Based on clinical record review, interviews, and review of facility documentation, for one of one sampled residents, (Resident #30) reviewed for choking, the facility failed to provide adequate supervision to a resident that required a specialized diet and/or follow a functional maintenance program to ensure safety of oral intake. The findings include: a. Resident #30's [DIAGNOSES REDACTED]. The Speech Therapist (SLT) Progress and Discharge Summary dated 6/27/16 identified Resident #30 was consuming mechanical soft solids and thin liquids without overt signs and symptoms of aspiration. Resident #30 demonstrated some independent carry over of safe feeding strategies, but required support from caregivers to utilize others. Therapist to recommend supervised dining to maximize environmental cues. Discharge summary identified that speech therapy designed a Functional Maintenance Program (FMP) for caregivers to follow. FMP included the following: 1. Place upper and lower dentures, 2. Seat resident in the dining room whenever possible, 3. Cut the resident's solids into quarter size pieces, 4. Cue the resident to feed at a slow pace; have the resident place the utensil down in between bites in order to prevent him/her from spooning more into mouth before swallowing what's already in it, 5. Cue the resident to alternate liquids and solids and to end meals with liquid wash, 6. Supervise thorough oral care, including denture maintenance, twice a day. A Restorative-Functional Maintenance Program dated 6/27/16 identified Resident #30's functional status at discharge from therapy and instructions included Nurse Aide (NA) #1's signature dated 6/27/16. The quarterly Minimum Data Set ((MDS) dated [DATE] identified Resident #30 with impaired short and long term memory, severely impaired cognitive skills for daily decision making, and required supervision, one person physical assistance for feeding. The Resident Care Plan dated 4/13/17 identified Resident #30 with dementia and dysphagia with interventions including: provide diet as ordered, monitor po intake/tolerance, SLT eval/treatment as neede and follow the functional maintenance program for speech-aspiration precautions. The physician's orders [REDACTED]. The Nurse's Note dated 6/27/17 identified during morning med pass, at approximately 9:00 AM the nurse was alerted by a nurse aide that Resident #30 was experiencing difficulty breathing. Upon approaching the resident, who was rolling her W/C independently in the hallway, near his/her room, obvious symptoms of respiratory distress were observed; bluish facial discoloration, along with gasping of air; coughing attempts were observed. The Heimlich maneuver was performed. Resident #30 started coughing up some eggs, but he/she swallowed them back immediately. Supervisor arrived and oxygen was applied and the physician (MD) that was present in the facility ordered the resident be transferred to the ER. Inter-Agency Patient Referral Report dated 6/29/17 identified Resident #30 was noted to have a witnessed choking event and was hypoxic on admission. Resident #30 was hospitalized (from 6/27/17-6/29/17) with a [DIAGNOSES REDACTED]. Review of the facility's investigation identified a written statement from NA #1 dated 6/27/17 reflecting that at approximately 9:00 AM he/she saw Resident #30 coming out of his/her room holding his/her chest and asking for help. Statement identified that NA #1 immediately alerted LPN #2 who performed the Heimlich Maneuver on the resident. Written statement from LPN #2 dated 6/27/17 identified that he/she was alerted by NA #1 that Resident #30 was having difficulty breathing. LPN #2 indicated in the statement that he/she performed the Heimlich Maneuver and the resident coughed up some egg. Written statement from RN #1 dated 6/27/17 identified that he/she was alerted that Resident #30 was having difficulty breathing. RN #1's statement indicated that he/she observed the resident's breakfast tray with a small amount of scrambled eggs on the plate with a soft donut. Statement further identified that Resident #30 had no dentures in his/her mouth and when RN #1 inquired why not, NA #1 reported removing them when Resident #30 started to have respiratory distress. Interview with NA #1 on 10/31/17 at 10:58 AM identified that he/she was assigned Resident #30 on the morning of 6/27/17. NA #1 identified that morning he/she provided Resident #30 with a shower and the resident was in his/her room when NA #1 delivered the breakfast tray, set up the tray and exited to the room to pass juices to the other resident's on the unit. NA #1 indicated that he/she was passing juices when he/she saw Resident #30 coming out of his/her room and was having trouble breathing and was turning blue. When asked why the resident did not have his/her dentures at the time of the choking incident, NA #1 identified that Resident #30 had removed them when he/she started to have difficulty breathing. NA #1 indicated he/she did not see Resident #30 remove the dentures, but they were on the overbed side table and NA #1 recalls putting the dentures in Resident #30's mouth before breakfast. Interview with Director of Rehab on 10/31/17 at 11:53 AM identified a Functional Maintenance Program (FMP) is a program designed by the speech therapist upon discharge from skilled services for the staff to follow, indicating the FMP should be written on the resident's care plan and on the nurse aide care card. Review of the Individualized Resident Assignment identified Resident #30 was on aspiration precautions and Resident #30 should eat in the dining room for all meals. Subsequent interview with NA #1 on 10/31/17 at 12:03 PM identified that he/she was aware that Resident #30 was supposed to eat all meals in the dining room, however he/she did not transfer Resident #30 to the dining room and provided Resident #30 with the breakfast tray on the morning of 6/27/17 because he/she was too busy on the unit. NA #1 identified that although he/she frequently complains to administration about not being able to get his/her work done on the unit, he/she did not specifically tell the Charge Nurse and/or the Supervisor that he/she was not able to transfer Resident #30 to the dining room. When asked if he/she received any counseling following the incident, NA #1 identified no he/she had not and was just told not to do it again. Interview with RN #1 on 10/31/17 at 12:40 PM identified that per his/her written statement Resident #30 did not have his/her dentures in at the time of the choking episode, indicating that NA #1 had reported that the nurse aide was the one that removed the dentures (despite NA #1 reporting to the surveyor that the resident had removed them.) Interview with LPN #2 on 11/1/17 at 9:28 AM identified that NA #1 had not reported that he/she was not able to transfer Resident #30 to the dining room on the morning of 6/27/17. LPN #2 identified that he/she also noted Resident #30 had no dentures in at the time of the choking incident, recalling the dentures were on the overbed side table. LPN #2 indicated that NA #1 had reported that Resident #30 removed the dentures on his/her own. LPN #2 further indicated that he/she was aware that Resident #30 was supposed to eat in the dining room. Interview with the Director of Nursing Services (DNS) on 11/1/17 at 12:30 PM identified that Functional Maintenance Programs are communicated to the staff as recommendations from speech therapy and details of the program should be identified on the Resident Care Plan and on the Resident Care Card. DNS indicated that staff members (including NA #1) were not provided with education and/or discipline following the incident because she was not aware that Resident #30 required supervision with eating and/or had a Functional Maintenance Program in place. DNS further identified that if NA #1 was unable to transfer Resident #30 to the dining room on the morning of 6/27/17 he/she should have reported that to the Charge Nurse and/or Supervisor. The facility's Functional Maintenance Nursing Program identified that residents that transition from therapy or no longer require a skilled service for a particular treatment modality or who have had a functional decline and have the potential for improvement that meet the functional nursing criteria will be assigned a Functional Maintenance Program. Nursing staff (licensed and nursing assistants) will be educated/trained on the Functional Program. The nursing assistant assigned to the resident for that day will be responsible for carrying out the treatment plan and documenting the resident's participation.

Based on review of the clinical record, facility documentation, and staff interviews for one of three sampled resident's reviewed for new admission (Resident # 1), the facility failed to verify physician orders [REDACTED]. The findings include: Resident #1 was admitted to the facility on [DATE] at 2:30PM with [DIAGNOSES REDACTED]. The admission interagency referral (W-10) and discharge summary dated 4/18/17 at 1:23PM identified Resident #1 failed a swallow study with speech therapy and self-removal of a NG tube (Dobb Hoff tube) at the hospital. The discharge plan was for conservative goals of care and comfort approach. The discharge summary further identified Resident #1's medications were adjusted, was started on pleasure foods, and the current plan was to transition the resident to rehabilitation to determine if mobility could be restored with conservative management. The discharge medications included; [MEDICATION NAME] 60mg po qd, Magnesium Oxide 400mg po bid, [MEDICATION NAME] 3mg at hs, [MEDICATION NAME] 150mg po qd, [MEDICATION NAME] 10mg po QD last given 4/17/17 at 6:42PM and due at 6:00PM on 4/18/17. Further review of the interagency referral and discharge summary identified Resident #1's blood pressure on discharge was 120/60 mm/Hg. Review of the admission orders [REDACTED] 200-250=2 units 251-300=4 units 301-350=6 units 351-400=8 units 401-450=10 units 451-500=15 units Over 500 give 20 units and call the physician. The admission nurse progress note dated 4/18/17 at 6:30PM identified Resident #1 arrived at the facility at 2:30PM and upon assessment was noted to have warm dry skin, with tenting noted greater than 3 seconds, tongue appeared to be discolored with white patches and dry, and the resident's blood pressure was 150/70 mm/Hg. Further review identified oral care would have to be provided by nursing staff because the resident did not display successful attempts to swallow. An RN bedside swallow evaluation was performed by RN#1 which included a tiny amount of applesauce placed on the resident's lips to stimulate response, however, the resident was noted to keep the contents in the mouth for a minute even when continued prompting from RN#1, resulting in the need to suction the residents mouth to remove food that was pocketed during the oral assessment. The care plan dated 4/18/17 identified a risk for aspiration due to difficulty swallowing, and at risk for dehydration related to altered intake process, cognitive state with interventions which included follow up with SLP as needed for safe swallowing techniques, monitor lung sounds, be aware of coughing, fever, wheezing, and watery eyes due to aspiration and to notify the MD as needed. A physician order [REDACTED]. A blood sugar was not obtained on 4/18/17 at 8:30PM. A review of the April 2017 MAR indicated [REDACTED]. Interview with LPN #1 on 4/28/17 at 1:00PM identified she did not provide Resident #1 anything by mouth, including medications as directed by RN #1 and was not aware she needed to obtain a blood sugar reading at 8:30PM as she did not review the medication or treatment kardexes by the end of her shift at 11:00PM. Interview with MD #1 on 4/28/17 at 1:30PM identified he/she does not recall ever receiving any phone calls or faxed orders on 4/18/17, with the exception of a fax sent that morning letting him know he/she had an admission coming later that day. MD #1 further identified the normal practice regarding new admissions was as soon as the resident arrived with the interagency referral, the facility would fax him/her the W-10 and/or the physician orders [REDACTED]. Further interview with MD #1 identified if he/she leaves the office and is not on call, the facility calls the on-call physician. MD#1 identified he/she was not made aware on 4/18/17 that Resident #1 did not receive anything PO, including medications, exhibited dry skin with tenting for 3 seconds, and an elevated blood pressure. MD #1 identified if he/she knew about the swallowing concerns along with the elevated B/P he would have directed to provide topical medications to lower the blood pressure. Interview with APRN #1 on 5/1/17 at 9:00AM identified he/she was on vacation 4/18/17 and did not return until late that evening. APRN#1 identified she recalled seeing the fax orders dated 4/18/17 on 4/19/17 and approved them knowing she/he would be in the facility within an hour. APRN #1 identified it is the responsibility of the licensed staff to call MD#1 or the on-call physician to obtain any orders and clarify any discrepancies. APRN #1 further identified he/she was not made aware of Resident #1's admission until the morning of 4/19/17 and it is the responsibility of the licensed staff to notify the physician regarding any abnormalities that are identified upon nursing assessment. Interview with RN#1 on 5/1/17 at 10:30AM identified on 4/18/17 she was involved with Resident #1's admission assessment for two and a half hours and felt it was inappropriate to leave the room with family present to seek out the Speech Therapist. RN #1 identified after she completed the RN admission assessment including a bedside swallow evaluation and Advanced Directive's form with the family, she felt MD#1 had probably left the office for the day and the Speech Therapist had left the facility for the day. RN#1 documented telephone orders from MD#1 for blood sugar checks bid x 7days, mouth care q 2hrs and suction q 2hrs while awake and prn for saliva, NPO until seen by Speech Therapy, neuro checks q shift x 10days, [MEDICAL CONDITION] precautions, aspiration precautions, and frequent repositioning /offloading heels. RN#1 further identified she did not call to speak to the physician to report the blood pressure elevation, results of her bedside swallowing evaluation and/or Resident #1's signs and symptoms of dehydration. Further interview identified MD#1 did not approve the above telephone orders and the signed fax was not returned to the facility for approval until seen by APRN#1 on 4/19/17.

Based on review of the clinical record, facility documentation, and staff interviews for one of three sampled resident's reviewed for new admission to the facility (Resident # 1), the facility failed to notify the physician to verify new admission orders [REDACTED]. The findings include: Resident #1 was admitted to the facility on [DATE] at 2:30PM with [DIAGNOSES REDACTED]. The admission interagency referral (W-10) and discharge summary dated [DATE] at 1:23PM identified Resident #1 failed a swallow study with speech therapy and self-removal of a NG tube (Dobb Hoff tube) at the hospital. The discharge plan was for conservative goals of care and comfort approach. The discharge summary further identified Resident #1's medications were adjusted, was started on pleasure foods, and the current plan was to transition the resident to rehabilitation to determine if mobility could be restored with conservative management. The discharge medications included; [MEDICATION NAME] 60mg po qd, Magnesium Oxide 400mg po bid, [MEDICATION NAME] 3mg at hs, [MEDICATION NAME] 150mg po qd, [MEDICATION NAME] 10mg po QD last given [DATE] at 6:42PM and due at 6:00PM on [DATE]. Further review of the interagency referral and discharge summary identified Resident #1's blood pressure on discharge was ,[DATE] mm/Hg. The admission nurse progress note dated [DATE] at 6:30PM identified Resident #1 arrived at the facility at 2:30PM and upon assessment was noted to have warm dry skin, with tenting noted greater than 3 seconds, tongue appeared to be discolored with white patches and dry, and the resident's blood pressure was ,[DATE] mm/Hg. Further review identified oral care would have to be provided by nursing staff because the resident did not display successful attempts to swallow. An RN bedside swallow evaluation was performed by RN#1 which included a tiny amount of applesauce placed on the resident's lips to stimulate response, however, the resident was noted to keep the contents in the mouth for a minute even when continued prompting from RN#1, resulting in the need to suction the residents mouth to remove food that was pocketed during the oral assessment. The care plan dated [DATE] identified a risk for aspiration due to difficulty swallowing, and at risk for dehydration related to altered intake process, cognitive state with interventions which included follow up with SLP as needed for safe swallowing techniques, monitor lung sounds, be aware of coughing, fever, wheezing, and watery eyes due to aspiration and to notify the MD as needed. Interview with MD #1 on [DATE] at 1:30PM identified he/she does not recall ever receiving any phone calls or faxed orders on [DATE], with the exception of a fax sent that morning letting him know he/she had an admission coming later that day. MD #1 further identified the normal practice regarding new admissions was as soon as the resident arrived with the interagency referral, the facility would fax him/her the W-10 and/or the physician orders [REDACTED]. Further interview with MD #1 identified if he/she leaves the office and is not on call, the facility calls the on-call physician. MD#1 identified he/she was not made aware on [DATE] that Resident #1 did not receive anything PO, including medications, exhibited dry skin with tenting for 3 seconds, and an elevated blood pressure. MD #1 identified if he/she knew about the swallowing concerns along with the elevated B/P he would have directed to provide topical medications to lower the blood pressure. Interview with APRN #1 on [DATE] at 9:00AM identified he/she was on vacation [DATE] and did not return until late that evening. APRN#1 identified she recalled seeing the fax orders dated [DATE] on [DATE] and approved them knowing she/he would be in the facility within an hour. APRN #1 identified it is the responsibility of the licensed staff to call MD#1 or the on-call physician to obtain any orders and clarify any discrepancies. APRN #1 further identified he/she was not made aware of Resident #1's admission until the morning of [DATE] and it is the responsibility of the licensed staff to notify the physician regarding any abnormalities that are identified upon nursing assessment. Interview with RN#1 on [DATE] at 10:30AM identified on [DATE] she was involved with Resident #1's admission assessment for two and a half hours and felt it was inappropriate to leave the room with family present to seek out the Speech Therapist. RN #1 identified after she completed the RN admission assessment including a bedside swallow evaluation and Advanced Directive's form with the family, she felt MD#1 had probably left the office for the day and the Speech Therapist had left the facility for the day. RN#1 documented telephone orders from MD#1 for blood sugar checks bid x 7days, mouth care q 2hrs and suction q 2hrs while awake and prn for saliva, NPO until seen by Speech Therapy, neuro checks q shift x 10days, [MEDICAL CONDITION] precautions, aspiration precautions, and frequent repositioning /offloading heels. RN#1 further identified she did not call to speak to the physician to report the blood pressure elevation, results of her bedside swallowing evaluation and/or Resident #1's signs and symptoms of dehydration. Further interview identified MD#1 did not approve the above telephone orders and the signed fax was not returned to the facility for approval until seen by APRN#1 on [DATE]. Resident #1 was kept NPO without a physician order [REDACTED].#1 expired on [DATE] at 7:27PM. Review of the facility admission policy and procedure identified licensed staff will verify all admitting orders with the attending physician or Medical Director. The change in condition policy identfied all significant change in residents condition will be reported to the physician and family. If the resident's physician is not available, the covering physician shall be notified.

Based on review of the clinical record, policy and procedures and interviews for one sampled resident (Resident #1) reviewed for new admission to the facility, facility failed to provide fluids, intake and output and/or conduct subsequent hydration assessments to prevent and/or treat the resident's dehydration. The findings include: Resident #1 was admitted to the facility on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. The admission interagency referral (W-10) and discharge summary dated [DATE] at 1:23PM identified Resident #1 failed a swallow study with speech therapy and self-removal of a NG tube (Dobb Hoff tube) at the hospital. The discharge plan was for conservative goals of care and comfort approach. The discharge summary further identified Resident #1's medications were adjusted, was started on pleasure foods, and the current plan was to transition the resident to rehabilitation to determine if mobility could be restored with conservative management. Review of the admission orders [REDACTED]. The care plan dated [DATE] identified a risk for aspiration due to difficulty swallowing, and at risk for dehydration related to altered intake process, cognitive state with interventions which included follow up with SLP as needed for safe swallowing techniques, monitor lung sounds, be aware of coughing, fever, wheezing, and watery eyes due to aspiration and to notify the MD as needed. Review of the [DATE] and [DATE] intake and output report were blank. An APRN progress note dated [DATE] at 9:00 AM identified APRN #1 met with Resident #1's family and an NPO order was recommended due to the high risk for aspiration. The note further identified that after discussion with the family intravenous fluids were initiated. Interview with MD #1 on [DATE] at 1:30 PM identified he was not made aware on [DATE] Resident #1 did not receive anything PO, including medications. MD #1 further indicated he had not been made aware of the resident's admission assessment including, dry skin with tenting for 3 seconds, and an elevated blood pressure. Interview with APRN #1 on [DATE] at 9:00AM identified he/she was on vacation [DATE] and did not return until late that evening. APRN#1 identified she recalled seeing the fax orders dated [DATE] on [DATE] and approved them knowing she/he would be in the facility within an hour. APRN #1 identified it is the responsibility of the licensed staff to call MD#1 or the on-call physician to obtain any orders and clarify any discrepancies and would have expected RN#1 to discuss her/his concerns regarding swallowing and dehydration which were identified upon admission with the physician. Interview with RN#1 on [DATE] at 10:30 AM identified on [DATE] she was involved with Resident #1's admission assessment for two and a half hours and felt it was inappropriate to leave the room with family present to seek out the Speech Therapist. RN #1 identified after she/he completed the RN admission assessment including a bedside swallow evaluation and Advanced Directive's form with the family, he/she felt MD#1 had probably left the office for the day and the Speech Therapist had left the facility for the day. RN#1 documented telephone orders from MD#1 for blood sugar checks bid x 7days, mouth care q 2hrs and suction q 2hrs while awake and prn for saliva, NPO until seen by Speech Therapy, neuro checks q shift x 10days, [MEDICAL CONDITION] precautions ,aspiration precautions, frequent repositioning /offloading heels. RN#1 further identified she/he did not call to speak to the physician to report the blood pressure elevation, results of his/her bedside swallowing evaluation and/or Resident #1's signs and symptoms of dehydration. Further interview identified MD#1 did not approve the above telephone orders and that the signed fax was not returned to the facility for approval until seen by APRN#1 on [DATE]. RN#1 identified Resident #1 was kept npo as a nursing measure as a result of her bedside swallow evaluation. Resident #1 arrived at the facility on [DATE] at 2:30PM and was kept NPO for 23 hours, when IV hydration was ordered APRN following discussion with the family. Resident #1 expired on [DATE] at 7:27PM. Review of the facility Hydration protocol identified newly admitted residents will have a fluid goal of 1500cc/day ( unless otherwise ordered by the Physician) until they are assessed by the dietician. The protocol further identifie intake and output is monitored on all new admissions for up to seven days to establish a baseline by the Dietitian to determine the resident individual fluid goal. The Hydration Policy further identifies that if a resident shows signs and symptoms of dehydration that the physician, dietician and family will be notified to determine any changes to the resident's plan of care.

Based on review of the clinical records, continuous resident observations, observations, review of facility documentation, review of facility policy and interviews for six of six residents with pressure ulcers and/or at risk for pressure ulcers (Residents #14, 15, 26, 32, 133, and 173), the facility failed to provide pressure relief, repositioning and/or incontinent care, and/or failed to implement the physician's orders when wounds declined, and/or conduct a registered nurse assessment with a change in wound condition and/or failed to ensure adequate professional nursing oversight to a wound care program resulting in a finding of immediate jeopardy. The findings include: 1a. Resident #173 was admitted to the facility for a respite stay with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified that the resident was cognitively impaired, required assistance with Activities of Daily Living (ADL's) and had a stage 2 pressure ulcer on his/her coccyx. The admission assessment measured the pressure ulcer at 3.1 centimeters (cm) in length, 2.5 cm in width with a depth of .01 cm, otherwise, no other noted areas of skin impairment were identified. a.Review of physician's orders and the Treatment Administration Record (TAR) dated 11/5/16 directed to apply triad cream to the coccyx every shift and as needed, offload heels every shift, and to turn and reposition per facility protocol. Review of a facsimile communication dated 11/8/16 to physician (MD) #1 identified a request to discontinue the current treatment to the coccyx and start skin prep to peri-wound, followed by Allevyn dressing, to change every three days and as needed. A wound tracking assessment dated [DATE] measured the coccyx wound as a stage 2 pressure ulcer 2.0 cm by 1.5cm with 0.1 cm of depth. The physician agreed to the recommendations and signed the bottom of the facsimile. Review of the November physician orders, and November 2016 Treatment Administration Record (TAR) failed to reflect that the treatment was changed as requested, and approved by the physician. Interview with Registered Nurse (RN) #4 who was the facility wound nurse on 11/8/16 on 1/31/17 at 2:00 PM identified that although he/she could not recall requesting a change in Resident #173's treatment, if he/she had requested to change the treatment to skin prep and a protective dressing, the wound was most likely closed and the treatment needed to be changed to protect the area from the re-occurrence of the skin breakdown. RN#4 further identified that if the physician had signed the facsimile the order change should have been transcribed onto the physician's orders and the TAR. Interview with MD#1 on 2/1/17 at 10:30 AM identified that if/he she had signed the facsimile dated 11/8/16, it would be his expectation that the recommended treatment be written as a physician's order. b. Review of a skin and wound tracking record dated 11/8/16 identified that the resident had a stage 3 pressure area to the right ankle that was red in color, measured 1.5 cm in length, 1.5 cm in width with a depth of 0.6, with no drainage noted. Review of a facsimile communication dated 11/8/16 signed by MD #1 identified that the resident had a newly noted stage 3 pressure ulcer to the right lateral ankle measuring 1.5 cm in length, 1.5 cm in width with a depth of 0.6 cm with a request to implement rinsing the wound with normal saline, apply a Solosite dressing, and cover with Allevyn gentle border. Additionally, documentation directed to change the resident's mattress to an alternating pressure air mattress. A physician's order dated 11/8/16 directed to cleanse the right ankle wound with normal saline, apply a Solosite dressing followed by Allevyn gentle border dressing, and change every day and as needed for 10 days. The physician's orders failed to identify the order for the alternating pressure air mattress. Review of the November 2016 TAR identified the treatment to the right ankle wound was to be cleansed with normal saline, a Solosite dressing and to be covered the Allevyn dressing and should be changed on the 3:00 to 11:00 shift, but the dressing should be checked on the 7:00 AM to 3:00 PM shift and 11:00 PM to 7:00 AM shift. Further review of the TAR failed to reflect that the alternating pressure air mattress was implemented until 11/11/16 (3 days after it was ordered). Interview with RN #4 (the facility wound nurse at the time the wound was discovered) on 2/1/17 at 2:00 PM identified that he/she was asked to evaluate an area on R#173's right ankle by the charge nurse on 11/8/16. RN#4 further identified that the resident had a tan inflatable boot on the right foot, RN#4 removed the boot from the right foot, and assessed the area to be a reddened full thickness wound to the right outer ankle. RN#4 further identified that the wound was discovered at a stage 3, and identified that the resident did not have an order for [REDACTED].#4 identified that the alternating pressure mattress was a nursing intervention for the newly acquired stage 3 pressure ulcer to the right ankle. Interview with RN#9 on 2/2/17 at 1:30 PM identified that he/she could not locate any documentation in the medical record about an inflatable boot to the right foot. RN#9 identified that although there is no physician's order required to apply offloading boots, there must be documentation in the medical record of assessments in skin integrity around where the boot was applied when donning and doffing. Additionally, he/she was unable to locate any assessments completed for the right foot since admission on 11/5/16. Further, RN#9 stated that all nursing supervisors are aware that the alternating pressure mattresses are available within the facility and should be applied when the physician's order is written, but was unable to find any documentation that the mattress was applied prior to 11/11/16. Interview with MD#1 on 2/2/17 at 10:00 AM identified that it is possible that the offloading boot could have caused the stage 3 pressure ulcer and it would be his/her expectation that the air mattress be in place when it was ordered. Interview with Person #1 on 1/31/17 identified that when he/she dropped of his/her family member for the respite stay, he/she brought a tan offloading boot with the resident's belongings. Review of the wound intervention policy identified in part, that pressure distribution mattresses are available for all beds, and to apply and remove splints or similar devices as ordered and to note the condition of the skin. c. Review of an admission assessment date 11/5/16 did not identify any areas of impaired skin integrity and/or abnormalities to Resident #173's feet and/or toes. Review of a skin/wound tracking record dated 11/9/16 identified that the resident had a reddened intact callus on the right 4th inner toe measuring 0.2 cm in length by 0.2 cm in width, a reddened intact callus on the right 5th inner toe measuring 0.3 cm in length, 0.3 cm in width, both areas were noted with intact skin around the periphery of the wound. Review of physician order's dated 11/9/16 directed to rinse the right 4th inner toe and right 5th inner toe with normal saline followed by an Avellyn dressing for protection, to change every 3 days and as needed, and to re-evaluate in 1 week. Interview with RN#3 on 1/31/17 at 10:30 AM identified that he/she had identified that areas on R#173 right 4th and 5th toe on 11/9/16. Upon assessment it was noted that the right 4th toe was overlapping the right 5th right toe and when assessed the toes were easily separated. RN#3 stated that the areas were initially assessed to be stage 1 pressure areas because the areas were non-blanchable and the Allevyn dressing was applied to relieve the pressure between the right 4th and 5th toe. Although these areas were related to pressure, RN#3 was unable to identify why these areas were identified as calluses on the skin wound tracking record. Interview with Licensed Practical Nurse (LPN) #9 on 2/1/17 at 3:30 PM identified that he/she was the nurse who completed resident #173's skin check on admission. He/she identified that although he/she recalled the resident's right 4th and 5thtoe overlapping, he/she did not assess the skin integrity between the toes, but had taken Resident #173's sock off and visually examined the foot. LPN#9 further identified that he/she did not find it necessary to inspect the toes and/or identify his/her findings on the admission skin assessment. Interview with RN#9 on 2/1/17 at 1:30 PM identified that given Resident #173's [DIAGNOSES REDACTED]. If the toes were easily separated, some type of pressure relief should have been implemented, but he/she was unable to find any documentation in the medical record about the overlapping toes, until the skin/wound report was filled out on 11/9/16. Review of the admission policy identified that the admitting nurse is responsible for completing the necessary documentation including the nursing assessments. d. Review of a nurses note dated 11/12/16 written by LPN#10 identified that the resident had a temperature of 101.1, had poor fluid intake, and had a moderate amount of drainage on his/her old ankle dressing. The nursing supervisor (RN#8) was notified. Review of the clinical record from 11/8/16-11/14/16 failed to identify any type of wound drainage was evident from the right ankle wound. Interview with LPN#10 on 1/31/17 identified that he/she was Resident #173's charge nurse on 11/12/16 when the resident was noted with a temperature of 101.1 and wound drainage, LPN#10 identified that he/she had notified the nursing supervisor (RN#8), but was unsure if he/she had contacted the physician. Interview with RN#8 on 1/21/17 at 2:00 PM identified that he/she could not recall the resident and would not be able to remember back to 11/12/16. Review of the medical record failed to identify that a re-assessment of the wound was conducted and/or that the physician was notified when the drainage was initially noted. Interview with Advanced Practice Registered Nurse (APRN) #2 on 1/31/17 at 10:30 AM identified that he/she would expect to be notified of a temperature of 101.1 and newly noted drainage from a wound. If he/she had been notified an order would have been given to push fluids and/or possibly ordered bloodwork. Interview with the Director of Nurses (DNS) on 1/31/17 at 2:00 PM identified that it would be his/her expectation that the nurse and/or supervisor should have notified the physician of the temperature of 101.1 and the wound drainage. Review of the change in condition policy identified that a significant change in the resident's condition should be reported to the physician. e. Review of the W-10 interagency report lacking a discharge date , identified that the resident was ready to be discharged home with family. The W-10 identified treatments as follows: right 5th inner toe, normal saline followed by Allevyn for protection, change every three days and as necessary and treatment to the right 4th toe, normal saline followed by Allevyn for protection, change every three days and as necessary. Additionally the W-10 requested nursing services at discharge. The W-10 failed to identify the stage 3 pressure area to the right ankle wound and the stage 2 coccyx wound and/or treatments that should be administered to the wound after discharge. Review of a nurse's note dated 11/14/16 and signed by LPN #9 identified that the resident was discharged home without incident. Review of Resident #173 facility discharge summary dated 11/14/16 identified that the resident was admitted for respite services and failed to identify that any services were arranged for discharge and/or any information regarding the stage 3 pressure ulcer on the right ankle and/or the stage 2 pressure ulcer on the coccyx and/or the areas that were being treated on the 4th and 5th toes on the right foot Interview with RN#5 on 2/1/17 at 10:30 AM identified that he/she filled out the discharge paperwork for Resident #173, and further identified that it is the 11:00 to 7:00 PM's shift responsibility to complete discharge paperwork. RN#5 identified that he/she had been directed to fill out the medication section of the report from the Medication Administration Record [REDACTED]. He/she does not include any treatments that the resident may be receiving because they change so frequently. He/she further stated that the nurse who is discharging the resident should ensure the discharge paperwork reflects the current status of the resident. Interview with LPN#9 on 2/2/17 at 3:40 PM identified that he/she had discharged the resident on 11/14/16. He/she identified that he/she did not review the medications and or treatment orders for Resident #173 prior to discussing the discharge paperwork with Person#1. He/she took the completed W-10 and reviewed Resident #173's medications with person #1 and discussed the areas on the resident's toes. LPN#9 identified that he/she was unaware that the resident had a stage 3 on his/her ankle and/or a stage 2 on the coccyx, although LPN#9 was Resident#173's charge nurse on 11/8 and 11/9/16. LPN#9 further identified that he/she did not change R#173's right ankle dressing before the resident was discharged on [DATE]. Review of the TAR identified the last dressing change to the right ankle was completed on the 3:00 to 11:00 shift on 11/13/16. Interview with Social Worker (SW) #1 on 1/31/17 at 10:30 AM identified that the resident was followed by a community agency while he/she was in the community, and the community agency case manager had contacted him/her and left a message to discuss the resident's services. SW#1 had not spoken to the case manager at any time during his/her stay at the facility up to and including discharge. SW#1 further identified that it would be his/her responsibility to arrange a discharge planning meeting for any resident that will be discharged into the community to ensure that the needed services are provided. SW#1 identified that Resident #173 did not have a discharge planning meeting because he/she was respite care and only scheduled to be in the facility for 1 week. SW#1 further identified that he/she was unaware that the resident had any type of skin impairment that required skilled nursing services in the community, if he/she and been aware he/she would have contacted a nursing agency to provide wound care once the resident had been discharged . Interview with Person #3 on 2/1/17 identified that he/she was Resident #173's case manager in the community, and although he/she had contacted SW#1 upon Resident #173's admission to discuss discharge planning, he/she had not received a return call from SW#1. Although the W-10 directed a referral for nursing services at discharge, interview with Person #4 who is a supervising nurse for a skilled nursing agency that R#173 had used prior to admission to the facility, identified that he/she had not received a referral for skilled nursing services from the facility. Person #4 further identified that if the agency had been notified of Resident #173's discharge, the agency would have arranged for a nurse to assess the resident on 11/15/16. Review of the facility W-10 and interview with RN#9 on 2/1/17 at 2:00 PM identified that he/she was unable to find any documentation that any type of home care services were arranged for Resident#173 upon discharge and or any information regarding the stage 3 pressure ulcer on the right ankle, and/or stage 2 to the coccyx on the discharge paperwork. RN#9 further identified that even though the resident was at the facility only for a week for respite care, a discharge meeting should have been held and nursing services arranged prior to Resident #173's discharge. Interview with MD#1 on 2/1/17 at 10:00 AM identified that it would be his/her expectation that the facility arrange for skilled nursing services upon a resident's discharge. Interview with Person #1 on 1/31/17 at 11:30 AM identified that he/she had not had any type of discharge planning meeting at the facility and was not offered any type of home care services after discharge, but Person #1 had arranged for a companion to stay with his/her mother during the day while he/she worked. Person #1 stated that he/she was unaware that the resident needed any type of nursing services upon discharge. Person #1 identified that he/she went to the facility to pick up Resident #173 for discharge home on 11/14/16. The nurse reviewed the discharge medications, and mentioned to Person #1 that the resident had a small area on his/her right ankle, but to leave the dressing in place for a few days, and then to remove it and let the area air dry. Person #1 identified that as per the directions given to him/her by the facility nurse he/she kept the dressing in place for 11/14, and 11/15/16. On 11/16/16 Person #1 had instructed the companion to remove the dressing to the right ankle. While at work on 11/16/16 around 2:00 PM, Person #1 stated that he/she received a call from the companion stating that he/she had removed the dressing on the right ankle and was very concerned by the wound's appearance. Person #1 stated that he/she left work and went home to look at the wound, and noted a large wound to the right ankle with a bad smell. Person #1 further identified he/she took R#173 immediately to the hospital and the resident was admitted with a wound infection. Review of a discharge summary from Hospital #1 dated 11/23/16 identified that the resident had been admitted on [DATE] (2 days after discharge from the skilled nursing facility) with a worsening pressure sore to the ankle with malodorous secretions and was treated with intravenous antibiotics. Review of the discharge policy identified that the interdisciplinary team will develop a comprehensive discharge plan with input from the family and physician, and upon discharge the resident will be referred to the appropriate community agency. 2 Resident #14's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified moderate cognitive impairment, extensive assistance for bed mobility with two and occasional incontinence of urine. The current nurse aide care card identified the resident was 7 feet 4 inches tall, incontinent of urine occasionally, and to off load the heels in bed. The care plan dated 1/6/17 identified a risk for skin breakdown due to a history of pressure ulcer on the coccyx that healed in November 2016 and an unstageable area on the right lateral malleolus. Interventions included to encourage turning and repositioning every 2 hours and reposition side to side when in bed. The January and February 2017 treatment kardex identified to off load the heels while the resident is in bed. The physician's order dated 1/24/17 directed to apply skin prep followed by AGB every day to the left malleolus for 14 days. Constant observations on 1/30/17 from 4:45 AM until 9:15 AM (4 .5 hours) identified the resident in bed on his/her back without the benefit of off-loading of the heels and/or repositioning or incontinent checks. Interview with NA #3 on 1/30/17 at 7:05 AM indicated she/he forgot to reposition the resident, however, when aware, the nurse aide left the facility and did not report to the day shift the resident did not have off-loading of the heels or repositioning per the care plan. Observations on 2/2/17 at 9:05 AM and 9:20 AM identified the resident was in bed on his/her back with the right leg crossed over the left leg. The right lateral malleolus was resting on the bed and due to the resident's height, the left foot and malleolus was resting on the foot board. Upon surveyor intervention the resident was provided off-loading of the heels and repositioning. Interview and observation with the corporate nurse (RN #1) on 2/2/17 at 9:37 AM identified the right lateral malleolus resting on the bed on a pillow and the left foot on the foot board. RN #1 indicated the bed in use was the resident's second bed, and maybe the foot board needed to be removed due to the resident's height. RN #1was unable to identify why off-loading of the resident's feet was not provided. 3a. Resident #15's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident was cognitively impaired and was totally dependent on two for bed mobility and transfers. The May 2016 physician's orders identified the use of non-skid socks only, not to wear shoes, off load heels at all times in bed, check bilateral heels every shift, and apply A&D ointment twice daily and as needed. The hospital discharge summary dated 5/23/16 identified the resident had an acute right distal femoral fracture and was placed in a knee immobilizer. The resident returned to the facility on [DATE] with a 2.0 cm x 2.0 cm x 0.1 cm. unstageable right heel ulcer. Recommendations included barrier spray daily and to off load the heels. The nursing re-admission assessment dated [DATE] identified the resident had an unstageable blackened heel that measured 5.0 cm x 5.5 cm, and a stage 2 open area on coccyx which measured <0.1 cm. Physician readmission orders [REDACTED]. Further, the physician orders directed to apply Allevyn Gentle Border (AGB) every 3 days to the coccyx and to check area every shift. The skin/wound tracking record dated 6/16/16 identified a new 6.8 cm x 6 cm x 0.1 cm unstageable open area on the right Achilles. The assessment identified the area had 75% slough in the wound, had an approximate quarter size area of darkened pigmentation with moderate amount of serosanguinous drainage, and the periwound was reddened. The nurse's note dated 6/16/16 at 2:55 PM identified two AGB dressings were in place above the back of the right heel. When the dressings were removed there was an open area underneath. The infection control nurse and nursing supervisor were notified. The note further identified the immobilizer was positioned below the knee and close to the right heel when removed. The orthopedic surgeon, who ordered the immobilizer, was notified because the immobilizer seemed to be causing a pressure area on the foot. The clinical record failed to reflect the immobilizer was discontinued until 6/24/16 (8 days later). Additionally, the clinical record failed to identify who identified the new open area, when the open area was first identified and when the ABG dressing was initiated. Physician's orders dated 6/16/16 at 1:00 PM directed to administer Keflex 500 mg twice a day for fourteen days, continue to offload bilateral heels with a pillow, when available use heel lift management to off-load bilateral heels while in bed. The Braden scale dated 11/24/16 identified Resident #15 was at moderate risk for pressure ulcer development. Observation of the right Achilles pressure ulcer on 1/31/17 at 10:18 AM with APRN #1, RN#3, and PT #1 identified the wound measured 2.0 cm x 0.8 cm x 0.2 cm and was pink with a surrounding area of maceration. Interview with RN #3 on 1/31/17 at 2:15 PM identified the resident developed the right Achilles pressure ulcer when a right knee immobilizer was initiated to treat the right femur fracture. RN #3 was unable to explain why two AGB dressings were in place above the back of the right heel on 6/16/16 and/or who placed the dressing over the open area and/or when the open area was first identified. Interview and review of the clinical record with APRN #1 on 2/3/17 at 10:51 AM identified the right Achilles wound was due to pressure from the immobilizer. APRN #1 was unable to explain why a pressure ulcer was not found before it was an unstageable area with 75% slough if every shift assessments of the skin were completed. b. The quarterly MDS dated [DATE] identified the resident was cognitively impaired and was totally dependent on two staff for bed mobility and transfers and was always incontinent of bowel and bladder. The physician's orders dated 11/27/16 directed to off load the resident's heels at all times. The physician's orders dated 1/10/17 directed to continue Continuous Pulsed Irrigation (CPI) to right heel, begin calcium alginate with silver rope to right heel, gently pack daily and as needed followed by a dry protective dressing and to check the dressing every shift. The order was clarified on 1/10/17 at 10 PM and directed staff to continue CPI to the right heel. Allevyn non-adhesive and loosely applied Kling to right heel daily and as needed for two weeks. Start calcium alginate with silver rope to depth of right heel (measure length, put in and remove) once product is available, check dressing every shift. The nursing note dated 1/10/17 at 7:16 PM identified a stage 4 pressure injury to the right heel noted to be improved measuring 5.5 cm x 4.0 cm x 1.5 cm, depth noted to be slightly increased this week while length and width decreased. Continue CPI and Allevyn non-adhesive followed by loosely applied Kling daily and as needed. Once the calcium alginate with silver rope was available, staff should lightly pack into the depth of wound daily. The APRN #1's wound progress note dated 1/10/17 identified the right heel had improved and measured 5.5 cm. x 4 cm x 1.5 cm with 80% granulation and 20 % slough, continue CPI and begin calcium alginate with silver rope, and lightly pack. The nursing note dated 1/17/17 at 9:11 PM identified the previously ordered treatment of [REDACTED]. The APRN #1's wound progress note dated 1/17/17 identified the right heel pressure ulcer declined and now measured 5.5 cm x 4 cm x 1.7 cm. The area had increased depth and the new treatment ordered on [DATE] had not been started. The wound now was noted with 40% granulation, 50% clear non-granular area and 10% slough. The APRN #1's wound note dated 1/24/17 identified the right Achilles wound was noted to be new/re-opened and measured 1.0 cm x 0.5 cm x 0.2 cm with 75% clear, non-granular tissue and 25% slough and the peri-wound was noted to have [DIAGNOSES REDACTED]. Review of the January 2017 treatment kardex identified that although the treatment for [REDACTED]. Review of the Reportable Event dated 1/24/17 identified Resident #15 had the incorrect wound care materials were noted on the wound on 1/24/17. The care plan dated 1/30/17 identified the resident was at risk for impaired skin integrity, with interventions that included to assist with repositioning side to side when in bed, a specialty mattress, no shoes, non-skid socks only, off load heels at all times, when in bed offer extra pillow between ankles to off load, wound care as ordered and wound consultant APRN visits as needed. c. The APRN #1's wound progress note dated 1/31/17 identified the right heel wound had declined and measured 6 cm x 3.4 cm x 1.4 cm with 75% clear, non-granular tissue and 25% slough with excoriation to the peri-wound noted. The right Achilles wound had declined and measured 2.0 cm x 0.8 cm x 0.2 cm with 80% clear, non-granular tissue and 20% slough. The physician's orders dated 1/31/17 directed to off load the resident's heels at all times. Observation of the wounds on 1/31/17 at 10:18 AM with APRN #1, RN#3, and PT #1 identified the right heel pressure wound measured 6.0 cm x 3.4 cm with a 0.4 cm with a dark tunnel and 25% slough and the remainder of the wound was beefy red/pink. The right Achilles pressure wound measured 2 cm x 0.8 cm x 0.2 cm and was pink with a surrounding area of maceration. Observation of Resident #15 on 2/2/17 at 9:05 AM and 9:20 AM identified the resident in a wheelchair with his/her bilateral heels resting on a pillow on top of the elevated foot rests without the benefit of off-loading. The off-loading boot was on the bed next to the resident. Further observation and interview with RN#1 on 2/2/17 at 9:35 AM identified the resident sitting in the wheelchair, bilateral heels resting on a pillow on the elevated foot rests without the benefit of off-loading and/or the off-loading boot which was still located on the bed. RN#1identified the heels needed to be off-loaded and that any at risk resident needs to have heels off loaded. Subsequent to surveyor inquiry the resident's heels were off-loaded. Interview and review of facility documentation with APRN #1 on 2/3/17 at 10:51 AM identified the calcium alginate rope treatment was ordered on [DATE] because the right heel wound had depth that a Q-tip swab could be inserted into and the area needed to heal from the inside out. The wound was healing in size but the depth was not improving. APRN #1 identified that on 1/17/17 he/she was surprised the new treatment for [REDACTED]. APRN #1 indicated the facility was using the wrong treatment. APRN #1 identified if the facility was unable to obtain the treatment ordered on [DATE], he/she should have notified. APRN #1 further indicated it should not take 8 days to obtain the treatment supplies. Further, APRN #1 noted that there was a decline to the resident's right heel wound from 1/10/17 to 1/17/17 and 1/31/17. Interview with RN #4 on 2/3/17 at 12 PM identified the Calcium Alginate silver rope was ordered because the standard Calcium Alginate would tear in the wound and staff were not be able to remove it from the wound bed. RN #4 identified the Corporate Supply staff was notified to obtain the Calcium Alginate silver rope. RN #4 failed to follow up when the Corporate Supply staff did not provide the Calcium Alginate silver rope. RN #4 identified he/she was unable to find the Calcium Alginate silver rope in stock at the facility. RN #4 identified that RN #1 was notified on 1/10/17 and indicated Calcium Alginate silver rope would be in the next day. Interview with RN #3 on 2/3/17 at 1:50 PM identified that on 1/24/17 observation of the right heel wound identified the calcium alginate silver rope was not in place and there was no packing in the right heel wound. RN #3 identified that on 1/31/17 the Calcium Alginate silver rope again was not used to treat the right heel wound. RN #3 indicated being concerned that the dry protective dressing, Cover-site put in place by staff had excoriated the wound. RN #3 identified he/she was not sure staff knew what Calcium Alginate silver rope was because Magsorb Ag rope (comprable) was located in the treatment cart on 1/24/17 when it was identified that Calcium Alginate silver rope was not available. RN#3 identified that during wound rounds on 1/31/17 the wounds had again declined. Interview and review of facility documentation with the DNS on 2/3/17 at 9:30 AM identified that on 1/24/17 the treatment done by LPN #2 on the 3-11 shift on 1/23/17 was not done according to the physician's orders. A Reportable Event was initiated and in-servicing taff was conducted to ensure the correct treatment was being completed by staff. The DNS identified LPN #2 and LPN #4 were in-serviced, however, on 1/31/17, the incorrect treatment had been provided to Resident #15. The DNS identified the Cover-site identified by RN#3 as not being appropriate was considered a dry clean dressing. d. Review of the January 2017 treatment kardex lacked documentation that the treatment to the

Based on clinical record reviews, observations, continuous resident observations, review of policies and procedures, review of facility documentation, and/or interviews for four of six residents reviewed for abuse (Residents # 3, 46, 113 and 116) and/or for seven of seven residents reviewed for pressure ulcers and/or at risk for pressure ulcers (Residents #14, 15, 26, 32, 98, 133, and 173), the facility failed to ensure residents were free from abuse, failed to conduct comprehensive investigations when allegations of abuse were identified and failed to substantiate abuse and/or neglected to provide appropriate treatments, and/or provide pressure relief, repositioning and/or incontinent care, and/or failed to implement the physician's orders when wounds declined or failed to improve, and/or failed to ensure adequate professional nursing oversight to a wound care program resulting in a finding of immediate jeopardy. The findings include: 1. Resident # 3's [DIAGNOSES REDACTED]. The care plan dated 1/6/17 identified the resident was at risk for falls. Interventions included not to leave the resident alone in the bathroom and to stay within sight of the resident. The annual MDS assessment dated [DATE] identified severe cognitive impairment, required extensive assistance of one staff for personal hygiene, two staff for transfers and was totally dependent for bathing. The Reportable Event report dated 1/19/17 identified that on 1/18/17 at 6:40 AM RN #5 found Resident #3 unattended in the shower room. The resident was unclothed, with the exception of slipper socks, sitting on a shower chair, holding the shower hose with the water running. NA #1 entered the shower room and told RN #5 that she/he instructed Resident #3 not to touch the water. When RN #5 returned to the nurse's station, NA #1was heard interacting with Resident #3 in an annoyed tone. NA #1was overheard to say to the resident that he/she had been told not to touch the water. Interview with NA #1 on 2/1/17 at 2:05 PM identified that on 1/18/17 at 6:45 AM she was in the shower room with Resident #3 who was seated on the shower chair. Before the shower was started, NA #1 realized she/he forgot to bring the resident's clean clothing to the shower room. NA #1 indicated Resident #3 was left unattended seated on the shower chair, with water running from the shower hose nozzle. The shower hose nozzle was resting on the grab bar behind the resident. The water from the shower nozzle was not running onto the resident. NA #1 identified the resident was unclothed with the exception of slipper socks, however, before leaving the shower room to retrieve the resident's clothes, she/he pulled the curtain to the shower closed and propped the door of the shower room open with a chair. Interview with RN #5 on 2/2/17 at 8:55 AM identified that on 1/18/17 at approximately 6:45 AM he/she was sitting at the nurse's station when he/she heard someone yelling for help. Upon investigating the call for help, Resident #3 was found sitting on a shower chair in the shower room clothed only in slipper socks, holding the shower wand in the left hand with the water running from the shower wand. RN #5 identified NA #1 returned within a minute or two of Resident #3 being found unattended. RN #5 identified that upon returning to the shower room NA #1 identified that he/she told Resident #3 not to touch the water. Further interview with RN #5 identified that she instructed NA #1 never to leave a resident unattended in the shower and returned to the nurse's station. RN #5 identified that while at the nurse's station, she heard NA #1 reprimanding Resident #3 in an annoyed tone saying, I told you not to touch the water. RN #5 described the tone of NA #1 as someone who had lost their patience. RN #5 indicated she/he did not consider the incident an allegation of abuse until later when she/he was at home and then called the Administrator to report the event. In a subsequent interview with RN #5 on 2/2/17 at 10:30 AM identified he/she would consider NA #1's statement to the resident intimidating to the resident. A sworn statement dated 2/2/17 at 10:49 AM written by RN #5 identified that in retrospect she did realized this was abuse when she considered how the resident would feel when he/she was unclothed and someone was standing over them stating in an annoyed tone I told you not to do something. Review of facility documentation identified the facility was unable to substantiate verbal abuse. 2. Resident #46's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident was cognitively intact, required extensive assistance for bed mobility, dressing, toilet use and personal hygiene and did not exhibit any behaviors. The Resident Care Plan dated 10/27/16 identified the resident needs assist with ADLS and is a set up at bedside and encourages to do as much for self as possible. The care plan further instructed staff to listen to resident concerns and complaints of pain and to be aware of expectations for pain relief and to observe for signs and symptoms for pain. The physician's order dated 12/2/16 identified that Resident #46 was a stand pivot transfer with assist of one with use of the bed rail. The Reportable Event dated 12/14/16 identified that NA#12 while providing care, pulled on Resident #46's left arm. The facility investigation identified that when NA#12 was asked to do something for Resident #46, NA#12 would do the opposite (asked to be put on side, NA #12 would put her/him on her/his back). The investigation further identified that NA#12 turned the resident on the left side and the resident told NA #12 he/she was experiencing pain in that position. NA#12 continued to provide care and did not change the resident's position. Resident #46 identified that NA#12 was asked to stop a few times because the resident did not want to get dressed because of the pain. The investigation further identified that NA #12 was rough when providing care. Review of NA#12's employee file on 1/31/17 identified that NA#12 received a written warning on 12/16/16 because NA#12 proceeded to provide care to the resident despite complaints of pain and a request to stop. Interview with the Administrator on 2/3/17 at 12:00PM identified the allegation of abuse was not substantiated because there were inconsistency in staff and resident statements. The facility concluded that NA#12 appeared rushed not rough and it was a customer service issue. Interview with NA#12 on 2/6/17 at 11:30AM identified that she/he recalls that Resident #46 had complaints of general discomfort but never requested for care to stop and leave her/him in bed. b. The annual Minimum Data Set ((MDS) dated [DATE] identified the resident was cognitively intact, required extensive assistance for bed mobility, dressing, toilet use and personal hygiene and did not exhibit any behaviors. The physician's orders dated 12/31/16 identified to provide a stand pivot transfer with assist of one with use of the bed rail. The care plan date 1/8/17 identified the resident needs assistance with ADLS, is a set up at bedside and to encourage the resident to do as much for self as possible. The care plan further identifies to offer support and reassurance if the resident appears anxious, to stop care and ask nurse for pain medication if pain is reported, use assistance of 2 for bed positioning or care if the resident is in pain, don't rush the resident, tell the nurse and reproach. The Reportable Event dated 1/29/17 identified an allegation of rough care, causing left arm pain. Resident #46 reported to LPN #8 that on 1/27/17 at about 8:00PM, NA #10 and NA#11 came in to put the resident to bed and were rough. Resident #46 indicated that the nurse aides were unsure how to assist her/him back to bed. There was a disagreement between the nurse aides and NA#10 pulled the resident's left arm hard one way and NA#11 pulled the opposite way. Resident #46 asked them to stop pulling as it was painful and they finally stopped and allowed the resident to get into bed her/himself. Resident #46 indicated the pain continued well after the nurse administered a pain medication. An x-ray of left arm completed on 1/29/17 was negative for fracture and/or dislocation. Review of NA#10's employee file identified a written warning was given on 6/9/16 for transferring a resident who was an assist of 2 independent resulting in a skin tear. An additional one to one in-service education was provided on 11/2/16 related to customer service and being aware of body language and tone of voice when interacting with residents. Interview with the Administrator on 2/3/17 at 2:00PM identified NA #10 was suspended pending the outcome of the 1/29/17 investigation. Several attempts to reach NA #10 for an interview were unsuccessful. 3. Resident #113 had [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] identified that the resident was alert and oriented, had no documented behaviors, and required extensive assistance with Activities of Daily Living (ADL's) including bed mobility. Review of reportable event dated 12/27/16 identified that Resident #113 stated that a nurse was rough with him/her while positioning him/her in bed on 12/12 or 12/13/16. Interview with Resident #113 on 2/1/17 at 10:30 AM identified about a month ago that he/she was sleeping when the nursing supervisor Registered Nurse (RN) #8 had come into his/her room at about 11:30 PM, and stated that he/she needed to check his/her ankle. Resident #113 stated to RN#8 that he/she wished to be left alone, but RN#8 proceeded to take the turning pad and roughly turn him to the opposite side of the bed. The resident stated that he/she again asked RN#8 to leave him/her alone, but RN#8 continued to roughly move his/her body in bed. Resident #113 stated that when RN#8 left the room, he/she did not leave him/her in a comfortable position. Resident #113 further stated that he/she rang his/her call bell and when Nurse Aide (NA#20) came into his room, he/she repositioned him/her. Resident #113 stated that he/she told NA#11 that he/she did not like RN#8 and did not want him/her taking care of him/her anymore. Interview with RN#8 on 2/1/17 at 1:30 PM identified that he/she had gone into Resident #113's room because the infection control nurse told him/her to check the skin integrity on his//her ankle. RN#8 stated that the resident's door was open, but the light was off. He/she called out to Resident #113 from the door and told him/her that he/she needed to do a treatment to his/her ankle. Resident #113 responded with now?, and RN#8 proceeded to tell the resident that the treatment needed to be done, and the resident responded OK. He/she identified that resident #113 was unable to uncross his/her legs, so he/she uncrossed his/her legs and proceeded with the treatment. When RN#8 was done with the treatment, he/she said goodnight and left the room. Interview with NA#20 on 2/1/17 at 2:00 PM identified that he/she was the NA who worked on the 11:00 PM to 7:00 AM shift on 12/13/16. He/she went into Resident #113's room at 12:00 AM and the resident identified that he/she did not want his/her feet elevated and no-one was going to tell him what to do, but did not inform him/her of any rough treatment. Interview with Person # 2 on 2/1/17 at 2:30 PM identified that he/she had also interviewed Resident #113 and clearly remembered the resident telling him/her that RN#8 had treated him/her roughly while turning him/her and was consistent with the details of his/her allegation. Interview with Social Worker (SW) #1 on 2/1/17 at 2:00 PM identified that the resident had no prior history of making allegations against staff and that when he/she interviewed Resident #113, he/she did inform him/her that he/she was treated roughly while being repositioned and was very emotional and teary eyed during the conversation. SW#1 stated that he/she provided emotional support and continued to monitor the resident's mood. Interview with RN#9 on 2/1/17 at 2:40 PM identified that although the reportable event and investigation was started on 12/27/16, it had been initially reported on 12/22/16 by the ombudsman to the former Director of Nurses (DNS), but the former DNS did not report and/or investigate the allegation until the ombudsman called for a follow up on the allegation on 12/27/16. RN#9 identified when conducting an abuse investigation the facility looks at staffing, conducts interviews with staff, and gets statements from employees and determines if the statements taken corroborate with each other, and if there is the slightest doubt, abuse is substantiated. RN#9 further stated that he/she interviewed Resident #113 about the allegation, but was unable to substantiate abuse because the resident felt that RN#8 did not mean to do it, and it was more poor technique in turning and repositioning him/her and RN#8 did not touch Resident #113, because he/she was turning him/her with a turning pad. RN#9 further stated that although the resident did not like RN#8's approach, and felt like he/she just wanted to finish his/her job, Resident #113 did not want RN#8 to care for him/her anymore. RN #9 stated that when he/she conducted the investigation, Resident #113 did not feel that he/she was abused. Additionally review of RN#8's time card punches identified that RN#8 was allowed to work as the nursing supervisor on 12/23, 12/24, and 12/25/16, before the allegation was investigated on 12/27/16. RN#8 was terminated for violating Resident #113's rights to refuse treatment. Review of the abuse policy identified that abuse or mistreatment of [REDACTED]. 4. Resident #116's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified the resident had intact cognition, required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The December 2016 care plan identified the resident required assistance for personal hygiene and being boosted up in bed. Interventions included to provide assistance with care that I cannot complete on my own. The Reportable Event dated 12/17/16 at 9:00 PM identified the resident asked NA #15 to boost her/him up in the bed. NA #15 told the resident he/she could not pull her/him up and left the room. The refusal to provide care was witnessed by NA #16. A statement written by NA #16, undated, indicated that NA #15 asked for help with a resident. The resident wanted to get pulled up in bed and NA #15 responded there was nothing there to pull him/her up with. A statement written by NA#15, dated 12/20/16 identified after the resident was put to bed he/she asked to be moved up in bed. NA #15 told the resident they needed to get the nurse to help and the resident would have to wait. NA #15 then went to another room. The Reportable Event dated 12/27/16 identified that the resident reported to the Social Worker that a couple of months ago, NA#15 told the resident he/she needed to go to Jenny Craig. The investigation indicated that the resident reported that NA #15 told the resident approximately five separate times he/she needed to go to Jenny Craig. The investigation identified NA #15 denied making the comments to the resident. However, NA #15 resigned from the facility. The investigation failed to identify the facility obtained a statement from the resident. Interview with the resident on 2/1/17 at 1:00 PM identified she/he reported during resident council with Person #2 present that every time a commercial for Jenny Craig came on the television, NA #15 would tell the resident she/he needed to go to Jenny Craig. NA #15 was asked by the resident to stop but NA #15 continued to make the statement. One day, the resident indicated he/she was very upset and reported the incidents to Person #2. Interview with NA #16 on 2/1/17 at 4:00 PM identified that NA #15 asked for assistance on 12/17/16 to boost the resident up in bed. NA #16 indicated there was not a draw sheet under the resident so and NA #15 told the resident she/he could not boost her/him up in bed. NA #16 indicated the charge nurse assisted to boost the resident up in bed when NA #15 refused to assist the resident. 5a. Resident #173 was admitted to the facility for a respite stay with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified that the resident was cognitively impaired, required assistance with Activities of Daily Living (ADL's) and had a stage 2 pressure ulcer on his/her coccyx. The admission assessment measured the pressure ulcer at 3.1 centimeters (cm) in length, 2.5 cm in width with a depth of .01 cm, otherwise, no other noted areas of skin impairment were identified. a.Review of physician's orders and the Treatment Administration Record (TAR) dated 11/5/16 directed to apply triad cream to the coccyx every shift and as needed, offload heels every shift, and to turn and reposition per facility protocol. Review of a facsimile communication dated 11/8/16 to physician (MD) #1 identified a request to discontinue the current treatment to the coccyx and start skin prep to peri-wound, followed by Allevyn dressing, to change every three days and as needed. A wound tracking assessment dated [DATE] measured the coccyx wound as a stage 2 pressure ulcer 2.0 cm by 1.5cm with 0.1 cm of depth. The physician agreed to the recommendations and signed the bottom of the facsimile. Review of the November physician orders, and November 2016 Treatment Administration Record (TAR) failed to reflect that the treatment was changed as requested, and approved by the physician. Interview with Registered Nurse (RN) #4 who was the facility wound nurse on 11/8/16 on 1/31/17 at 2:00 PM identified that although he/she could not recall requesting a change in Resident #173's treatment, if he/she had requested to change the treatment to skin prep and a protective dressing, the wound was most likely closed and the treatment needed to be changed to protect the area from the re-occurrence of the skin breakdown. RN#4 further identified that if the physician had signed the facsimile the order change should have been transcribed onto the physician's orders and the TAR. Interview with MD#1 on 2/1/17 at 10:30 AM identified that if/he she had signed the facsimile dated 11/8/16, it would be his expectation that the recommended treatment be written as a physician's order. b. Review of a skin and wound tracking record dated 11/8/16 identified that the resident had a stage 3 pressure area to the right ankle that was red in color, measured 1.5 cm in length, 1.5 cm in width with a depth of 0.6, with no drainage noted. Review of a facsimile communication dated 11/8/16 signed by MD #1 identified that the resident had a newly noted stage 3 pressure ulcer to the right lateral ankle measuring 1.5 cm in length, 1.5 cm in width with a depth of 0.6 cm with a request to implement rinsing the wound with normal saline, apply a Solosite dressing, and cover with Allevyn gentle border. Additionally, documentation directed to change the resident's mattress to an alternating pressure air mattress. A physician's order dated 11/8/16 directed to cleanse the right ankle wound with normal saline, apply a Solosite dressing followed by Allevyn gentle border dressing, and change every day and as needed for 10 days. The physician's orders failed to identify the order for the alternating pressure air mattress. Review of the November 2016 TAR identified the treatment to the right ankle wound was to be cleansed with normal saline, a Solosite dressing and to be covered the Allevyn dressing and should be changed on the 3:00 to 11:00 shift, but the dressing should be checked on the 7:00 AM to 3:00 PM shift and 11:00 PM to 7:00 AM shift. Further review of the TAR failed to reflect that the alternating pressure air mattress was implemented until 11/11/16 (3 days after it was ordered). Interview with RN #4 (the facility wound nurse at the time the wound was discovered) on 2/1/17 at 2:00 PM identified that he/she was asked to evaluate an area on R#173's right ankle by the charge nurse on 11/8/16. RN#4 further identified that the resident had a tan inflatable boot on the right foot, RN#4 removed the boot from the right foot, and assessed the area to be a reddened full thickness wound to the right outer ankle. RN#4 further identified that the wound was discovered at a stage 3, and identified that the resident did not have an order for [REDACTED].#4 identified that the alternating pressure mattress was a nursing intervention for the newly acquired stage 3 pressure ulcer to the right ankle. Interview with RN#9 on 2/2/17 at 1:30 PM identified that he/she could not locate any documentation in the medical record about an inflatable boot to the right foot. RN#9 identified that although there is no physician's order required to apply offloading boots, there must be documentation in the medical record of assessments in skin integrity around where the boot was applied when donning and doffing. Additionally, he/she was unable to locate any assessments completed for the right foot since admission on 11/5/16. Further, RN#9 stated that all nursing supervisors are aware that the alternating pressure mattresses are available within the facility and should be applied when the physician's order is written, but was unable to find any documentation that the mattress was applied prior to 11/11/16. Interview with MD#1 on 2/2/17 at 10:00 AM identified that it is possible that the offloading boot could have caused the stage 3 pressure ulcer and it would be his/her expectation that the air mattress be in place when it was ordered. Interview with Person #1 on 1/31/17 identified that when he/she dropped of his/her family member for the respite stay, he/she brought a tan offloading boot with the resident's belongings. Review of the wound intervention policy identified in part, that pressure distribution mattresses are available for all beds, and to apply and remove splints or similar devices as ordered and to note the condition of the skin. c. Review of an admission assessment date 11/5/16 did not identify any areas of impaired skin integrity and/or abnormalities to Resident #173's feet and/or toes. Review of a skin/wound tracking record dated 11/9/16 identified that the resident had a reddened intact callus on the right 4th inner toe measuring 0.2 cm in length by 0.2 cm in width, a reddened intact callus on the right 5th inner toe measuring 0.3 cm in length, 0.3 cm in width, both areas were noted with intact skin around the periphery of the wound. Review of physician order's dated 11/9/16 directed to rinse the right 4th inner toe and right 5th inner toe with normal saline followed by an Avellyn dressing for protection, to change every 3 days and as needed, and to re-evaluate in 1 week. Interview with RN#3 on 1/31/17 at 10:30 AM identified that he/she had identified that areas on R#173 right 4th and 5th toe on 11/9/16. Upon assessment it was noted that the right 4th toe was overlapping the right 5th right toe and when assessed the toes were easily separated. RN#3 stated that the areas were initially assessed to be stage 1 pressure areas because the areas were non-blanchable and the Allevyn dressing was applied to relieve the pressure between the right 4th and 5th toe. Although these areas were related to pressure, RN#3 was unable to identify why these areas were identified as calluses on the skin wound tracking record. Interview with Licensed Practical Nurse (LPN) #9 on 2/1/17 at 3:30 PM identified that he/she was the nurse who completed resident #173's skin check on admission. He/she identified that although he/she recalled the resident's right 4th and 5thtoe overlapping, he/she did not assess the skin integrity between the toes, but had taken Resident #173's sock off and visually examined the foot. LPN#9 further identified that he/she did not find it necessary to inspect the toes and/or identify his/her findings on the admission skin assessment. Interview with RN#9 on 2/1/17 at 1:30 PM identified that given Resident #173's [DIAGNOSES REDACTED]. If the toes were easily separated, some type of pressure relief should have been implemented, but he/she was unable to find any documentation in the medical record about the overlapping toes, until the skin/wound report was filled out on 11/9/16. Review of the admission policy identified that the admitting nurse is responsible for completing the necessary documentation including the nursing assessments. d. Review of a nurses note dated 11/12/16 written by LPN#10 identified that the resident had a temperature of 101.1, had poor fluid intake, and had a moderate amount of drainage on his/her old ankle dressing. The nursing supervisor (RN#8) was notified. Review of the clinical record from 11/8/16-11/14/16 failed to identify any type of wound drainage was evident from the right ankle wound. Interview with LPN#10 on 1/31/17 identified that he/she was Resident #173's charge nurse on 11/12/16 when the resident was noted with a temperature of 101.1 and wound drainage, LPN#10 identified that he/she had notified the nursing supervisor (RN#8), but was unsure if he/she had contacted the physician. Interview with RN#8 on 1/21/17 at 2:00 PM identified that he/she could not recall the resident and would not be able to remember back to 11/12/16. Review of the medical record failed to identify that a re-assessment of the wound was conducted and/or that the physician was notified when the drainage was initially noted. Interview with Advanced Practice Registered Nurse (APRN) #2 on 1/31/17 at 10:30 AM identified that he/she would expect to be notified of a temperature of 101.1 and newly noted drainage from a wound. If he/she had been notified an order would have been given to push fluids and/or possibly ordered bloodwork. Interview with the Director of Nurses (DNS) on 1/31/17 at 2:00 PM identified that it would be his/her expectation that the nurse and/or supervisor should have notified the physician of the temperature of 101.1 and the wound drainage. Review of the change in condition policy identified that a significant change in the resident's condition should be reported to the physician. e. Review of the W-10 interagency report lacking a discharge date , identified that the resident was ready to be discharged home with family. The W-10 identified treatments as follows: right 5th inner toe, normal saline followed by Allevyn for protection, change every three days and as necessary and treatment to the right 4th toe, normal saline followed by Allevyn for protection, change every three days and as necessary. Additionally the W-10 requested nursing services at discharge. The W-10 failed to identify the stage 3 pressure area to the right ankle wound and the stage 2 coccyx wound and/or treatments that should be administered to the wound after discharge. Review of a nurse's note dated 11/14/16 and signed by LPN #9 identified that the resident was discharged home without incident. Review of Resident #173 facility discharge summary dated 11/14/16 identified that the resident was admitted for respite services and failed to identify that any services were arranged for discharge and/or any information regarding the stage 3 pressure ulcer on the right ankle and/or the stage 2 pressure ulcer on the coccyx and/or the areas that were being treated on the 4th and 5th toes on the right foot Interview with RN#5 on 2/1/17 at 10:30 AM identified that he/she filled out the discharge paperwork for Resident #173, and further identified that it is the 11:00 to 7:00 PM's shift responsibility to complete discharge paperwork. RN#5 identified that he/she had been directed to fill out the medication section of the report from the Medication Administration Record [REDACTED]. He/she does not include any treatments that the resident may be receiving because they change so frequently. He/she further stated that the nurse who is discharging the resident should ensure the discharge paperwork reflects the current status of the resident. Interview with LPN#9 on 2/2/17 at 3:40 PM identified that he/she had discharged the resident on 11/14/16. He/she identified that he/she did not review the medications and or treatment orders for Resident #173 prior to discussing the discharge paperwork with Person#1. He/she took the completed W-10 and reviewed Resident #173's medications with person #1 and discussed the areas on the resident's toes. LPN#9 identified that he/she was unaware that the resident had a stage 3 on his/her ankle and/or a stage 2 on the coccyx, although LPN#9 was Resident#173's charge nurse on 11/8 and 11/9/16. LPN#9 further identified that he/she did not change R#173's right ankle dressing before the resident was discharged on [DATE]. Review of the TAR identified the last dressing change to the right ankle was completed on the 3:00 to 11:00 shift on 11/13/16. Interview with Social Worker (SW) #1 on 1/31/17 at 10:30 AM identified that the resident was followed by a community agency while he/she was in the community, and the community agency case manager had contacted him/her and left a message to discuss the resident's services. SW#1 had not spoken to the case manager at any time during his/her stay at the facility up to and including discharge. SW#1 further identified that it would be his/her responsibility to arrange a discharge planning meeting for any resident that will be discharged into the community to ensure that the needed services are provided. SW#1 identified that Resident #173 did not have a discharge planning meeting because he/she was respite care and only scheduled to be in the facility for 1 week. SW#1 further identified that he/she was unaware that the resident had any type of skin impairment that required skilled nursing services in the community, if he/she and been aware he/she would have contacted a nursing agency to provide wound care once the resident had been discharged . Interview with Person #3 on 2/1/17 identified that he/she was Resident #173's case manager in the community, and although he/she had contacted SW#1 upon Resident #173's admission to discuss discharge planning, he/she had not received a return call from SW#1. Although the W-10 directed a referral for nursing services at discharge, interview with Person #4 who is a supervising nurse for a skilled nursing agency that R#173 had used prior to admission to the facility, identified that he/she had not received a referral for skilled nursing services from the facility. Person #4 further identified that if the agency had been notified of Resident #173's discharge, the agency would have arranged for a nurse to assess the resident on 11/15/16. Review of the facility W-10 and interview with RN#9 on 2/1/17 at 2:00 PM identified that he/she was unable to find any documentation that any type of home care services were arranged for Resident#173 upon discharge and or any information regarding the stage 3 pressure ulcer on the right ankle, and/or stage 2 to the coccyx on the discharge paperwork. RN#9 further identified that even though the resident was at the facility only for a week for respite care, a discharge meeting should have been held and nursing services arranged prior to Resident #173's discharge. Interview with MD#1 on 2/1/17 at 10:00 AM identified that it would be his/her expectation that the facility arrange for skilled nursing services upon a resident's discharge. Interview with Person #1 on 1/31/17 at 11:30 AM identified that he/she had not had any type of discharge planning meeting at the facility and was not offered any type of hom

Based on review of clinical records and facility documentation, and interviews for three of six residents (Residents # 15, 98 and 173) reviewed for a change in condition, the facility failed to notify the physician after a change in condition was identified. The findings include: 1. Resident #15's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident was cognitively impaired and was totally dependent on two for bed mobility and transfers. The May 2016 physician's orders [REDACTED]. The hospital discharge summary dated 5/23/16 identified the resident had an acute right distal femoral fracture and was placed in a knee immobilizer. The resident returned to the facility on [DATE] with a 2.0 cm x 2.0 cm x 0.1 cm. unstageable right heel ulcer. Recommendations included barrier spray daily and to off load the heels. The skin/wound tracking record dated 6/16/16 identified a new 6.8 cm x 6 cm x 0.1 cm unstageable open area on the right Achilles. The assessment identified the area had 75% slough in the wound, had an approximate quarter size area of darkened pigmentation with moderate amount of serosanguinous drainage, and the periwound was reddened. physician's orders [REDACTED]. The Braden scale dated 11/24/16 identified Resident #15 was at moderate risk for pressure ulcer development. The quarterly MDS dated [DATE] identified the resident was cognitively impaired and was totally dependent on two staff for bed mobility and transfers and was always incontinent of bowel and bladder. The physician's orders [REDACTED]. The order was clarified on 1/10/17 at 10 PM and directed staff to continue CPI to the right heel. Allevyn non-adhesive and loosely applied Kling to right heel daily and as needed for two weeks. Start calcium alginate with silver rope to depth of right heel (measure length, put in and remove) once product is available, check dressing every shift. The nursing note dated 1/10/17 at 7:16 PM identified a stage 4 pressure injury to the right heel noted to be improved measuring 5.5 cm x 4.0 cm x 1.5 cm, depth noted to be slightly increased this week while length and width decreased. Continue CPI and Allevyn non-adhesive followed by loosely applied Kling daily and as needed. Once the calcium alginate with silver rope was available, staff should lightly pack into the depth of wound daily. The APRN #1's wound progress note dated 1/10/17 identified the right heel had improved and measured 5.5 cm. x 4 cm x 1.5 cm with 80% granulation and 20 % slough, continue CPI and begin calcium alginate with silver rope, and lightly pack. The nursing note dated 1/17/17 at 9:11 PM identified the previously ordered treatment of [REDACTED]. The APRN #1's wound progress note dated 1/17/17 identified the right heel pressure ulcer declined and now measured 5.5 cm x 4 cm x 1.7 cm. The area had increased depth and the new treatment ordered on [DATE] had not been started. The wound now was noted with 40% granulation, 50% clear non-granular area and 10% slough. The APRN #1's wound note dated 1/24/17 identified the right Achilles wound was noted to be new/re-opened and measured 1.0 cm x 0.5 cm x 0.2 cm with 75% clear, non-granular tissue and 25% slough and the peri-wound was noted to have [DIAGNOSES REDACTED]. Review of the January 2017 treatment kardex identified that although the treatment for [REDACTED]. Interview and review of facility documentation with APRN #1 on 2/3/17 at 10:51 AM identified the calcium alginate rope treatment was ordered on [DATE] because the right heel wound had depth that a Q-tip swab could be inserted into and the area needed to heal from the inside out. The wound was healing in size but the depth was not improving. APRN #1 identified that on 1/17/17 he/she was surprised the new treatment for [REDACTED]. APRN #1 indicated the facility was using the wrong treatment. APRN #1 identified if the facility was unable to obtain the treatment ordered on [DATE], he/she should have notified. APRN #1 further indicated it should not take 8 days to obtain the treatment supplies. Further, APRN #1 noted that there was a decline to the resident's right heel wound from 1/10/17 to 1/17/17 and 1/31/17. 2. Resident #98's [DIAGNOSES REDACTED]. The hospital discharge summary dated 1/8/17 identified the resident was treated with intravenous antibiotic therapy due [MEDICAL CONDITION] secondary to left lower extremity [MEDICAL CONDITION] around the suture site from the recent orthopedic surgery on the left ankle. The resident was noted to have a soft cast on the right ankle and a hard cast on the left ankle. The nursing re-admission assessment dated [DATE] identified the resident was alert and oriented to time, person and place and the presence of a cast on both ankles. The nurse's note dated 1/8/17 identified casts on the right and left ankle. The nurse's note dated 1/9/17 identified the resident was medicated with [MEDICATION NAME] 10mg IR for bilateral lower extremity pain at 4:00 PM and 9:00PM with good effect both times. An assessment identified positive color, motion and sensation (+CMS) to bilateral lower extremities. The nurse's note dated 1/10/17 identified the resident was medicated for pain ([MEDICATION NAME]) twice with little effect. The resident stated the skin underneath the cast was burning and that ice was applied around the cast with little relief. The notes further indicated the resident had a scheduled appointment later that afternoon at 2:50 PM with a plan to medicate for pain until seen by the physician (Podiatrist). Further review of the nurse notes dated 1/10/17 at 8:08 PM identified the resident was sent directly from the Podiatrist office to the hospital via ambulance. Review of the interagency referral report (W10) from the hospital dated 1/17/17 identified the resident underwent [REDACTED]. On 1/17/17 medications included [MEDICATION NAME] 1 gram/50ml Solution of D5W three times a day (intravenous antibiotic) and application of a [DEVICE] upon arrival to the facility to be set at 125mmHg continuously. Interview with LPN #3 on 2/1/17 at 9:00 AM identified the resident complained of pain at 2:00AM on 1/10/17 despite being administered [MEDICATION NAME] 10 mg at 12:00AM. [MEDICATION NAME] 10 mg at 4:00AM. The resident reported a new sensation of burning underneath the cast and LPN #3 indicated there was a new foul odor from under the cast. LPN#3 stated the change in the resident's condition was reported to nursing supervisor RN #5 with instructions to apply ice over the cast as needed for comfort since this was a change from the previous shift's report. Interview with RN #5 on 2/1/17 at 9:00AM indicated that he/she directed to apply the ice over the cast as a nursing measure to relieve the resident of the burning sensation. Further interview identified that RNS#5 did not conduct an assessment of the resident or call the physician for directions. RN #5 and LPN #3 identified the resident declined to go to the emergency room because he/she had a pending appointment with the Podiatrist later that day and did not want to miss it. Review of the clinical record failed to reflect there was a conversation with the resident the conversation about possible transfer to the hospital. Interview with the resident on 2/1/17 at 9:45 AM identified that if the physician wanted her/him to go to the emergency room , he/she would do what the physician recommended. Further review of the clinical record and interview with RN #6 (who was the 7-3 PM nursing supervisor on the 7-3PM shift on 1/10/17) identified he/she was unaware of the change in Resident #98's condition. RN #6 identified he/she did not receive information in the change of shift report that the resident identified burning or unrelieved pain under the left ankle cast. Review of the clinical record identified that the resident was seen by the Podiatrist at 2:50 PM on 1/10/17 (13 hours after the initial change in condition was noted). In addition, the clinical record failed to provide documentation that additional and sequential assessments were completed despite the presence and reported malodor. Interview with NA# 7 on 2/03/17 10:53AM indicated that on 1/10/17, LPN #5 was notified reported of the malodor when she/he entered resident's room around breakfast time. NA #7 indicated LPN #5 entered the resident's room with NA#7 and noted the resident had a scheduled appointment to see the Podiatrist at 2:50PM that day. Interview with LPN#5 on 2/1/17 at 11:17AM identified the presence of malodor at the site of the left ankle cast, however, did not do further assessment Interview and clinical record review with the Podiatrist on 2/1/17 at 3:40PM indicated if notified of the resident's change in condition the resident would have been seen earlier than the scheduled time of 2:50 PM and/or sent to the hospital for additional interventions. 3. Resident #173 was admitted to the facility for a respite stay with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified that the resident was cognitively impaired, required assistance with Activities of Daily Living (ADL's) and had a stage 2 pressure ulcer on his/her coccyx. Review of a skin and wound tracking record dated 11/8/16 identified that the resident had a stage 3 pressure area to the right ankle that was red in color, measured 1.5 cm in length, 1.5 cm in width with a depth of 0.6, and no drainage noted. Review of a nurse's note dated 11/12/16 written by Licensed Practical Nurse (LPN) #10 identified that the resident had a temperature of 101.1 degrees at 4:00PM, poor fluid intake, and had a moderate amount of drainage on his/her old ankle dressing. The resident had no order for as needed Tylenol, but received scheduled Tylenol at 8:00 PM with a repeat temperature of 99.0. The nursing supervisor (RN#8) was notified. Review of the clinical record from 11/8/16-11/14/16 failed to identify any type of wound drainage was evident from the right ankle wound. Interview with LPN#10 on 1/31/17 identified that he/she was Resident #173's charge nurse on 11/12/16 when the resident was noted with a temperature of 101.1 and wound drainage. LPN#10 identified that he/she had notified the nursing supervisor (Registered Nurse (RN) #8), but was unsure if he/she had contacted the physician. LPN#10 further identified that he/she could not give the resident any Tylenol because he/she had scheduled doses, and lacked an as needed order, and he/she had recently administered the Tylenol at 8:00PM (4 hours after the temperature was identified). He/she further stated that Resident #173's temperature was repeated at 8:00 PM and it was 99.0 degrees. Interview with RN#8 on 1/21/17 at 2:00 PM identified that he/she could not recall the resident and would not be able to remember back to 11/12/16. Review of the medical record failed to identify that the physician was notified when the drainage and/or temperature was initially noted. Interview with Advanced Practice Registered Nurse (APRN) #2 on 1/31/17 at 10:30 AM identified that he/she would expect to be notified of a temperature of 101.1, and newly noted drainage from a wound. If APRN#2 he/she had been notified an orders would have been given to push fluids, to give the scheduled Tylenol early and/or possibly ordered bloodwork. Interview with the Director of Nurses (DNS) on 1/31/17 at 2:00 PM identified that it would be his/her expectation that the nurse and/or supervisor should have notified the physician of the temperature of 101.1 and the wound drainage. Review of the change in condition policy identified that a significant change in the resident's condition should be reported to the physician.

Based on clinical record reviews, observations, review of facility documentation and interviews for six of fourteen residents (Resident #10, #11, #12, #14 #15, and #16) who had an open area and/or were at risk for skin breakdown, the facility failed to off load the resident's heels, ensure the dressing was intact, identify factors that could cause areas to open, review the care plan and/or implement new interventions to prevent breakdown and/or promote healing. The findings include: 1. Resident #10's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 had poor decision making skills and required cues and/or supervision, required extensive two person assistance with bed mobility, was at risk for pressure ulcers, had a stage three (3) and two (2) unstageable pressure areas and the application of dressings to the feet. The resident care plan dated 12/1/16 identified the resident was at risk for skin breakdown and had an area of pressure to the right outer heel identified on 7/25/16. Interventions directed a new pressure reducing mattress and treatment to the right outer heel, inspect my skin when giving care for signs and symptoms of breakdown and off load pressure to the heels with a pillow. The individualized resident assignment directed to off load the heels. The December 2016 Treatment Administration Record (TAR) identified to off load the heels every shift. Interview and observations with the Infection Control Nurse, Registered Nurse (RN) #2, on 12/12/16 at 2:35 PM identified Resident #10 had just returned from [MEDICAL TREATMENT]. Observations identified one pillow was under the resident's calves and the heels were touching the bed. RN #2 placed two (2) pillows under the resident's legs to off load the heels. 2. Resident #14's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #14 had poor decision making skills, required extensive one person assistance with activities of daily living, was at risk for developing a pressure ulcer and did not have one at the time of the assessment. The resident care plan dated 11/28/16 identified the resident was at risk for skin breakdown. Interventions directed to encourage and/or assist with repositioning side to side and pressure redistribution mattress. The care plan failed to address the unstageable area on the right malleolus that was first identified on 11/18/16. Observations on 12/12/16 at 2:20 PM identified Resident #14 sitting upright in bed watching television, there were no pillows under the resident's heels and the mattress was one of the facility's standard mattresses. Observations with the wound Advanced Practice Registered Nurse (APRN) #2, and the Infection Control Nurse, Registered Nurse (RN) #2, on 12/13/16 at 8:45 AM identified Resident #14 lying in bed. When attempting to examine the right ankle area, the resident 's right leg would roll outward and APRN #2 requested each time for the resident to roll the leg inward. Subsequent to the observations, RN #2 stated the resident would be getting a new mattress and APRN #2 stated physical therapy will evaluate the right leg rolling outward. The wound consult note dated 12/13/16 identified an improving stage three (3) right lateral malleolus, continue Allevyn every three (3) days and as needed and physical therapy evaluation for ongoing abduction of the right leg. 3. Resident #11's [DIAGNOSES REDACTED]. The admission and 14-day Minimum Data Set assessments dated 11/6/16 and 11/11/16 identified Resident #11 identified had some memory deficits, required extensive one person assistance with bed mobility, transfers in and/or out of the bed and chair, toilet use and personal hygiene, was frequently incontinent of urine, weighed seventy-one (71) pounds and had no pressure areas. The resident care plan dated 11/1/16 identified the resident was at risk for skin breakdown. Interventions directed to encourage and/or assist the resident to reposition every two (2) hours, inspect the skin when giving care, and wound care as ordered. A revision dated 11/15/16 directed to apply a M65 mattress to the bed and set firmness to weight. The November 2016 Treatment Administration Record (TAR) identified a sacral wound on 11/8/16. A physician's order [REDACTED]. A physician's orders [REDACTED]. The skin and wound tracking record dated 11/11/16 identified an area of maceration on the sacrum that evolved to a stage two (2) pressure area on 11/15/16 measuring 1 centimeter (cm) by 0.1 cm. A physician's orders [REDACTED]. The wound consult note dated 12/6/16 identified the coccyx area was now unstageable related to 100% slough and the treatment was changed to protective ointment to the periwound, then Santyl and Allevyn to cover the wound daily times fourteen (14) days. On 12/13/16 the wound consult note identified improvement and the treatment remained the same. Interview with Resident #11 on 12/12/16 at 10:10 AM identified the area opened because of sitting on the bedpan waiting for staff to assist with getting off. Resident #11 indicated he/she used the small bedpan and questioned why a larger could not be used. Review of the resident plan failed to reflect documentation that the care plan was reviewed and/or revised to implement new interventions to promote healing and/or prevent further occurrence. 4. Resident #12's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #11 required extensive two person assistance with bed mobility, one person extensive assistance with personal hygiene and dressing, was at risk for pressure ulcers and had no open areas. Review of the resident care plan dated 10/27/16 through present failed to reflect documentation that the risk for skin breakdown was addressed and interventions implemented. The weight record summary identified from 10/12/16 through 12/5/16 Resident #12's weight ranged from the lowest being 94.8 pounds to the highest 103.6 pounds. Review of the individualized resident assignment identified an air loss mattress (MA 85) to be set at #3. The card failed to reflect documentation to off load the heels. The wound consult note dated 11/221/6 identified a left heel deep tissue injury area with the onset on 11/18/16. The note directed to off load at all times and to continue with Allevyn, change every three days and as needed times fourteen (14) days. The skin and wound tracking record identified the area was a stage two (2) area. Observations on 12/12/16 at 11:00AM Resident #12 was seated in a wheelchair with socks on and an air loss mattress was noted on the bed with the setting at #3. Observations of the control panel identified the mattress was set according to the resident's weight and the setting of #3 was for a weight of 140 pounds and the weight of 105 was #2. Interview with the Administrator, Director of Nursing, RN #2 and the Corporate Nurse on 12/13/16 at 2:00 PM identified off-loading meant to suspend the heels off the bed. The mattress settings were by weight for the MA85 and/or resident comfort for the other air mattresses. Observations with the Infection Control Nurse, Registered Nurse (RN) #2, and the Corporate Nurse on 12/13/16 at 2:55 PM identified Resident #12 lying in bed on the left side, the mattress seating was #3, the heels were noted on the bed and the right foot was pressing into the left heel area. Subsequent to the observation, the setting was changed to #2 and the heels were off loaded. Interview with the Wound Advanced Practice Registered Nurse on 12/13/16 at 7:55 AM identified that she has been in the facility for a couple of months, not a full year. Interview with the Infection Control Nurse, Registered Nurse (RN) #2, on 12/13/16 at 7:55 AM identified she started at the end of October. RN #2 stated that she completed an Infection Control course which included wound care prevention, staging, nutrition, etc., the course was not a specific wound management course. Interview with the Corporate Nurse on 12/13/16 at 2:30 PM identified RN #2 was new to wound management and she was not aware if RN #2 had taken and/or was enrolled in a wound management course. Review of the policy for Heel Ulcer Management identified the most effective intervention for heal ulcers was to eliminate pressure by suspending the heels off the surface of the bed. If utilizing a low air loss mattress which provides pressure redistribution, the off-loading of heels may not be indicated unless otherwise ordered by the physician. 5. Resident #15's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #15 had no memory or cognitive deficits, required extensive one person assistance with bed mobility, dressing and personal hygiene, had functional limitation in range of motion on one side upper and lower extremities, was at risk for the development of pressure ulcers and had no open areas. The resident care plan dated 11/17/16 identified the resident was at risk for pressure ulcers. Interventions directed to off load pressure to the heels with a pillow and pressure redistribution mattress. The individualized resident assignment directed to off load in bed, the resident has a blue hell manager. A physician's orders [REDACTED]. Observations and interview with the wound Advanced Practice Registered Nurse (APRN) #2, and the Infection Control Nurse, Registered Nurse (RN) #2, on 12/13/16 at 8:54 AM identified the resident ' s heels were on the mattress, there was no pillow under the feet and the feet were noted with [MEDICAL CONDITION]. 6. Resident #16's [DIAGNOSES REDACTED]. The resident care plan dated 11/21/16 identified the resident was at risk for skin breakdown. Interventions directed to encourage and/or assist to reposition side to side when in bed, inspect skin when giving care, and to provide a pressure reduction cushion for the wheelchair and chair. The 14-day Minimum Data Set assessment dated [DATE] identified Resident #16 had no memory or cognitive deficits, required extensive one person assistance with bed mobility, limited one person assistance with personal hygiene and dressing, was continent of bowel and bladder, and had no pressure ulcers. The skin and wound tracking record dated 12/8/16 identified a stage two (2) pressure area on the coccyx that measured 1.8 centimeters (cm) by 1.5 cm by 0.1 cm resulting from ruptured blisters. A fax sheet dated 12/8/16 identified the physician was notified of the open area and directed to cleanse the area with normal saline followed by Allevyn Gentle Border dressing , change every three (3) days and as needed times fourteen(14) days. Review of the December 2016 Treatment Administration Record (TAR) identified triad paste to the coccyx and buttocks twice a day and offload the heel at all times. The TAR failed to reflect the physician's orders [REDACTED]. A physician's orders [REDACTED]. Observations with the wound Advanced Practice Registered Nurse (APRN) #2, and the Infection Control Nurse, Registered Nurse (RN) #2, on 12/13/16 at 8:35 AM identified Resident #16 lying in bed on his/her back with a pillow under the thighs to the knees and the heels were noted to be directly on the mattress. Resident #16 was repositioned onto the right side for an observation of the coccyx area. The coccyx was noted to have a white cream and no dressing. RN #2 identified the resident was supposed to have a dressing on the area. At the time of the observations, Resident #16 stated the mattress was firm and the previous mattress was more comfortable. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #5 on 12/13/16 at 8:31 AM identified she had not been informed by the 11PM-7AM charge nurse there was no dressing and/or by the 7AM-3PM nurse aide. Interview with the 7AM-3PM nurse aide on 12/13/16 at 8:33 AM identified she was not aware the dressing was off.

Based on clinical record review and interviews for 1 (R#1) of 3 residents reviewed for anticoagulant use the facility failed to ensure safe administration of anticoagulants. The findings include: R#1 was admitted to the facility with [DIAGNOSES REDACTED]. An annual minimum data set ((MDS) dated [DATE] indicated R#1 had severely impaired cognition with deficits in long and short term memory. The assessment further indicated R#1 required extensive assistance of one staff member for activities of daily living (ADL's). A Resident Care Plan (RCP) updated 10/1/16 indicated R#1 was at risk for bleeding and interventions included to provide R#1 with medications as ordered by the physician. A subsequent RCP dated 11/15/16 indicated R#1 had received two anticoagulant medications simultantiously in error. Interventions included discontinuation of all anticoagulant medications with the exception of Aspirin. 1a. A physician order [REDACTED].) daily by mouth (PO). The order was noted on 10/19/16 by Licensed Practical Nurse (LPN)#1 and co-noted by LPN#2 on 10/19/16. b. A Medication Administration Record [REDACTED]. on 10/20/16 at 9:00 AM. The MAR indicated [REDACTED]. c. Review of the medical record failed to identify that the pharmacy had been contacted to inquire as to why the Xarelto was not available and/or that the physician/APRN was notified that R#1 was not receiving the Xarelto and/or [MEDICATION NAME] from 10/20/16 to 10/23/16. 2a. According to the MAR indicated [REDACTED]. orally by LPN#1. In addition on 10/24/16 a telephone physician's orders [REDACTED]. was to be administered orally for 2 days with a repeat INR on 10/26/26. According to the MAR indicated [REDACTED]. on 10/24/16 at 8:00 PM by LPN#2. 2b. According to the MAR indicated [REDACTED]. at 9:00 AM and [MEDICATION NAME] 2 mg. at 8:00 PM. 2c. According to the MAR indicated [REDACTED]. at 9:00 AM and [MEDICATION NAME] 3 mg. at 8:00 PM. 2d. According to the MAR indicated [REDACTED]. at 9:00 AM. A nurse's note dated 10/27/16 indicated R#1 had a nosebleed at 10:00 AM that intermittently lasted until 12:00PM. The physician was notified, an INR was obtained and [MEDICATION NAME] was held for an elevated INR of 3.1. A repeat INR was ordered for 10/28/16. 2e. According to the MAR indicated [REDACTED]. at 9:00 AM. R#1's INR result was 2.1 and [MEDICATION NAME] 2 mg. was administered at 8:00 PM per physician order. A repeat INR was ordered for 10/31/16. 2d. A physicians order dated 10/29/16 instructed that R#1 be sent to Hospital #1 for evaluation of an uncontrolled nosebleed. A subsequent Surgical Critical Care Progress Note from Hospital #1 indicated upon arrival R#1 presented with epistaxis (nosebleed) and was found to have a supratherapeutic INR of 4.0 (normal 2.0 to 3.0). During nasal packing R#1 had an episode of voluminous hematemesis (prolonged and vigorous retching that causes tears in the mucosa). After the event R#1 desaturated to an oxygen saturation in the 40' s requiring rescue [MEDICAL CONDITION] (a form of non-invasive mechanical pressure support ventilation). R#1 was treated at Hospital #1 from 10/29/16 to 11/15/16 and was then readmitted to the facility. In addition review of the Nursing Supervisor 24 hour report sheets dated 10/19/16 through 10/23/16 failed to identify the Xarelto was ordered and was not available and/or had not been administered. During an interview with LPN#1 on 12/8/16 at 1:15 PM LPN#1 indicated after noting the physicians order for the Xarelto on 10/19/16 he/she inadvertently did not complete the ordering process by notifying the pharmacy of the new order. LPN#1 indicated on 10/24/16 when he/she saw R#1 was not receiving the medication he/she notified the pharmacy of the order and administered the first dose. LPN#1 indicated he/she had not questioned R#1 being on [MEDICATION NAME] and Xarelto concurrently. During an interview with Medical Doctor (MD) #1/Advanced Practice Registered Nurse (APRN) #1 on 12/8/16 at 2:00 PM, MD#1 and APRN#1 indicated neither he/she had not been notified that R#1 had not received the Xarelto from 10/20/16 to 10/23/16. In addition APRN#1 indicated he/she had not recalled R#1 being placed on Xarelto when ordering the [MEDICATION NAME]. MD#1 indicated he/she would expect the nurse, who had access to the chart, to question the ordering practioner when 2 anticoagulants are ordered for concurrent administration. During an interview with the Director of Nursing (DON) and Corporate Registered Nurse (RN) on 12/8/16 at 2:00 PM he/she indicated when the Xarelto was not available the nurse should have documented the reason the medication was not administered and question why it had not been administered after 24 hours. In addition the nurses should have questioned the use of two anticoagulants concurrently. They indicated when the medication was not administered the physician/APRN should have been notified. They also indicated all new orders and medications not available should have been communicated through shift to shift supervisor report. Facility Non-Controlled Medication Order Documentation Policy indicated the prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be administered. Facility Medication Administration Policy indicated if a nurse is unfamiliar with a medication he/she should consult a drug reference, manufacturer package insert, or pharmacist for more information.

Based on observations, clinical record reviews and interviews for eight of thirty seven sampled residents reviewed for the provision of necessary care and services to attain or maintain the highest practicable physical,mental and psychosocial well being, in accordance with the comprehensive assessment and plan of care. For two of six residents reviewed for pain (Resident#149 and Resident #162) the facility failed to address the resident's pain during a treatment and/or administer medications according to physician orders and/or For one sampled resident (Resident #137), the facility failed to ensure the dressing was conducted per the physician's order and/or For two of six residents (Resident #158 , Resident #162 ) reviewed for accidents, the facility failed to ensure a Registered Nurse was notified and conducted an assessment following a fall and/or For three of three sampled residents (Resident #72, #50 and #105) who required [MEDICAL TREATMENT], the facility failed to monitor the residents' fluid consumption to ensure compliance with the fluid restriction in accordance with the physician's order and/or failed to ensure physician orders were followed regarding medication time administration and/or For one of three sampled residents (Resident #105) who required [MEDICAL TREATMENT], the facility failed ot obtain a physician's order prior to administering a medication without a physician's order and/or For one of three sampled residents (Resident #72) who required [MEDICAL TREATMENT], the facility failed to maintain communication with the [MEDICAL TREATMENT] center post treatment . The findings include: 1. Resident #149 ' s [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident had severely impaired cognition, required extensive assistance of two for bed mobility, functional limitations in range of motion to bilateral lower extremities (i.e. hip, knee, ankle, foot) and 3 unstageable pressure ulcers. The care plan dated 04/06/16 identified the potential for pain related to bilateral heel pressure ulcers and osteo[DIAGNOSES REDACTED] with interventions that included; determine the characteristics of pain such as quality, location, severity, onset, duration and any precipitating factors, offer a distraction to take thoughts away from the pain that the resident may be experiencing, listen to my complaints of pain and administer scheduled pain medication as ordered. A review of the monthly physician ' s orders for May 2016 identified an order for [REDACTED].#1 performing a dressing change to the unstageable pressure ulcer on the coccyx and to 3 unstageable pressure ulcers on the right and left heel and the left great toe. Resident #149's heels were placed on the bed and the resident immediately began verbalizing that his/her heels hurt and asked if his/her heels could hang off of the bed. Resident #149 moved her legs in a restless motion but was unable to relieve the pressure. Resident #149 verbalized that her heels were sore throughout the process of LPN#1 performing the dressing changes. The resident ' s feet were not offloaded during the treatment; they remained on the mattress surface throughout the entire time. The resident ' s heels were not relieved of pressure until 12:05 PM( thirty six minutes after the treatment began).Interview with LPN #1 on 05/12/16 at 12:15 PM identified she had not pre-medicated the resident for pain and could not explain why she had not elevated the resident ' s heel off of the mattress surface upon resident request and continued to complaints of heel pain during the treatment. 2a. Resident #162's [DIAGNOSES REDACTED]. The admission physician's order dated 6/23/15 directed [MEDICATION NAME] HCL Extended Release 40 milligram (mg) twice daily, [MEDICATION NAME] 500 mg two (2) tablets every six (6) hours as needed, [MEDICATION NAME] 5 mg every three (3) hours as needed for moderate pain, and [MEDICATION NAME] 10 mg every three (3) hours as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #162 had no cognitive impairments, received a scheduled pain medication regimen, received an as needed pain medication, verbalized complaints of pain, and the pain was observed daily. The MDS further identified the resident required extensive two person assistance with transfers in and/or out of the bed and chair, assist of one person with locomotion on and off the unit, balance during transition was not steady but the resident was able to stabilize without staff assistance and a walker and wheelchair were utilized for mobility. Review of the clinical record identified Resident #162 received the [MEDICATION NAME] on 6/25/15 at 12:30 PM and on 6/26/15 at 4:00 PM. The record failed to reflect documentation the [MEDICATION NAME] was administered on 6/26/15 from 8:30 AM through 4:00 PM. The Reportable Event Form dated 6/26/15, 11-7 AM shift, identified Resident #162 requested pain medication from the charge nurse but did not receive medication. In an interview and review of the clinical record with the 11-7 AM charge nurse, LPN #2, on 4/28/16 at 7:45 AM identified she administered [MEDICATION NAME] 5 mg and [MEDICATION NAME] 1000 mg on 6/26/15 at 12:30 AM. LPN #2 stated at approximately 8:30 AM a nurse aide informed her that Resident #162 requested pain medication and she prepared [MEDICATION NAME] 10 mg. LPN #2 identified when she went to administer the medication, the 7-3 PM Nursing Supervisor requested to conduct the narcotic count since the oncoming 7-3:00 PM charge nurse was late. LPN #2 stated after the narcotic count was completed she administered the [MEDICATION NAME] 10 mg at 8:30 AM and at this time Resident #1 requested the [MEDICATION NAME]. LPN #2 identified she informed the resident she will return with the requested medication or she will inform the oncoming nurse of the request. LPN #2 stated that she informed the oncoming 7-3 PM nurse of the resident's request. LPN #2 stated that she became aware that the resident did not receive the medication when she received a phone call from the DON. In an interview on 4/28/16 at 11:15 AM and review of a written statement dated 6/26/15, RN #3 could not recall the details of the incident on the morning of 6/26/15. In an interview on 4/28/16 at 2:15 PM, the DON identified that a resident's request for medication should be addressed at the time of the request. b. The fall assessment dated [DATE] identified the resident was at risk for falls. The Resident Care Plan (RCP) dated 7/1/15 identified the resident was at risk for falls. Interventions directed to keep the bed in lowest position, transfer assist of one with a rolling walker, sensor alarm when in bed and check placement and function every shift, and call bell within reach when in bed or bedside chair. The 11-7 AM Registered Nurse (RN) nurse's note dated 8/23/15 at 3:00 AM identified that Resident #162 complained of left hip and thigh pain stating that he/she fell this past evening after supper and a nurse aide and nurse assisted him/her back to bed. The assessment identified there was no discoloration, no visible signs of trauma and there was positive range of motion with no distress. The physician and responsible party were notified and recommendations were pending. The 11-7 AM Nursing Supervisor nurse's note dated 8/23/15 at 5:00 AM identified Resident #162 was complaining of not feeling well, had a temperature of 100.3 degree Fahrenheit, pending x-ray for left hip pain and the resident requested to be sent to the hospital. Subsequent to an update a physician's order directed to send the resident to hospital for an evaluation. An addendum nurse's note dated 8/23/15 written by the 3-11 PM charge nurse, Licensed Practical Nurse (LPN) #4, for 8/22/15 identified at 6:45 PM the nurse aide assigned to Resident #162 notified LPN #4 that the resident had slid out of the wheelchair. On entering the resident's room LPN #4 observed Resident #162 sitting on the floor in front of the wheelchair and upon inquiry the resident stated I was standing up and my legs felt very weak so I sat down and sat too close to the edge of the wheelchair and slid to the floor. The note indicated Resident #162 was insistent that the Nursing Supervisor not be notified and further stated I did not hit my head or anywhere else I am not hurt I just want to be put back into my chair. The nurse's note identified that LPN #4 assessed Resident #162 with no findings to upper or lower extremities, noted ongoing [MEDICAL CONDITION] to the right foot and elevated the right foot on a chair. Resident #162 was medicated with [MEDICATION NAME] at 7:00 PM with a positive effect noted at 8:30 PM. The note identified that Resident #162 was assisted to the bathroom and to bed and rested comfortably for the remainder of the shift. The nurse's note failed to reflect documentation the 3-11 PM Supervisor was notified and/or an assessment was conducted by a registered Nurse. The Reportable Event Form dated 8/23/15 identified that Resident #162 complained of left hip pain and alleged that she slid from the wheelchair to the floor on 8/22/15. Review of facility investigation and staff statements identified Resident #162 was found on the floor in his/her room on 8/22/15 at 6:30 PM by the Nurse Aide (NA) #3. LPN #4 was notified by NA #3 of the incident. LPN #4 assessed the resident and with the assistance from NA #3 transferred the resident to the bed without notifying the supervisor. LPN #4 was terminated on 8/26/15. In an interview on 4/28/16 at 9:15 AM, NA #3 identified during the 3:00-11:00 PM shift on 8/22/15 she found Resident #162 on the floor in the resident's room and reported this to LPN #4. NA #3 stated that LPN #4 assessed Resident #162 and then she and LPN #4 transferred the resident back to bed or the chair. Interview with the 3-11 PM Nursing Supervisor, RN #2, on 4/28/16 at 10:05 AM identified she was on duty 8/22/15 and was not informed that Resident #162 had fallen. RN #2 stated she was notified of the incident on 8/23/15 when she came in to work at 3:00 PM. Multiple attempts were made to contact LPN #4 with no return call. 3. Resident #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note dated 4/8/16 identified the resident was found with an abrasion to the left upper arm and after physician notification, the area was cleansed and a dry clean dressing was applied. Physician orders dated 4/8/16 directed to cleanse the left arm abrasion with normal saline, pat dry and apply a dry clean dressing every three days for fourteen days. Observation on 5/9/16 at 10:00 AM identified the resident had a dressing on the left elbow area dated 4/27/16 (12 days prior).Interview and observation with the ADNS on 5/9/16 at 10:00 AM identified he/she could not identify why the dressing had not been changed for 12 days. The ADNS removed the dressing dated 4/27 and a small open area was noted. The ADNS indicated the charge nurse is responsible to ensure the treatments are renewed and completed. Additionally, he/she indicated the treatment for [REDACTED]. Physician order dated 5/9/16 directed to cleanse the left elbow area with normal saline, apply skin prep to the periwound followed by AGB dressing, change every three days and check every shift. Review of the facility protocol on skin tears directed that current interventions should be re-assessed weekly to determine their appropriateness. 4. Resident#158 [DIAGNOSES REDACTED]. The nursing fall risk assessment dated [DATE] identified the resident was a moderate risk for falls. The admission MDS assessment dated [DATE] identified severe cognitive impairment, extensive assistance for transfers, ambulation, personal hygiene and toilet use. The care plan dated 4/15/16 identified a risk for falls with interventions that included to keep the resident within visual field of the staff as resident allows, use of a sensor alarm when in bed or the wheelchair, frequent checks for safety and anticipate the resident needs. The nurses note dated 4/16/16 at 3:45 PM identified that while the charge nurse was assisting the resident to the bathroom, the resident stumbled and the charge nurse was unable to break the fall. The nurse's note failed to identify the resident was assessed after the fall. A subsequent nurse ' s note indicated the resident sustained [REDACTED]. Interview with LPN#2 on 5/11/16 at 3:50 PM identified on 4/16/16 Resident#158 was seated at the nurse's station. LPN #2 heard the chair alarm sound and the resident was observed to be independently ambulating off the unit. LPN#2 assisted the resident back to the unit at which time Resident #158 requested to use the bathroom. While LPN#2 was holding onto Resident #158 by the waist to lead R#158 back to his/her wheelchair, the resident bent forward to pick up toilet paper and lost his/her balance. LPN#2 then grabbed the resident's waist to break his/her fall and Resident #158 bumped the wall with his/her upper body . Further interview indicated that LPN#2 did not report the incident to the RN Supervisor for evaluation and assessment following the incident. LPN#2 indicated that since a fall did not occur, he/she did not believe a report and further assessment was warranted. Interview and clinical record with the DNS on 5/11/16 at 4:30 PM identified that an assessment of the area and intervention was completed when a family member noted the area on the left arm more than two hours later. The nurse notes indicated that ice pack and Tylenol 650 mg was provided for pain control. The DNS further identified it is the responsibility of the charge nurse to notify the Nursing Supervisor regarding any incidents that require an assessment of the resident. 5. Resident #72's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] identified Resident #72 had severe cognitive impairment, required extensive one person assistance with activities of daily living, received a therapeutic diet and required [MEDICAL TREATMENT]. The Resident Care Plan dated 1/12/16 and 4/7/16 identified [MEDICAL TREATMENT]. Interventions directed to monitor the fluid intake and output, monitor the [MEDICAL TREATMENT] site as ordered, monitor weights, administer medications, and provide a therapeutic diet. A physician's order dated 1/4/16 directed to increase the resident's the fluid restriction from 1000 cubic centimeters (cc) to 1300cc per day. Observations on 4/26/16 at 12:30 PM Resident #72 was lying in bed with the over the bed table in front of the resident. Noted on the table was a 20 ounce bottle of iced tea with a quarter of the bottle missing, a water pitcher, a small cup of water that was almost empty and a bowl of soup. On 4/27/16 at 11:05 AM Resident #72 was out of bed sitting in the wheelchair with the over the bed table in front of the resident with a 20 ounce bottle of iced tea, a large cup of water half gone and a small glass of cranberry juice. On 4/28/16 at 2:10 PM Resident #72 was observed sitting in his/her room with the over the bed table in front of the resident. The table had a water pitcher, a large cup of water, a small cup of water, a large cup of cranberry juice, a small cup of juice not opened, a cup of ice cream and on the night stand was a 20 ounce bottle of iced tea and ginger ale, both half gone. The Advanced Practice Registered Nurse (APRN) progress note dated 2/3/16 identified the resident's blood pressure was usually acceptable, and the dates when there were evaluated intake records corresponded with increased blood pressures. The note indicated the APRN discussed with the patient and staff the need to remain at and/or under the fluid restriction limit. An APRN order dated 2/3/16 directed strict intake and output, fluid restriction of 1300 cc per day and do not exceed the fluid restriction secondary to an increase of fluids can elevated the resident's blood pressure. Review of the intake and output sheets from 1/4/16 through 4/26/16 identified out of one hundred and fourteen days (114) days the resident's fluid intake, seventy-one (71) days the resident was over the 1300cc fluid restriction, the excess ranged from 1320cc to 1920cc. Interview with the APRN on 4/27/16 at 10:45 AM identified the reason for the resident's fluid restriction was due to the [MEDICAL TREATMENT] and a history of [MEDICAL CONDITION]. The APRN stated that if the resident was exceeding the fluid restriction then staff should have notified the [MEDICAL TREATMENT] center. Interview with the Registered Dietician on 4/27/16 at 2:45 PM identified the dietary department does not monitor how the resident receives fluids and/or how much. The Dietician stated that she does not always look at the resident's intake and output, but when she did she had in the past reported the results to the [MEDICAL TREATMENT] unit. Interview with the Director of Nursing (DON) on 4/27/16 at 1:25 PM identified the 11-7 shift was responsible for totaling the intake and output and if the resident was going over the fluid restriction the physician is to be made aware. Review of the clinical record at that time with the DON failed to reflect documentation that the physician was informed the resident exceeded the fluid restriction. a. Review of the physician's orders from 12/25/15 through 5/13/16 (4 months and 19 days) identified Resident #72's scheduled morning medications [MEDICATION NAME], Aspirin, [MEDICATION NAME], [MEDICATION NAME], Phoslo Calcium Acetate, [MEDICATION NAME] were to be administered at 9:00 AM. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Upon further review the MAR indicated [REDACTED]. Interview with Resident #72 on 4/26/16 at 12:30 PM identified he/she went to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. Resident #72 stated that he/she eats breakfast before going and takes the medications upon returning to the facility. Interview with the Director of Nursing (DON) on 4/27/16 at 1:25 PM identified Resident #72 usually arrived back to the facility from [MEDICAL TREATMENT] between 10:00 and 11:00 AM and was unaware the resident was receiving the 9:00 AM medications upon return from [MEDICAL TREATMENT] until approximately two weeks ago. The DON stated that after she was told she had the medication times changed so Resident #72 received the morning dose of medications before going to [MEDICAL TREATMENT]. b. A physician's order dated 1/4/16 directed to administer Nephro 240 milliliters (ml) three times a day and to document the percentage taken. Review of the January 2016 MAR indicated [REDACTED]. The February 2016 MAR indicated [REDACTED]. The April 2016 MAR failed to reflect documentation of the percentage consumed from 5/1/16 through 5/27/16. Interview and review of the clinical record with the Dietician on 4/27/16 at 2:45 PM identified she was not aware the staff was not recording the percentage of supplement Resident #72 consumed. c. The Resident Care Plan dated 1/12/16 and 4/7/16 identified [MEDICAL TREATMENT]. Interventions directed to monitor the fluid intake and output, monitor the [MEDICAL TREATMENT] site as ordered, monitor weights, administer medications, and provide a therapeutic diet. Review of the communication book between the [MEDICAL TREATMENT] center and the facility identified Resident #72 had received fifty-two (52) days of treatment since admission and for nine (9) days there was no communication back from the [MEDICAL TREATMENT] center. Review of the nurse's notes failed to reflect documentation that the facility contacted the [MEDICAL TREATMENT] center for a report of the resident's treatment on 1/7/16, 1/12/16, 1/30/16, 2/2/16, 2/20/16, 2/23/16, 4/5/16, 4/7/16 and 4/16/16. Interview and review of Resident #72's clinical record with the Director of Nursing (DON) on 4/27/16 at 1:25 PM identified that if the resident comes back to the facility and there is no documentation, staff are expected to call over to the [MEDICAL TREATMENT] center and document the report in the nursing notes. Review of the clinical record with the DON identified that the nurse's notes failed to reflect documentation the [MEDICAL TREATMENT] center was called on the above dates. 6a. Resident #50's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #50 had no cognitive impairments, required extensive one to two person assistance with activities of daily living, was frequently incontinent of urine, received a therapeutic diet, and received [MEDICAL TREATMENT]. The resident care plan dated 3/9/16 identified a history of [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Interventions directed to administer medications in a timely manner, any questions contact the [MEDICAL TREATMENT] center, [MEDICAL TREATMENT] three times a week, a renal diet 2 Gram Sodium , low fat, low cholesterol fluid restricted diet, monitor the fluid intake and output, monitor blood work, monitor weight as ordered, and observe the [MEDICAL TREATMENT] site as ordered. A physician's order dated 3/27/16 directed to discontinue the fluid restriction of 1000 cubic centimeters (cc) and start 1200 cc per day fluid restriction. Review of the intake and output report from 2/26/16 through 4/27/16 identified that out of fifty-nine (59) days Resident #50 exceeded the fluid forty-seven days and four days the intake and output report failed to reflect documentation of the fluid amount consumed for a twenty-four (24) hour time frame. b. Review of the physician's orders from 4/1/16 through 4/27/16 identified daily medication administration times were at 9:00 AM, twice a day 9:00 AM and 5:00 PM and three times a day 9:00 AM, 1:00 PM and 5:00 PM. Review of the April 2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Interview with the 7-3PM charge nurse, Licensed Practical Nurse (LPN) #3 on 4/28/16 identified Resident #50 received the morning doses of medication when he/she returned from [MEDICAL TREATMENT] around 11:00 AM -12:00 PM and the 9:00 AM was not given. LPN #3 stated on 4/27/16 she reviewed the medication times and updated the attending physician at which time an order was obtained to change the times of the medication. 7a. Resident #105's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #105 had no cognitive impairments, required limited one person assistance with personal hygiene, received a therapeutic diet, and received [MEDICAL TREATMENT]. The resident care plan dated 3/24/16 identified a history of [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Interventions directed to administer medications in a timely manner, any questions contact the [MEDICAL TREATMENT] center, [MEDICAL TREATMENT] three times a week, a consistent carbohydrate, renal diet with a 1500 cubic centimeter (cc) fluid restriction, monitor the fluid intake and output, monitor blood work, monitor weight as ordered, and observe the [MEDICAL TREATMENT] site as ordered. A physician's order dated 4/15/16 directed to resume the 1500 cc fluid restriction. Review of the intake and output report from 4/15/16 through 4/26/16 identified that on four (4) of eleven (11) days Resident #105 exceeded the fluid of 1500 cc and one day the intake and output report failed to reflect documentation of the fluids consumed for a twenty-four (24) hour time frame. The facility policy, Intake and Output (I&O) directs that I&O are instituted on admission and then quarterly for all residents and if there is a physician's order on a resident with a fluid restriction, to record all fluids in the proper column and do not leave a column blank. b. The nurse's note dated 4/23/16 at 8:00 AM identified Resident #105's blood sugar at 6:00 AM was 82, orange juice was given, the blood sugar at 7:15 AM was 41, [MEDICATION NAME] 1 milligram (mg) was administered, the blood sugar at 7:30 AM was 75, the resident was alert and verbal. The note failed to reflect documentation the physician and/or Advanced Practice Registered Nurse (APRN) were notified of the low blood sugar level of 41. Review of the physician's orders from 4/14/16 through 4/26/16 failed to reflect documentation an order for [REDACTED]. If the resident was having an insulin reaction, low blood sugar with symptoms, administer a highly concentrated sugar product while awaiting the physician's direction if the resident is able to take something by mouth. [MEDICATION NAME] is also available in the emergency drug box for administration per the physician's order, notify the responsible party of the change in condition and document in the clinical record all observations, findings and interventions. Interview with the Assistant Director of Nursing (ADON) on 4/28/16 at 1:15 PM identified that [MEDICATION NAME] would normally be administered for a blood sugar less than 60 and/or in accordance with the physician's order.

Based on observations, review of the clinical records and staff interviews for four of six residents ( Resident #50,Resident #149, Resident #2 and Resident #137 ) reviewed for pressure ulcers, the facility failed to implement interventions to prevent the development of a pressure ulcer. The findings include: 1. Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Braden score completed upon admission identified a score of 19 which represented a mild risk for the development of pressure ulcers. The nursing admission assessment dated [DATE] identified redness to the buttocks and boggy heels. The admission MDS assessment dated [DATE] identified intact cognition and required extensive assistance of two staff members for bed mobility and transfers and no pressure ulcers. The care plan dated 3/9/16 identified a risk for skin breakdown with interventions which included to elevate legs when out of bed, inspect skin when giving care for signs of skin breakdown and to offload heels. A review of the weekly body audit dated 3/10/16 identified no pressure areas. The wound APRN note dated 3/11/16 identified a new stage 3 pressure ulcer on the right buttock and recommended treatment with [MEDICATION NAME] and AGB every three days and as needed, initiate MA65 mattress( (low air loss with alternating pressure) and repositioning. Interview and review of the clinical record with LPN#3 on 5/11/16 at 2:25PM identified that although Resident #50 utilized a pressure reducing mattress, she was unable to provide documentation that additional interventions such as turning and repostioning were implemented at the time of admission to prevent the development of a pressure ulcer. LPN#3 identified it is the responsibility of the licensed staff who admitted the resident to implement measures to prevent the development of a pressure ulcer. Interview with Wound APRN#1 on 05/12/16 at 2:00PM identified that the resident ' s skin condition is fragile and that it was possible for the skin to develop a pressure ulcer over a short period of time if interventions such as a turning and repositioning schedule was not implemented in a timely manner . 2. Resident #149 ' s was readmitted on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified severely impaired cognition, required extensive assistance of two for bed mobility, was always incontinent of bowel and bladder, functional limitations in range of motion to bilateral lower extremities (i.e. hip, knee, ankle, foot) and 3 unstageable pressure ulcers. A care plan dated 04/06/16 identified a risk for alteration in skin integrity related to decreased mobility and incontinence, three unstageable pressure ulcers from admission on the heels and left great toe with interventions which included a MA65 mattress (alternating air), assess skin when providing care for signs and symptoms of breakdown, bruising, infection and report any issues as needed, offer to assist with turning and positioning approximately every two hours as needed. The care plan further identified that the MA65 (rented mattress) mattress was changed to a APM (facility mattress) on 05/02/16. a. Review of the skin/wound tracking record identified on 05/09/16 Resident #149 developed a new unstageable pressure ulcer on the coccyx area that measured 1.0cm by 1.0 cm with 100% slough in the wound bed. A physician ' s order dated 05/09/16 directed to cleanse the coccyx wound with Normal Saline, pat dry, apply skin prep to the peri-wound area and apply Santyl ointment and secure with a dry clean dressing daily. The physician orders also directed to discontinue the APM mattress and change to the MA65 mattress. Review of the clinical record and facility documentation failed to identify documentation of a positioning plan/schedule. Interview with the Infection Control Nurse on 05/12/16 at 10:20 AM identified the MA65 mattress was discontinued on 5/2/16 due to budgetary constraints. The Infection Control Nurse further identified the pressure ulcer developed because the resident was changed from the MA65 mattress to the facility mattress which was not as therapeutic as the MA65 mattress. An interview with Wound APRN#1 on 05/12/16 at 2:00PM identified that the resident ' s skin condition is fragile and that it was possible for the skin to develop an unstageable pressure ulcer over a short period of time. Wound APRN #1 further identified that the resident could not change position/off load her weight off of her back/coccyx independently, as she had to assist the resident to turn in order to assess the coccyx wound. An interview with the ADNS on 05/12/16 at 2:15 PM identified that there was no documentation of position changes for the resident because the resident was not on a formal positioning plan. b. Observation on 05/12/16 at 11:29 AM of the dressing change to the coccyx identified LPN #1 failed to apply the Santyl to the wound bed as ordered. Resident # 149 required assistance with changing position during the dressing change process by LPN #1. Interview with LPN #1 on 05/12/16 at 12:15 PM identified that she had not applied the Santyl because it was not available. 3. Resident #2's [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] identified intact cognition, requires extensive assistance of two staff members for bed mobility, transfers and the presence of one unstageable pressure ulcer. The care plan dated 2/4/16 identified the resident was at risk for skin breakdown with interventions that included to encourage the resident to reposition every two hours and offload pressure to heels with a pillow.A physician order dated 3/3/16 directed to discontinue skin prep to the right heel ulcer because it was resolved, but continue to monitor the heels. The 14 day PPS MDS dated [DATE] identified intact cognition, required extensive assistance of two staff for bed mobility, required total assistance of two staff for transfers, and total assistance for toilet use. Additionally, the resident had intact skin but was at risk to develop a pressure ulcer.Physician order dated 4/1/16 directed to off load the heels at all times in bed and complete a body audit weekly on shower day.Nurse's note dated 4/19/16 identified the resident went to the hospital for elective day surgery at 7:00AM. A nurses note dated 4/19/16 identified the resident returned to the facility at 10:00PM, 15 hours later. The interagency transportation report dated 4/19/16, sent with the resident to the hospital for outpatient surgery, identified the residents skin was intact, however, there was no documentation that the resident had a recently healed a pressure ulcer on the right heel or the physician order that directed the heels to be offloaded at all times in bed. The clinical record failed to show a skin assessment was completed when the resident returned from the hospital on [DATE] at 10:00PM, after having been at the hospital for 15 hours. A skin check dated 4/21/16, done during the 3:00PM-11:00PM shift by LPN# 4 identified the residents skin was clean, dry and intact. A nurse's note dated 4/22/16 during the 7:00AM-3:00PM shift, identified that a new unstageable pressure ulcer on the right heel was identified that measured 0.5cm by 0.5cm x 0.0cm with 100% eschar.A wound care specialist note, by Wound APRN #1, dated 5/9/16 identified the resident previously had a pressure ulcer to this area on the right heel that had resolved. Recommendations included offloading the heel with a heel lift and continuing with skin prep twice daily. Interview with LPN# 4 on 5/11/16 at 2:40PM identified that after the resident ' s bed bath on 4/21/16 during the 3:00PM-11:00PM shift and he/she did go in and look at the residents skin. LPN# 4 indicated that there were no noted areas. Interview with the ADNS on 5/9/16 at 1:15PM identified that the facility does not have a policy that directs staff to complete a skin assessment when the resident returns from a procedure. However, if the resident had an incident while out, then he/she would expect a skin assessment to be completed. Interview with Wound APRN #1 on 5/11/16 at 3:15PM identified that regarding the skin check by LPN#4 of 4/21/16 that documented the resident ' s skin as intact; he/she indicated that eschar takes time to develop. The skin would become red and non blanchable, then purple then brown then with eschar. It is not likely that eschar would have developed in less than 24 hours between the clear skin audit of 4/21/16 and the identification of the eschar on the heel on 4/22/16. When the resident was transported to the hospital on [DATE], it would have been good practice to communicate to the hospital the intervention of offloading the heels. Wound APRN #1 indicated that the resident had something in that area on the right heel in past, so it's more likely to have skin breakdown in that area. Being at the hospital without pressure relief for an extended time could have caused the skin to decline. Wound APRN #1 indicated that it is prudent to communicate to the hospital that there is a need for elevation of the heels, but APRN #1 indicated that he/she does not see that type of communication occurring. 4a. Resident #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].Physician order dated 11/1/15 directed to complete a full body audit every week on shower day.The care plan dated 11/4/15 identified a risk for pressure ulcer development with interventions that included to consult with the dietitian as needed and to lotion the skin everyday with care. A skin audit dated 11/23/15 identified no pressure ulcers were present and the skin was intact. Review of the clinical record, skin audit sheet and TAR identified that a complete skin check was not completed on 11/30/15 per the physician order.The wound record dated 12/2/15 identified the resident developed a Suspected Deep Tissue Injury (SDTI) on the left lateral heel. The physician was notified and directed to provide offloading of both heels at all times in bed, no shoes, non-skid socks only and a special mattress for the bed. The physician's order dated 1/16/16 directed to apply Prevalon heel lift boots to offload heels and remove for care. b. Observation on 5/12/16 at 11:00AM identified the resident in bed, without the benefit of the Prevelon boots or another device to afford offloading of the heels. Additionally, the resident ' s left heel pressure ulcer was directly in contact with the mattress. Interview with NA#7 on 5/12/16 at 11:15AM identified that he/she did not see the boots on the resident today or yesterday 5/11/16. Interview with the ADNS on 5/12/16 at 11:20AM he/she checked the resident's room and could not find the Prevelon boots. The ADNS indicated he/she would check to see where the Prevelon boots were and placed a pillow under the resident ' s calves to offload the heels. Interview with LPN #3 on 5/12/16 at 1:00PM identified a wound note dated 4/18/16 indicating the APRN discontinued the Prevelon boots because the resident was noncompliant with wearing them. Review of the clinical record failed to reflect documentation that other measures to offload the heels were implemented when the resident was noncompliant. Although, LPN#3 indicated staff had attempted to use a heel lift manager and other measures to offload the heels the clinical record failed to reflect other pressure relieving interventions were implemented after the discontinuation of the Prevelon boots. Review of the facility policy on body audits identified that all residents will have a weekly body audit completed and documented, by a licensed nurse. The procedure directed that a licensed nurse will conduct a weekly skin audit, preferably on shower day to identify any alterations in skin integrity.

Based on clinical record review and interview for two of three residents (Resident #158 ) reviewed for accidents, the facility failed to revise the care plan for a resident with a history of falls to address the residents impulsive behavior of standing and ambulating independently,and/or for one of three sampled residents( Resident #10) reviewed for accidents, the facility failed to ensure that the resident was provided adequate supervision during a transfer and/or for one of three sampled residents (Resident #81) who had difficulty with swallowing and was at risk of aspiration, the facility failed to ensure the resident was supervised during a meal. The findings include: 1. Resident#158 [DIAGNOSES REDACTED]. The nursing fall risk assessment dated [DATE] identified the resident was a moderate risk for falls. The admission MDS assessment dated [DATE] identified severe cognitive impairment, extensive assistance for transfers, ambulation, personal hygiene and toilet use. The care plan dated 4/15/16 identified a risk for falls with interventions that included to keep the resident within visual field of the staff as resident allows, use of a sensor alarm when in bed or the wheelchair, frequent checks for safety and anticipate the resident needs. The nurses note dated 4/16/16 at 3:45PM identified that while the charge nurse was assisting the resident to the bathroom, the resident stumbled and the charge nurse was unable to break the fall. The nurse's note failed to identify the resident was assessed after the fall. A subsequent nurse ' s note indicated the resident sustained [REDACTED]. Interview with LPN#2 on 5/11/16 at 3:50PM identified on 4/16/16 Resident#158 was seated at the nurse's station. LPN #2 heard the chair alarm sound and the resident was observed to be independently ambulating off the unit. LPN#2 assisted the resident back to the unit at which time Resident #158 requested to use the bathroom. While LPN#2 was holding onto Resident #158 by the waist to lead R#158 back to his/her wheelchair, the resident bent forward to pick up toilet paper and lost his/her balance. LPN#2 then grabbed the resident's waist to break his/her fall and Resident #158 bumped the wall with his/her upper body . Further interview indicated that LPN#2 did not report the incident to the RN Supervisor for evaluation and assessment following the incident. LPN#2 indicated that since a fall did not occur, he/she did not believe a report and further assessment was warranted. Interview and clinical record with the DNS on 5/11/16 at 4:30PM identified that an assessment of the area and intervention was completed when a family member noted the area on the left arm more than two hours later. The nurse notes indicated that ice pack and Tylenol 650 mg was provided for pain control. The DNS further identified it is the responsibility of the charge nurse to notify the Nursing Supervisor regarding any incidents that require an assessment of the resident. b. The nurse notes dated 4/22/16 at 1:55PM identified the resident was found on the floor near a waste basket. Interview with the Social Worker (SW) on 5/11/16 at 12:39PM identified Resident #158 chair alarm sounded and the resident was observed in front of the nurse's station walking independently toward a waste basket and discarded a piece of paper. The SW called the resident's name in an attempt to redirect the resident, however the resident lost his/her balance and was assisted to the floor by the SW. No injuries were identified following the incident.The accident/indicdent report dated 4/22/16 at 1:55PM identified actions taken following the incident included to provide adult coloring sheet, magazine or musical instrument. The clinical record lacked documentation that the care plan was revised to include the diversional activities as identified on the accident/incident report following the fall. c. The accident/incident report dated 4/29/16 at 6:25PM identified the staff responded to the alarm sounding and the found the resident on the floor in his/her room. Resident#158 complained of right shoulder pain and a small laceration was found on the back of the head. The resident was then sent to the emergency room for an evaluation. The Orthopedic consultation identified the resident sustained [REDACTED]. The hospital evaluation further identified the resident sustained [REDACTED]. Interview with NA#5 on 5/11/16 at 3:10PM identified the resident normally eats supper in the dining room, however the resident requested to eat in her room on 4/29/16. NA #5 identified she passed by the resident's room and observed the resident eating supper in between providing care to other residents. NA#5 indicated that she then walked into the adjoining hallway and was notified shortly after that the resident was on the floor. Although the care plan was updated regarding the fall, the care plan was not revised and/or new interventions implemented to address the residents implusive behavior. d. The nurse notes dated 5/7/16 identified the resident was seated at nurse's station, stood up and immediately fell to the floor, striking her forehead on the floor . The forehead was bleeding and a ecchymotic right eye was observed. Emergency 911 was called and the resident was sent to the emergency room for an evaluation. Review of hospital records dated 5/7/16 identified the resident sustained [REDACTED].#2 on 5/11/16 at 3:15PM identified that the resident was observed to stand up suddenly but she could not respond quick enough to prevent the resident from falling. Interview and review of the clinical record with the DNS on 5/11/16 at 3:30PM failed to identifiy that interventions were implemented following the 4/29/16 fall to address Resident # 158's implusive behaviors of standing and ambulating independently. The DNS identified Resident #158 was placed at the nurse station due to its high visibility so that staff can monitor the resident, however he/she was not able to ensure staff remained at the nurse's station to provide supervison. 2. Resident #10 ' s [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified moderately c impaired cognition, required extensive assistance of two staff members for transfers, did not ambulate, had upper and lower extremity functional limitations in range of motion and was unsteady and only able to stabilize with human assistance with surface to surface transfers which would include transfers from the wheelchair to the bed. A fall risk assessment dated [DATE] identified a score of 17 which represented a risk for falls. The current care plan identified a history of falls, decreased balance and strength with interventions that included encouraging the resident to wear nonskid socks only. The May 2016 physician orders [REDACTED].An observation on 05/09/16 at 12:45 PM identified the resident in his/her room requesting to go to bed. LPN#5 and NA#4 transferred the resident from the wheelchair to the bed without the benefit of a gait belt and/or nonskid socks. NA#4 provided support and guidance to the resident by holding and pulling on to the waist band of the resident ' s pants. The resident did not stand erect; she remained in a bent over position during the transfer and did not appear steady on her/his feet. In an interview on 05/12/16 at 9:50 AM with NA #4, she identified that she is supposed to use a gait belt for all transfers and noted that that the resident usually stands and pivots but the transfer was more difficult. An interview on 05/12/16 at 10:00 AM with the ADNS identified that the staff had recently been in serviced on the use of gait belts and the facility policy directs for the use of a gait belt for all resident transfers.Review of the facility ' s gait belt policy identified that each nurse aid will have a gait belt on his/her person, or readily available and gait belts will be used for transfers of residents who need the assist of 1 or 2 or who are unsteady with ambulation. 3. Resident #81's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #81 had moderate cognitive impairments, required extensive one person assistance with eating, had functional limitation in range of motion of both upper extremities, received a mechanical altered diet and failed to reflect the resident had signs and/or symptoms of a swallowing disorder. The Resident Care Plan (RCP) dated 5/7/15 identified the resident had difficulty swallowing and was at risk for aspiration. Interventions directed one to one supervision during meals, total assist for feeding, alternate liquids and solids, provide diet as ordered, to remain in an upright position at ninety (90) degrees for all oral intake and for at least thirty (30) minutes after, encourage to eat slowly and take time chewing and swallowing and follow up with the speech therapist as needed for safe swallowing techniques. A physician's orders [REDACTED]. The nurse's note dated 6/16/15 at 8:30 AM identified that a code blue was called when Resident #81 was observed to be in acute respiratory distress and undigested food was noted in the resident's mouth. The note indicated the Advanced Practice Registered Nurse (APRN) #1 was in the facility at the time and performed the Heimlich maneuver with back and abdominal thrusts. Circumoral cyanosis, a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood was noted, the resident was suctioned, placed on oxygen via a non-rebreather and transferred to the hospital at 9:15 AM. The Reportable Event Form dated 6/16/15 identified during breakfast Resident #81 was observed to be in acute respiratory distress. In a written statement the cook identified she served Resident #81 breakfast on 6/16/15 and at the time a nurse aide was seated at the table. The report identified Nurse Aide (NA) #1 was feeding Resident #81 and left the resident to attend to another resident. When NA #1 returned to Resident #81 she noted the resident was attempting to retrieve something from his/her mouth. NA #1 called for assistance, the Heimlich maneuver was performed, an obstruction blocking the airway was removed and the resident was transferred to the hospital. The facility's conclusion identified Resident #81 was an impulsive eater and that was the reason why he/she needed to be fed. The hospital discharge summary dated 6/19/15 identified Resident #81's discharge [DIAGNOSES REDACTED]. The discharge orders directed a pureed diet, honey thickened liquids and that the resident could not eat by him/herself. The APRN progress note dated 6/22/15 identified that during transport to the hospital on [DATE], a large food bolus was removed by the Emergency Medical Technician. Interview with NA #1 on 4/27/16 at 10:20 AM identified on 6/16/15 during the breakfast meal she was assigned to the residents who required assistance with feeding. NA #1 stated Resident #81 was seated at the table and prior to feeding the resident she went to attend to another resident. NA #1 recalled the meal was uncovered, placed out of Resident #81's reach and there was another nurse aide (NA #2) at the other end of the table. NA #1 identified that she did not tell the other she was leaving Resident #81 unattended. NA #1 stated upon return to Resident #81 she noted the resident had removed something from his/her mouth, looked funny and told NA #2 to get help while she remained with the resident. In an interview on 4/27/16 at 10:40 AM, NA #2 identified on the morning of 6/16/15 she was in the dining room setting up residents who were independent with their meals when NA #1 called for assistance. NA #2 stated Resident #81 looked like he/she was choking and proceeded to get help from the Nursing Supervisor who was in close proximity at the time. Interview with the Director of Nursing (DON) on 4/28/16 at 2:15 PM identified that the tray should not have been left in front of the resident while unattended. Subsequent to the incident all nursing and dietary staff received an in-service education on the Heimlich maneuver and not to leave food unattended for a resident that required assistance.

Based on clinical record review, review of facility documentation and video recordings and interviews for one of five sampled residents who was at risk for elopement (R#26), the facility failed to provide supervision to a resident who exhibited wandering behaviors and/or failed to provide a safe, secure environment, which resulted in immediate jeopardy. The findings include: R#26's was admitted with [DIAGNOSES REDACTED]. A history and physical dated [DATE] identified R#26 was mildly forgetful. An elopement risk assessment dated [DATE] identified R#26 as not at risk for elopement. A subsequent elopement risk assessment dated [DATE] identified R#26 had exhibited exit seeking behaviors and had indicated he/she wanted to leave the facility. A review of physician's orders [REDACTED].#26's ankle. Placement was to be verified every shift and function was to be tested daily. Review of a nurse's note dated [DATE] at 7:20 AM indicated R#26 had removed his/her wanderguard device and the device was replaced on R#26's ankle and the function was verified. Interview and review of R#26's medical record with Corporate Nurse #3 identified a physician order [REDACTED]. ) as needed for anxiety. The Medication Administration Record (MAR) indicated R#26 received Trazadone 25 mg on [DATE] at 8:00 PM. The medical record lacked documentation indicating the reason the medication was given and the effectiveness of the intervention. Review of the admission Resident Care Plan [DATE] and Nursing Assistant individualized resident assignment documentation directing the resident's care on [DATE] failed to identify R#26 was at risk for elopement, had a wanderguard device applied for safety and had exhibited exit seeking behaviors. An admission Minimum (MDS) data set [DATE] indicated R#26 had short and long term memory deficits and required limited assistance of one person with ambulation, transfer and personal hygiene. The assessment indicated R#26 used a wheelchair or walker. A nurse's note dated [DATE] at 1:00 AM indicated R#26 was sitting at the nurse's station. At the time R#26 was alert and confused and conversing. A subsequent nurse's note dated [DATE] identified at 1:40 AM R#26 was found outside the facility at the bottom of four stairs lying on his/her back with no apparent injury to his/her head or face. R#26 was breathing yet unresponsive. Subsequently R#26's breathing subsided and Cardiopulmonary Resuscitation (CPR) was initiated. Emergency Medical Services (EMS) arrived and assumed care. R#26 was transferred to the hospital. Interview with NA #1 on [DATE] at 12:50 PM, NA #1 indicated that although the alarm did not sound, R#26 had been wandering towards an alarmed exit door. NA#2 redirected him/her and brought R#26 to the nurse's station. NA #1 and NA #2 sat in front of the nurse's station charting and R#26 was in the same area to the side of where they were sitting. R#26 was slowly wandering in the immediate area in his/her wheelchair and NA #1 thought R#26 had a wanderguard device on and didn't think R#26 would leave. Upon surveyor inquiry NA #1 indicated he/she had not verified R#26 had a wanderguard device on while he/she had been caring for R#26 as she believed that task was the nurse's responsibility. An interview with NA #2 on [DATE] at 3:30 PM, NA #2 indicated he/she had redirected R#26 away from an alarmed exit door at the end of the east wing, although no alarm had sounded. NA #2 then escorted R#26 to the nurse's station. NA #2 and NA #1 were seated in front of the nurse's station charting and R#26 was in the same area to the side of where they were sitting. NA #2 indicated because of R#26's confusion the nurse aides were keeping R#26 near them. NA #2 indicated it was only several minutes. One minute R#26 was right there and the next thing the phone rang and staff was notified by nursing staff from another unit that R#26 was outside. NA #2 indicated he/she had not checked placement of the wanderguard device yet that shift but routinely would verify placement at some point during care. NA #2 identified staff would be updated during report if a resident had a wanderguard device. In addition, the nurse aides had routine assignments and knew the residents well. An interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 2:40 PM, LPN #1 indicated when he/she saw R#26 at the nurse's station around 1:00 AM R#26 was calm and exhibited no exit seeking behaviors. LPN #1 indicated R#26 was the calmest he/she had been and LPN #1 was not aware R#26 was exit seeking. An interview with the Director of Nursing Services (DNS) on [DATE] at 9:10 AM, the DNS indicated after the incident R#26's wanderguard device without the bracelet had been found in his/her room on the window ledge. The bracelet was never located. In examining the device it could not be determined how R#26 removed the device. According to the Treatment Administration Record (TAR) the device's function had been verified on [DATE] sometime during the 11:00 PM to 7:00 AM and placement was checked [DATE], 7:00 AM- 3:00 PM and [DATE] 3:00 PM-11:00 PM shifts. At the time of the incident on [DATE] at 1:00 AM placement and function of the wanderguard had not been checked. An interview and review of the medical record with Corporate Nurse #1 and the Administrator on [DATE] at 1:40 PM identified the admission RCP did not indicate R#26 required a wanderguard device. They indicated when R#26 had first removed the wanderguard device on [DATE] additional interventions should have been put into place in response to R#26 removing the device. A video and audio recording dated [DATE] was reviewed identifying at 1:19 AM R#26 approached the exit door and at 1:26 AM R#26 exited the building through the unlocked side exit door of the facility. No alarm was heard to engage at the time the resident exited the door. An interview with the Administrator on [DATE] at 8:30 AM identified at the time of the incident on [DATE] the involved exit door locked automatically at 8:00 PM from the outside but was unsure if the door was locked to prevent exiting the building however the door did remain unlocked during the daytime hours. A review of the remaining exit doors to the facility identified the exits were secure and alarmed. Although the resident was identified with exit seeking behaviors and had verbalized a desire to leave the facility on [DATE], the facility did not identify additional approaches to keep the resident safe after the resident was found to have removed the wanderguard bracelet from his/her ankle.

Based on clinical record review, review of facility documentation and staff interviews for one sampled resident (Resident #169), the facility failed to immediately report three incidents of potential abuse which resulted in immediate jeopardy. The findings include: Resident #169's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #169 had severe cognitive impairment, episodes of feeling down, depressed or hopelessness, exhibited physical and verbal behavioral symptoms directed towards others, and required extensive assistance with activities of daily living. The resident care plan dated 6/17/13 identified a history of attempting to verbally lash out at residents and staff. Interventions included offering clear simple explanations, monitoring mood and reporting any changes. The interim care plan dated 8/12/13 identified a male visitor was observed touching Resident #169 inappropriately on 7/30/13, 8/4/13 and 8/8/13. Interventions directed to notify the local authorities and conservator of person and to restrict the male visitor from visiting. The Reportable Event Form dated 8/9/13 identified that on 8/8/13 at 8:05 PM Nurse Aide (NA) #3 and NA #4 reported that Person #5 was observed to be inappropriately touching Resident #169. Person #5 was observed kissing and touching the resident's breasts. NA #3 and NA #4 reported the incident to Social Service Designee on 8/8/13. Review of the facility's investigation identified that on two other occasions, 7/30/13 and 8/4/13, Person #5 was observed touching Resident #169 inappropriately. The investigation further identified that on 7/30/13, NA #4 reported observing Person #5 kissing the resident and her/his hands where under the resident shirt touching the breasts. NA #4 reported the incident to the charge nurse, Licensed Practical Nurse (LPN) #7 at the time she witnessed the incident. Review of NA #3's written statement identified on 8/4/13, Person #5 requested Resident #169's pants be changed to a larger size because she/he stated the resident's pants were too tight. Subsequent to changing the resident's pants, NA #3 observed Person #5 with her/his hands down Resident #169's pants. During an interview with LPN #7 on 8/14/13 at 3:00 PM she stated that although the events were reported to her on two of the three occasions that Person #5 was observed inappropriately touching Resident #169, she did not speak to the resident and/or the visitor regarding the allegation, she did not assess the resident either time, nor did she report this to anyone in accordance with facility policy and procedure. LPN #7 stated that she was aware of the facility's abuse policy; however upon surveyor interview LPN #7 did not recognize sexual abuse as one of the types. LPN #7 further stated that she didn't think it was a "big deal because Person #5 was an older gentleman". During an interview with the Social Work Designee on 8/15/13 at 10:00 AM, she stated that NA # 3 and NA #4 reported that they observed Person #5 inappropriately touching the resident on 8/8/13. The Social Work Designee stated that although she was aware of the facility's abuse policy and the immediate reporting of alleged abuse, she just did not report the incident until the next day, nor did she speak with Resident #169. The Social Work Designee further stated that she instructed the nurse aides if they witness any allegations in the future to report it to the nurse, but did not instruct the nurse aides to report the current incident. During an interview with LPN #8 on 8/15/13 at 1:45 PM, she identified NA #3 had commented she did not care for Person #5 but did not elaborate nor did LPN #8 make further inquiry. During an interview with NA #3 on 8/15/13 at 2:00 PM stated that on 8/4/13 Person #5 asked her to change the resident's pants because she/he felt they were too tight. NA #3 stated she changed the pants and left the room. NA #3 further stated that a short time later she returned to Resident #169's room and observed Person #5's hand was down and inside the resident's pants. NA #3 stated she went to tell the charge nurse but got interrupted and never reported it. Additionally, NA #3 stated that on 8/8/13 she observed in the presence of NA #4, Person #5 kissing and fondling Resident #169's breasts. NA #3 stated she reported this to the Social Work Designee and NA #4 reported the incident to the charge nurse, LPN #7 on 8/8/13. Interview with NA #4 on 8/15/13 at 3:00 PM identified that she witnessed Person #5 kissing Resident #169 and Person #5's hands were noted to be under the resident's shirt fondling the breast area on 7/30/13. She further identified that she informed LPN #7 immediately thereafter. Additionally, she stated that a subsequent observation was made on 8/8/13 with NA #3. Person #5 was kissing and touching Resident #169 inappropriately. NA #4 stated that she immediately notified LPN #7. Interview with the Director of Nurse (DNS) on 8/15/13 at 10:00 AM identified that the incident of 8/8/13 was reported to her on 8/9/13 at which time an investigation was initiated. The DNS stated that during the investigation of the 8/8/13 incident it was identified that on two other occasions (7/30/13 and 8/4/13) Person #5 was observed to be touching Resident #169 inappropriately. The DNS stated that LPN #7, NA #3 and the Social Work Designee were suspended for not reporting the incidents according to the facility abuse policy. The DNS further stated that during the investigation the resident's Conservator was made aware of the incidents and the Social Worker spoke to the resident. Review of facility documentation and staff interviews identified that although on 7/30/13 NA #4 reported an observation of kissing and inappropriate touching to LPN #7, no action was taken. Additionally, while on 8/4/13, NA #3 observed Person #5 touching Resident #169 inappropriately, she failed to report her observations. Further review identified that on 8/8/13, NA #3 and NA #4 observed Person #5 kissing and touching Resident #169 inappropriately and although the incident was reported to LPN #7 and the Social Service Designee on 8/8/13, an investigation was not initiated until 8/9/13. While three observations were identified on 7/30/13, 8/4/13 and 8/8/13, the facility failed to ensure the resident was protected from abuse until after the third incident. The facility Abuse Policy directs anyone witnessing and/or having knowledge of abuse or mistreatment of [REDACTED].

Based on clinical record review, review of facility documentation and video recordings and interviews for one of five sampled residents reviewed who was at risk for elopement (R#26), the facility failed to assess, implement and/or revise interventions that were identified to protect a resident with dementia having exit seeking behaviors which resulted in immediate jeopardy and/or for one sampled resident (Resident #178) who required [MEDICAL TREATMENT] treatment, the facility failed to monitor the resident's Intake and Output (I&O). The findings include: 1. R#26 was admitted with [DIAGNOSES REDACTED]. A history and physical dated [DATE] identified R#26 was mildly forgetful. An elopement risk assessment dated [DATE] and the [DATE] admission Resident Care Plan identified R#26 as not at risk for elopement. A subsequent elopement risk assessment dated [DATE] identified R#26 had exhibited exit seeking behaviors and had indicated he/she wanted to leave the facility. Although a subsequent elopement assessment was completed, no further assessment was completed to identify any issues that may be contributing to the resident's change in condition. A review of physician's orders [REDACTED].#26's ankle. Placement was to be verified every shift and function was to be tested daily. Review of a nurse's note dated [DATE] at 7:20 AM indicated R#26 had removed his/her wanderguard device and the device was replaced on R#26's ankle and the function was verified. Interview and review of R#26's medical record with Corporate Nurse #3 identified a physician's orders [REDACTED].) as needed for anxiety. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. on [DATE] at 8:00 PM. The medical record lacked documentation indicating the reason the medication was given and the effectiveness of the intervention. An admission Minimum Data Set ((MDS) dated [DATE] indicated R#26 had short and long term memory deficits and required limited assistance of one person with ambulation, transfer and personal hygiene. The assessment indicated R#26 used a wheelchair or walker. A Nursing Assistant individualized resident assignment documentation and Resident Care Plan directing the resident's care on [DATE] failed to identify R#26 was at risk for elopement, or that the resident had a wanderguard device applied for safety and had exhibited exit seeking behaviors. A nurse's note dated [DATE] at 1:00 AM indicated R#26 was sitting at the nurse's station. At the time R#26 was alert and confused and conversing. A subsequent nurse's note dated [DATE] identified at 1:40 AM R#26 was found outside the facility at the bottom of four stairs lying on his/her back with no apparent injury to his/her head or face. R#26 was breathing yet unresponsive. Subsequently R#26's breathing subsided and Cardiopulmonary Resuscitation (CPR) was initiated. Emergency Medical Services (EMS) arrived and assumed care. R#26 was transferred to the hospital. Interview with NA #1 on [DATE] at 12:50 PM and NA #2 on ,[DATE] at 3:30 PM indicated that although R#26 had been exhibiting wandering behavior, neither the nurse aide verified that R#26's wanderguard was in place at the time the resident was observed to be wandering. Additionally, both NA #1 and NA #2 stated that R#26 indicated she was looking for her son and "dead baby". An interview with the Director of Nursing Services (DNS) on [DATE] at 9:10 AM, the DNS indicated after the incident R#26's wanderguard device without the bracelet had been found in his/her room on the window ledge. The bracelet was never located. In examining the device it could not be determined how R#26 removed the device. An interview and review of the medical record with Corporate Nurse #1 and the Administrator on [DATE] at 1:40 PM identified the admission RCP did not indicate R#26 required a wanderguard device. They indicated when R#26 had first removed the wanderguard device on [DATE] additional interventions should have been put into place in response to R#26 removing the device. A video and audio recording dated [DATE] was reviewed identifying at 1:19 AM R#26 approached the exit door and at 1:26 AM R#26 exited the building through the unlocked side exit door of the facility. No alarm was heard to engage at the time the resident exited the door. An interview with the Administrator on [DATE] at 8:30 AM identified at the time of the incident on [DATE] the involved exit door locked automatically at 8:00 PM from the outside but was unsure if the door was locked to prevent exiting the building however the door did remain unlocked during the daytime hours. A review of the remaining exit doors to the facility identified the exits were secure and alarmed. Although the resident was identified with exit seeking behaviors and had verbalized a desire to leave the facility and/or search for her son and "dead baby" on [DATE], the facility did not follow the plan of care and/or assess or re-evaluate the changes in the resident behavior and/or identify any additional resident-centered approaches to address the resident's behavior of removing the wanderguard and/or desire to leave the facility. 2. Resident #178's [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] identified that Resident #178 had a Blood Urea Nitrogen (BUN) of 117 with recommendation for weekly blood work. The resident care plan dated [DATE] identified the [MEDICAL CONDITION] and [MEDICAL CONDITION] diagnoses. Interventions directed to record intake and output every shift. The admission Minimum Data Set assessment dated [DATE] identified that Resident #178 had no memory and/or cognitive deficits, required limited two-person assistance with toilet use, was continent of bladder and received a diuretic medication daily. A physician's orders [REDACTED]. The nurse's note dated [DATE] indicated that the BUN was 171, the physician was notified, a repeat BMP was ordered for [DATE], the dose of the diuretic medication was decreased and a nephrology consult was ordered. The nurse's note dated [DATE] identified the repeat BUN was 178, the physician was notified and Resident #178 was transferred to the hospital. The hospital discharge summary dated [DATE] identified that the Resident #178 had an elevated BUN of 161 compared to the resident's baseline, the resident denied flank pain, hematuria, fevers, and abdominal pain, nausea and vomiting and the resident was found to have [MEDICAL CONDITION] secondary to volume depletion. The discharge summary indicated the diuretic medication was held and cautious rehydration with intravenous normal saline was completed. In an interview and review of the clinical record with Corporate Registered Nurse (RN) #3 on [DATE] at 10:30 AM, Corporate RN #3 indicated that the clinical record failed to reflect that the resident's intake and output (I&O) and/or hydration status had been monitored from [DATE] through [DATE].

Based on review of the clinical record, facility documentation and staff interviews for 1 of 3 sampled residents reviewed for accidents (Resident #1), the facility failed to ensure assistive devices were in place to prevent a fall. The findings include: Resident #1 ' s [DIAGNOSES REDACTED]. The MDS dated [DATE] identified moderately impaired cognition, inattention, and extensive assistance required for transfers, mobility and locomotion. The resident care plan dated 12/5/12 identified a risk for falls with interventions that included providing a tray table on the wheelchair and to check placement and reposition the resident every two hours. The physician's orders [REDACTED]. The individual resident assignment card (NA care card) identified to apply a tray table to the wheelchair and to remove and reapply every two hours. The nurse's note dated 2/14/13 at 9:20am identified the resident was found on the floor and complained of left hip pain. R #1 was transferred to the hospital and diagnosed with [REDACTED]. The Reportable Event dated 2/14/13 at 9:20am identified R #1 was found on the floor, lying on his/her back between the beds. The resident was assessed and sent to the ED for an evaluation and subsequently diagnosed with [REDACTED]. Interview with LPN #1 on 6/17/13 at 1:25pm identified that he/she was outside the resident's room and observed R #1 lying on the floor. LPN #1 noted the Nursing Supervisor was notified and after conducting an assessment the resident was transferred to the hospital for evaluation for a possible left hip fracture. LPN #1 further stated that when he/she entered the resident's room the tray table was not on the wheelchair. Interview with the Acting DNS on 6/17/13 at 2:00pm identified that during the investigation NA #1 stated he/she forgot to place the tray table on the wheelchair when the resident was transferred out of bed. Interview with NA #1 on 6/17/13 at 1:20pm indicated he/she was aware the resident required a tray table when up in the wheelchair because the resident constantly tried to get out of the chair independently. NA #1 indicated he/she forgot to put the tray table on the resident's wheelchair on 2/14/13 after transferring the resident out of bed.

Based on clinical record reviews, review of facility investigations, and staff interviews for 3 of 6 residents reviewed for accidents (R # 119, #158, R #231) the facility failed to ensure the residents were free from accidents. The findings include: Resident #119 (R #119) had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified that R #119 required extensive assistance of two persons for bed mobility, and was totally dependent on two staff persons for transfer and totally dependent on one staff person for locomotion off the unit. A physical therapy screen dated 10/2/12 noted that R #119 was evaluated after a fall in room his/her room. Interventions subsequent to the evaluation included that a full lap tray be applied to R #119 ' s wheelchair. An elopement risk evaluation dated 10/23/12 identified that R #119 repeatedly expressed the desire to leave the facility and sought out exit areas. The care plan dated 10/23/12 identified that R #119 frequently wandered and was at risk for exiting the building. Interventions included to apply a wanderguard device to the resident ' s wheelchair and that if the resident was seen heading toward an exit door, to redirect the resident to another area of the building. The psychiatric assessment dated [DATE] identified R #119 with extensive progressive dementia, was currently displaying impulsive and agitated behaviors that placed him/her at risk to fall. Review of the nursing note dated 11/3/12 identified that R #119 was found by Dietary Aide #1, ambulating in the parking lot at approximately 7:05 P.M. Review of facility documentation dated 11/3/12 and interview with Nursing Assistant #1(NA #1) on 11/28/12 at 1:30 PM identified that R #119's lap tray was removed for R #119 ' s evening meal in the dining room on 11/3/12 and that the lap tray was left on the nursing unit. NA #1 identified that he/she did not replace the lap chair on R #119 ' s wheelchair upon the completion of the meal as he/she was assisting other residents. Review of facility documentation identified that R #119 was able to rise from his/her wheelchair and ambulate out the facility exit doors and into the facility parking lot. As R #119 ' s wanderguard bracelet was attached to the resident ' s wheelchair, no alarm sounded upon R #119 ' s elopement. Subsequent to finding R #119 outdoors, the wander guard device was removed from the wheelchair and attached to the resident's left ankle. The facility policy for elopement risk directed, in part, care plan to be developed and interventions implemented if the resident is identified to be at risk for elopement. The policy directed that a wanderguard bracelet be applied to the resident ' s wrist or ankle 2. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] noted the resident had no bruising on the upper extremities. An admission MDS dated [DATE] identified the resident had mild cognitive impairment and required extensive assistance with bed mobility and transfers. A resident care plan dated 11/2/12 identified a problem with bruising due to anticoagulant therapy. Interventions included observe for signs and symptoms of bruising. Observation on 11/28/12 at 10:30 am noted R #158 with two bruises of the right forearm. At that time R #158 indicated the bruises occurred during a transfer with the Hoyer lift the previous day. An interview on 11/29/12 at 10:55 AM with LPN # 5 indicated she was unaware of the bruising on the resident's arm. An observation on 11/29/12 at 11:10 am noted R #158 transferred via a Hoyer lift. The bars to the side of the Hoyer lift pad were noted to be in close proximity of the resident's forearms. During the transfer on two separate occasions NA # 5 reminded the resident to keep his/her arms folded across the chest. 3. Resident #231's [DIAGNOSES REDACTED]. The significant change assessment dated [DATE] identified that the resident was cognitively impaired, and totally dependent on staff for bed mobility, transfers and ADL's. The hospital discharge summary and Intra- Agency Patient Referral Report (W10) dated 2/8/12 identified that R #231 had a left hip fracture with surgical repair. The care plan dated 2/8/12 identified the risk for fractured hip due to a fall. Interventions included to not allow the resident cross his/her legs, monitor the surgical site for signs and symptoms of infection, and to administer medication when needed. The nurse's note dated 2/13/12 on the 11 p.m. to 7 a.m. shift identified that R #231's left hip area appeared to be swollen, and that the resident called out throughout the shift. The resident was medicated with pain medication with fair effect and the physician was notified via fax. The nurse's notes dated 2/13/12 on the day shift identified that Resident #231's left hip was painful to the touch and a new order was obtained to x-ray the resident's left hip. The x ray results dated 2/13/12 noted a left hip arthroplasty with superior-lateral dislocation. The resident was transferred to the hospital for an evaluation. Interview with NA #15 on 11/29/12 at 4:45 p.m. identified that when she provided care to Resident # 231 on 2/11 and 12, 2012 she used a pad with a pillow to turn the resident in bed alone. Interview with NA #16 on 11/29/12 at 4:30 p.m. identified that when she provided care to Resident # 231 on 2/10, 11 and 12, 2012, she used a pad to turn the resident in bed and a placed a pillow behind her/ his head. The Nurse Aides failed to verbalize the importance of ensuring that the resident does not cross his/her legs in accordance to the plan of care and/or the appropriate techniques for log rolling a resident and/or prevention of hip adduction status [REDACTED].