Every finding on record at Apple Rehab Saybrook

Based on observations, interviews, and reviews of the clinical record and policy for 7 of 13 sampled residents (Resident #12, #17, #20, #31, #35, #49, and #56) reviewed during a Resident Council meeting, the facility failed to notify residents of their rights upon admission to the facility. The findings include:Resident #12's diagnoses included mild cognitive disorder, major depressive disorder, and anxiety. A Brief Interview of Mental Status dated 5/14/26 for Resident #12 identified a score of 14 indicating he/she was cognitively intact. Resident #17's diagnoses included atrial fibrillation, hypothyroidism, and anxiety disorder. A Brief Interview of Mental Status dated 6/16/26 for Resident #17 identified a score of 15 indicating he/she was cognitively intact. Resident #20's diagnoses included chronic kidney disease, heart failure, and chronic respiratory failure. A Brief Interview of Mental Status dated 5/11/26 for Resident #20 identified a score of 15 indicating he/she was cognitively intact. Resident #31's diagnoses included chronic lymphocytic leukemia, hypertension, and adjustment disorder. A Brief Interview of Mental Status dated 6/12/26 for Resident #31 identified a score of 3 indicating severe cognitive impairment. Resident #35's diagnoses included hemiplegia and hemiparesis, hypertension, and anxiety disorder. A Brief Interview of Mental Status dated 7/1/26 for Resident #35 identified a score of 15 indicating he/she was cognitively intact. Resident #49's diagnoses included major depressive disorder and adjustment disorder. A Brief Interview of Mental Status dated 5/8/26 for Resident #49 identified a score of 13 indicating he/she was cognitively intact. Resident #56's diagnoses included multiple sclerosis, chronic obstructive pulmonary disease, and generalized anxiety disorder. A Brief Interview of Mental Status dated 6/15/26 for Resident #56 identified a score of 11 indicating moderate cognitive impairment. A Resident Council meeting on 7/16/26 at 1:35 PM identified that Resident #12, #17, #20, #31, #35, #49, and #56 were not aware while resident at the facility, what their rights were, given a copy of their right or had seen a copy of rights anywhere in the facility. Additionally, once they were informed rights were located on a board in the hallway near the lobby, the residents indicated an awareness of the board, but that the board was too high to read from wheelchair level. Interview and facility documentation review with Social Worker (SW) #1 on 7/15/26 at 11:22 AM identified that during the admission process to the facility, she did not go over resident rights with residents or their responsible party. SW #1 indicated that residents were made aware of their rights when they received a copy which was included in the admission packet. Review of the facility admission packet with SW #1 failed to identify that the facility had been including resident right information within the packet and that she was unaware how residents were being informed of their rights. SW #1 indicated that resident rights were reviewed during Resident Council meetings but was unable to explain how residents who did not attend Resident Council were made aware of their rights. Interview, facility documentation review, and observation with the Administrator on 7/15/26 at 12:51 PM identified that residents were made aware of their rights upon admission when they received the information contained in the admission packet. Additionally, he stated that the Social Worker reviewed resident rights with the residents. Review of the facility admission packet with the Administrator identified that it did not include any resident right documentation. The Administrator indicated he had been unaware that the information was not located within the admission packet and indicated he would investigate why the information was missing stating that resident right information would be included for future admissions. Additionally, the Administrator was unaware that the Social Worker was not providing residents with their rights during admission. Review of the undated Resident Rights policy directed, in part, that residents have the right to be fully informed, orally and in writing, in a form and manner they understand, of their rights and the facility's rules governing their conduct and responsibilities, and of changes in their rights and facility rules.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 sampled residents (Resident #24 and 32) observed during the initial facility tour, for residents on the East Unit dining room observed during dining, and for 11 of 16 rooms observed for the environment, the facility failed to provide a homelike environment. The findings include:1. Resident #24's diagnoses included non-traumatic brain dysfunction and Alzheimer's disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #24 had a Brief Interview for Mental Status score of 0 indicating severe cognitive impairment and was dependent on staff for all activities of daily living including bed mobility, transfers, eating, incontinent care, oral hygiene, dressing, and personal hygiene.2. Resident #32's diagnoses included profound intellectual disability, functional quadriplegia, and epilepsy.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 had a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment and was dependent on staff for all activities of daily living, including eating, oral hygiene, bed mobility, dressing, transfers, and incontinent care.Observation on 7/13/26 at 10:45 AM during the initial tour in Resident #24's and 32's room identified Resident #24's bed frame was visibly soiled with tan and brown matter with dust adhered on the right upper side of the frame and at the point of attachment for the bedrail where it met the mattress. Resident #32's footboard bed trim was missing, and the entire right-side corner was broken off exposing a wood type particle board that was rough to the touch. Additionally, the floor in the room had a dirty appearance with a coating of a brown, sticky substance around the periphery of a substantial portion of the room, behind the door, and around the bed, and when walked upon was noted to cause shoes to stick to the floor making an audible noise upon movement.Interview with Nurse Aide (NA) #4 on 7/16/26 at 9:40 AM identified she was aware the bed had been broken for a long time, though NA #4 was not able to state how long. When asked what the policy was for notifying the proper department when something was broken, she stated a note was to be left in a maintenance book kept at the nurse's station. Review of the Maintenance Log from 1/1/26 to 7/16/26 failed to identify Resident #32's bed had been listed as requiring repair.Interview with Director of Maintenance on 7/16/26 at 9:52 AM identified she was not aware of Resident #32's broken bed, and that if she had been notified, she would have repaired the bed. Interview and observation with the Administrator on 7/17/26 at 11:08 AM identified Resident #24's bed frame and Resident #32's footboard was broken and missing trim and the floor remained sticky with a brown substance around the room. The Administrator was noncommittal regarding Resident #24 and 32's room having a homelike appearance stating, yes and no.3. Observations on 7/13/26 at 11:15 AM identified 11 of 16 rooms (105, 106, 107, 108, 109, 110, 113, 115, 112, 114, 117) on the East Unit had visibly soiled floors with brown, sticky matter observed in patches and around the periphery in each room and caused shoes to stick to the floor making an audible noise while walking. Interview with Resident #28 on 7/13/26 at 11:41 AM identified that the floors in the room were disgusting and that he/she wouldn't/t walk barefoot in his/her room due to the condition of the floor. Additionally, Resident #28 stated that his/her family member indicated they thought the floor was so gross he/she wanted to burn their shoes when they returned home.Interview and observation with the Administrator on 7/17/26 at 11:08 AM identified the floor in room [ROOM NUMBER] with the coating of the brown, sticky substance, when attempted, was able to be scraped off with a putty knife. The Administrator stated there was a plan for floor replacement and some of the floors had already been replaced, but due to budgetary constraints, no floors had been replaced since 3/2026. The Administrator indicated that the Director of Housekeeping was responsible for the cleaning process to remove the coating of the soiled brown, sticky substance and that an interview with her should be conducted. Interview with the Director of Housekeeping on 7/17/26 at 11:27 AM identified that she was aware of the current condition of the floors and had recently purchased putty knives for the housekeeping carts and asked housekeepers to try to scrape up what they could. She further stated she had been at the facility for 2 years and the floors were in this condition when she started employment and was told the soiling could be wax build up, but the facility did not have the proper equipment for stripping the floor because the machine had broken. Additionally, she stated 1 resident room was deep cleaned each day, and that Resident #24's and 32's room had been deep cleaned on 7/16/26 (1 day prior) and that Resident #24's soiled bedframe should have been addressed during the deep cleaning on 7/16/26 (1 day prior). Review of the Hard Floor, Stripping policy directed, in part, to use a high-speed rotary floor machine to remove old floor finish and sealer to prepare the floor for finishing.Review of the Hard Floor, Stripping policy directed, in part, to use a high-speed rotary floor machine to remove old floor finish and sealer to prepare the floor for finishing.Review of the Resident Room Occupied/Discharge, Clean policy directed, in part, to clean the bed and to clean the floor using dust and damp mopping.4. Dining observations on 7/13/26 at 12:15 PM identified 9 residents in the East Unit dining area/resident lounge having lunch. A resident wheelchair scale (roll on scale meant for wheelchairs) and 7 unoccupied wheelchairs were visible to residents and stored in the room. On 7/15/26 at 12:15 PM 8 residents were in the East Unit dining area/lounge with 7 unoccupied wheelchairs stored and visible to residents while eating lunch. Additionally, the floor was noted to be soiled around the edges of the room as well as the area of the floor on which the wheelchairs were stored on both occasions.Interview and observation of the East Unit lounge with the Administrator on 7/17/26 at 11:30 AM identified 7 wheelchairs stored in the lounge where residents were gathering for lunch and soiling was observed around the edges of the room in the area where the wheelchairs were stored. The Administrator did not feel storing wheelchairs and a scale in a resident lounge used for socializing, eating, activity attendance, and visitation impacted the homelike appearance of the environment for residents.Although requested, policies for dining and meal service were not provided.

Based on observations, interviews, review of the clinical record, and facility policy for the 3 of 5 sampled residents (Resident #1, 16, and 32) reviewed for dignity, for Resident #1, the facility failed to provide a privacy cover for a urinary collection bag, and for Resident #'s 16 and 32, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #1's diagnoses included type 2 diabetes, bipolar disorder, and urine retention. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment, was dependent with toileting hygiene, and currently had an indwelling urinary catheter. The Resident Care Plan in effect from 4/27/26 through 7/17/26 identified that Resident #1 had an indwelling suprapubic (lower abdominal) catheter (urine drainage tube) in place. Interventions included placing a privacy cover over the resident's urinary drainage bag. A physician's order dated in effect from 7/1/26 through 7/16/26 directed to provide catheter care every shift and as needed for the resident's suprapubic catheter. Observation on 7/14/26 at 11:05 AM identified that Resident #1's urinary collection bag was not covered, hanging from the side of his/her wheelchair armrest, while the resident was self-propelling in their wheelchair in the hallway on the East Wing. The urine in the collection bag was observed to have clear, yellow urine measuring less than 100 milliliters (ml) in quantity. Observation and interview with Nurse Aid (NA) #5 on 7/16/26 at 11:55 AM identified that Resident #1 was sitting in his/her wheelchair in the [NAME] Wing dining room, with his/her urinary collection bag uncovered hanging from the side of his/her wheelchair armrest. NA #5 identified that Resident #1's urinary collection bag was uncovered however, she was unsure if covering the bag was a requirement, and was unaware of the protocol, but felt it was her responsibility to make sure the urinary collection bag was covered if it should have been. Observation and interview with Registered Nurse (RN) #1 on 7/16/26 at 12:01 PM identified that Resident #1 was sitting in his/her wheelchair in the [NAME] Wing Dining Room, with his/her urinary collection bag uncovered hanging from the side of his/her wheelchair armrest. RN #1 identified that the resident should have a cover over his/her urinary collection bag. RN #1 further indicated that every resident with a urinary catheter bag was provided a cover. RN #1 stated she did not know why Resident #1's urinary collection bag was uncovered, and that it was the NAs responsibility to make sure all residents with urinary collection bags had a privacy covering. Subsequent to surveyor interview, NA #5 obtained a cover from the East Unit supply closet and covered Resident #1's urinary catheter bag. Interview with the Director of Nursing (DON) on 7/16/26 at 2:57 PM identified that all residents who have urinary catheter collection bags should have privacy covers. The DON indicated that she did not know why Resident #1 did not have a privacy covering over his/her urinary catheter collection bag, and that it was all staff's responsibility to ensure residents with a urinary catheter collection bag had a privacy covering. Review of the Urinary Catheter Management policy directs, in part that drainage bags, and leg bags will utilize privacy bags to promote dignity. 2. Resident #16's diagnoses included Alzheimer's disease and rheumatoid arthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 had a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment and was totally dependent on staff for all activities of daily living, including eating. The Resident Care Plan dated 6/18/26 identified Resident #16 was at risk for nutritional decline due to multiple medical problems and was dependent on staff for eating. Interventions included providing assistance with meals and supplements as ordered. The Individualized Resident Assignment in effect on 7/13/26 identified Resident #16 had an order for a dysphagia 3 (pureed) diet with thin liquids and was totally dependent on staff assistance to eat. During a dining observation and interview on 7/13/26 from 12:05 PM to 12:50 PM in the East Unit dining area, 10 residents were present. The lunch meals arrived at 12:00 PM and by 12:18 PM, 9 of those residents had received their meals and were eating. Resident #16 was seated with Resident #10. Resident #10 was assisted to eat while Resident #16 had not yet received his/her meal. Interview with Nurse Aide (NA) #9 on 7/13/26 at 12:48 PM (30 minutes after all other residents were served and eating) failed to identify that she was aware Resident #16 had not received a meal until brought it to her attention by the surveyor. NA #9 then was heard discussing Resident #9's meal status. Interview with NA #2 on 7/13/26 at 12:51 PM identified Resident #16's meal had not been delivered on the meal cart from the kitchen and had now been requested. Another resident, Resident #7 had received a pureed consistency meal in error (instead of the ordered mechanical soft consistency), and the pureed food with Resident #7's name on the dietary ticket may have been the meal intended for Resident #16 as he/she required pureed food. Interview with the Corporate Food Service Supervisor on 7/16/26 at 10:00 AM identified 4 recent resignations in the Dietary Department had occurred, however she was unable to identify how Resident #16's meal had been missed by both the dietary staff and the NA. Review of the Point of Service Dining policy identified, in part, the point of service dining was to promote socialization and to increase satisfaction with meals and to improve meal intake by stimulating the senses. Additionally, the policy directed, in part, to utilize a diet roster list or tray ticket containing resident room, name, diet, and allergies while serving meals. 3. Resident #32's diagnoses included profound intellectual disability, functional quadriplegia, and epilepsy (seizures). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 had a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment, and was totally dependent on staff assistance with all activities of daily living including eating. A physician order dated 6/30/26 directed to transfer Resident #32 to his/her custom wheelchair with a head rest at all times, anterior trunk support (chest harness) with pelvic positioning belt, and to be out of bed for 6 hours a day seated upright for all meals. The Resident Care Plan in effect on 7/13/26 identified Resident #32 had difficulty positioning due to decreased core strength and balance and utilized a custom wheelchair including a chest harness for trunk support. Interventions included following a positioning plan and to reposition every 2 hours as needed. During a dining observation on 7/13/26 at 12:15 PM Resident #32 was identified seated in his/her custom wheelchair. Prior to being served lunch, the chest harness attached across his/her trunk area was noted to be visibly soiled with white and tan crusted, dried matter over 75% of the surface of the harness. Staff attempted to assist Resident #32 to eat but he/she was unable to be awoken, and lunch was not eaten. Resident #32 was not wearing a clothing protector prior to attempts to assist to eat. A follow-up dining observation and interview with NA #2 on 7/15/26 at 12:40 PM identified Nurse Aide (NA) #2 assisting Resident #32 to eat. The resident was noted to be spitting food from his/her mouth, smearing food on his/her face, neck, and chest area, as well as on the chest harness of the custom wheelchair. Resident #32 was not wearing a clothing protector, and tan and white crusted, dried and fresh soiling was visible over 75% of the chest harness. NA #2 indicated she believed housekeeping had a schedule for routinely cleaning wheelchairs. When the chest harness was visibly soiled, NA #2 stated staff would try to clean it with disinfecting wipes. NA #2 stated it was not dignified for Resident #2 to be seated with a soiled chest harness, and normally clothing protectors would be used but none were available on 7/15/26. Interview and observation with Director of Nursing (DON) on 7/15/26 at 2:17 PM identified she was not sure who was responsible for cleaning wheelchairs but after speaking with the Director of Housekeeping indicated wheelchairs were power-cleaned every 1-3 months. She indicated that NAs should be cleaning wheelchairs in between scheduled cleaning but if debris was unable to be removed, they should have notified a supervising Registered Nurse (RN) or herself. The DON stated it was not dignified for Resident #32 to be sitting in a resident area with a stained harness that was visible over his/her clothing. Observation on 7/17/26 at 11:50 AM, subsequent to Surveyor inquiry, identified Resident #32 was seated in the lounge in the custom wheelchair, and the chest harness was noted to be free of soiling/stains. A review of the Custom Wheelchairs and Positioning policy failed to direct cleaning and maintenance policies and procedures.

Based on review of the clinical record, facility policy and interviews for 1 of 5 sampled residents (Resident #56) reviewed for unnecessary medications, the facility failed to obtain and complete consent for the use of psychotropic medications. The findings include:Resident #56's diagnoses included multiple sclerosis, dementia with agitation, metabolic encephalopathy, depression, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #56 was moderately cognitively impaired, had no signs of delirium, had moderately severe depression, and required assistance with activities of daily living.The following antipsychotic medications were ordered by Resident 56's physician since the previous survey:A physician order dated 7/13/26 directed to administer Aripiprazole 12.5 mg daily and Mirtazapine 7.5 mg daily, Lorazepam 0.5 mg Lorazepam twice daily, and Lorazepam 0.5 mg every 6 hours as needed for anxiety.A review of the clinical record failed to identify verbal consent or written consent was obtained by Resident #56 or his/her conservator.In an interview and clinical record review with Registered Nurse (RN) #2 on 7/16/26 at 3:15 PM, the failed to identify that consents had been obtained verbally or in writing prior to the administration of any psychotropic medications.Re-interview on 7/17/26 at 9:23 AM with RN #2 failed to identify that the facility had documentation in the overflow clinical record files that were not part of Resident #56's current electronic clinical record or the paper clinical record on the unit. RN #2 indicated that medication consents should be in the paper chart in the same section as consents for admission and care.Review of the Consent for Psychotropic Medications policy (no date) directed, in part, staff to acquire consent prior to administration of psychotropic medication.

Based on interviews, facility documentation, and reviews of the clinical record and facility policy, for the only sampled resident (Resident #8) reviewed for edema, the facility failed to update the provider of a significant weight gain for a resident with a diagnosis of Congestive Heart Failure (CHF). The findings include:Resident #8's diagnoses included acute on chronic congestive heart failure, obstructive sleep apnea, and acute pulmonary edema.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status of 15 indicating intact cognition and was dependent on staff for toileting and transfers. Additionally, the MDS identified Resident #55 did not reject care.The Resident Care Plan dated 6/19/26 identified Resident #8 had bilateral lower extremity edema and lymphedema. Interventions included observing signs of edema and updating the provider with any concerns/changes in condition.A physician's order dated 6/30/26, and in effect since 3/23/26 directed to obtain a weekly weight on the shower days for CHF/edema monitoring.Review of the Weights and Vital Sign Summary for Resident #8 identified he/she weighed:259 lbs. on 7/2/26254.5 lbs. on 7/9/26261 lbs. on 7/13/26 Interview and clinical record review with the supervising Registered Nurse (RN) #1 on 7/15/26 at 2:35 PM identified the facility's policy was to obtain monthly weights on a resident unless they had CHF in which case weights were obtained per the physician's order. Review of Resident #8's clinical record identified he/she was to be weighed weekly and weighed 254.5 lbs. on 7/9/26 and 261 lbs. on 7/13/26 (a 6.5-pound weight gain in 4 days). Additionally, RN #1 identified that the dietician kept track of resident weights, and even though Resident #8 had a weight increase and a diagnosis of CHF/edema the provider was not notified because the weight increase did not meet criteria for provider notification (defined as a 5% increase in a month with a warning prompted by the electronic health record).Interview and record review with the Director of Nursing on 7/16/26 at 9:38 AM identified it was the facility's policy to weigh residents weekly for 4 weeks on admission, and then monthly unless there was another reason such as a 5% weight increase or decrease, a concern had been brought up, or a resident had a diagnosis of CHF, then obtaining weights was per physician's order. Review of Resident #8's clinical record identified he/she had a weekly weight order for CHF/edema monitoring, and that there was a weight increase of 6.5 pounds between 7/9/26 and 7/13/26. The DNS indicated that for a CHF residents with a weight gain she would expect the provider to be notified, but first a reweight should have been conducted to confirm the weight. Further review of Resident #8's clinical record failed to identify if the provider was notified or a reweigh was available.Interview and record review with APRN #1 on 7/16/26 at 11:37 AM identified the plan of care for CHF residents was determined by the cardiologist or the provider, adding she was not the regular APRN for the building but was covering that week. Review of Resident #8's clinical record identified a weight of 254.5 lbs. on 7/9/26 and 262 lbs. on 7/13/26. APRN #1 identified that she was in the facility on 7/13/26, was not notified of the weight gain but would expect to have been as there was a physician order. Additionally, APRN #1 stated if she had been notified, she would have requested a reweight and if the weight was confirmed, she would have seen the resident to assess for edema and potentially increase the diuretic (medication that helps excrete extra water, reducing edema).Subsequent to surveyor inquiry an order was initiated to obtain a weight for 3 days and Resident #8 was assessed by APRN #1 on 7/16/26 at 1:00 PM for possible weight gain with an order to administer one dose torsemide 40 milligrams (a diuretic).Review of the Change in Resident Condition and Notification Policy directed, in part, that significant changes in a resident's physical, mental, emotional or clinical condition will be assessed promptly and communicated to the physician and resident representative/responsible party as appropriate. Review of the Heart Failure Management directed in part that Nursing staff will notify the physician or licensed provider of significant changes in condition or signs of possible heart failure exacerbation. Additionally, assessments, weight trends, symptoms, intervention, physician notification, medication responses, and changes in condition will be documented in the medical record. Review of the Weight Monitoring Policy directed in part that a re-weight shall be obtained whenever there is a weight discrepancy of 5 pounds or greater from the precious record. Additionally, significant weight changes shall be reported to the provider, responsible party, registered dietician, DNS/ADNS and MDS coordinator as appropriate.

Based on interviews, reviews of the clinical record, facility documentation, and facility policy for 1 of the 4 sampled residents (Resident #3) reviewed for personal property, the facility failed to ensure a resident was free from misappropriation of money. The findings include: Resident #3's diagnoses included kidney disease, dependence on kidney hemolytic treatment, depression, and schizoaffective disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status score of 13, indicating intact cognition, and was independent with transferring from chair/bed to chair and bed mobility. The Resident Care Plan (RCP) in effect from 4/7/26 through 7/17/26 identified Resident #3 attended hemolytic treatment 3 times per week. Interventions included ensuring treatments on Monday, Wednesday, and Friday. Additionally, the RCP indicated that Resident #3 may prefer at times to keep his/her clothes/personal belongings in bags in their room, rather than keeping them in his/her closet. Interventions included encouraging the resident to keep their extra belongings in the closet to help decrease clutter as Resident #3 allowed. A physician's order dated 6/30/26 directed to obtain the resident's weight prior to hemolytic treatment on Monday's, Wednesday's, and Friday's. A Social Services progress note dated 7/8/26 at 9:57 AM identified that Resident #3 met with Social Worker (SW) #1 per his/her request to report he/she had $100 missing from his/her room. Resident #3 stated the money was taken from his/her room and that Resident #3 believed another resident (Resident #17) was responsible for taking the money as that resident was previously in his/her room. A draft formal grievance was filed, and the matter was to be investigated. A Grievance Form dated 7/8/26 written by SW #1 identified Resident #3 reported $100 was missing from his/her room and staff and residents were interviewed; all deny seeing any money (and) residents deny entering patient's room or taking money. Under the Summary of Findings, the Grievance Form indicated, that Resident #3's money had not been located, under Actions Taken it indicated that SW #1 worked out a system with the patient to ensure his/her belongings stay safe and the patient (Resident #3) was in agreement with this system. Review of Resident #3's facility personal needs account statement provided by the Administrator identified that on 7/1/26, the resident received two withdrawals of $50.00 from petty cash, on 7/8/26 the resident received a $50.00 and $25.00 withdrawal from petty cash.Interview with Resident #3 on 7/14/26 at 10:16 AM identified that he/she had an ongoing issue with missing property at the facility and that approximately 1-2 weeks ago he/she had $100 stolen from his/her room. Resident #3 indicated $100 was received from the facility banker and that the money was placed in an envelope and left under his/her pillow per his/her request while he/she was out of the facility receiving a hemolytic treatment. Upon return he/she found the envelope containing the money. Resident #3 stated the envelope was resealed, placed back under his/her pillow, he/she went to the bathroom, and when he/she returned the envelope containing the money was gone. Resident #3 stated that SW #1 was working on it and he/she was still waiting to hear back for a solution as the facility hadn't provided him/her with a lockbox, hadn't called the police, and hadn't refunded the $100 that had been taken indicating I hope they (the facility) give my money back. Resident #3 indicated that he/she no longer trusted his/her belongings to be left in the room and had resorted to placing valuables in a second pillowcase overnight, transferring the belongings to a backpack in the morning, and then he/she would carry the backpack with him/her during the day for security. Resident #3 did not know why the police had not been called since he/she reported the money was stolen. Interview with SW #1 on 7/17/26 at 10:15 AM and at 11:54 AM identified that when residents reported funds missing, the information was given to her, and she would then ask permission to the search the resident's room. SW #1 further identified that she conducted an investigation from 7/8/26 to 7/10/26 believing that another resident (Resident #17) known to have taken food from Resident #3 had taken his/her money. Upon asking for permission, Resident #17 refused to have his/her room searched so SW #1 was only able to visually inspect the room. SW #1 also identified that she did not investigate if Resident #3 had withdrawn money from his/her personal need account as she didn't work with facility funds and didn't want to appear as if she was accessing the resident's financial account information. SW #1 indicated that Resident #3 insisted that he/she did not want the missing $100 reimbursed from the facility and declined to receive a lock box to place his/her valuables inside which the facility would have provided and that the outcome/findings of her investigation were discussed with Resident #3 verbally but never documented. SW #1 indicated that the written resolution on the resident's Grievance Form was left vague to attempt to protect Resident #3's privacy, and that she didn't call the police to report the missing funds because Resident #3 had insisted that the facility not involve the police, which was also not documented. SW #1 further stated that she had not documented the names of staff or residents' that had been interviewed during the investigation but would do so moving forward. Attempts to conduct and interview the facility's banker were unsuccessful as she was not available during survey and was away.Interview with the Administrator on 7/17/26 at 10:46 AM identified that his signature was at the bottom of Resident #3's Grievance Form, along with SW #1's signature. The Administrator further identified that the procedure for misappropriation of funds was that SW #1 conducted the investigation. The Administrator identified that he did read the Grievance Form prior to signing it and indicated that he did not report the misappropriation of funds to the State Agency. The Administrator further indicated that he wasn't sure why he didn't report the incident but was aware that the occurrence should have been reported to the State Agency and a thorough investigation should have been conducted as well. Subsequent to the interview with the Administrator, a Reportable Event was submitted to the State Agency regarding Resident #3's missing $100. Review of the policy regarding Personal Property and Missing Items directs, in part, allegations of theft, exploitation, or misappropriation of resident property will be investigated in accordance with the facility's Abuse Prevention and Reporting Policy. The policy further directs that investigation activities may include searching resident rooms and common areas; interviewing staff; reviewing recent transfers, appointments, or outings; and other appropriate investigative measures and if theft or misappropriation was suspected, then required reporting, investigation and regulatory requirements will be followed as applicable. The Personal Property and Missing Items policy also directs that for follow-up, the social worker/designee will maintain documentation related to missing property investigations and outcomes and that the resident and/or responsible party will be informed of investigation findings and outcomes. Review of the policy regarding Abuse Prevention and Reporting directed, in part, that any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the DON and the Administrator; an A/I (Reportable Event) report will be completed for each resident involved; the DON or designee will notify the resident's family, physician, DPH, and local police as needed and submit an online report to FLIS within 2 hours of notification. The Administrator/DON or designee will initiate an investigation and the investigation will include: interviews with all witnesses, including the accused; interviews with any individuals with relevant information; and signed and dated statements from all involved parties.

Based on interviews, reviews of the clinical record, facility documentation and facility policy for 1 of the 4 sampled residents (Resident #3) reviewed for personal property, the facility failed to report an incident of misappropriation of money to the State Agency per the requirement. The findings include:Resident #3's diagnoses included kidney disease, dependence on kidney hemolytic treatment, depression, and schizoaffective disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status score of 13, indicating intact cognition, and was independent with transferring from chair/bed to chair and bed mobility. The Resident Care Plan (RCP) in effect from 4/7/26 through 7/17/26 identified Resident #3 attended hemolytic treatment 3 times per week. Interventions included ensuring treatments on Monday, Wednesday, and Friday. Additionally, the RCP indicated that Resident #3 may prefer at times to keep his/her clothes/personal belongings in bags in their room, rather than keeping them in his/her closet. Interventions included encouraging the resident to keep their extra belongings in the closet to help decrease clutter as Resident #3 allowed. A physician's order dated 6/30/26 directed to obtain the resident's weight prior to hemolytic treatment on Monday's, Wednesday's, and Friday's. A Social Services progress note dated 7/8/26 at 9:57 AM identified that Resident #3 met with Social Worker (SW) #1 per his/her request to report he/she had $100 missing from his/her room. Resident #3 stated the money was taken from his/her room and that Resident #3 believed another resident (Resident #17) was responsible for taking the money as that resident was previously in his/her room. A draft formal grievance was filed, and the matter was to be investigated. A Grievance Form dated 7/8/26 written by SW #1 identified Resident #3 reported $100 was missing from his/her room and staff and residents were interviewed; all deny seeing any money (and) residents deny entering patient's room or taking money. Under the Summary of Findings, the Grievance Form indicated, that Resident #3's money had not been located, under Actions Taken it indicated that SW #1 worked out a system with the patient to ensure his/her belongings stay safe and the patient (Resident #3) was in agreement with this system. Review of Resident #3's facility personal needs account statement provided by the Administrator identified that on 7/1/26, the resident received two withdrawals of $50.00 from petty cash, on 7/8/26 the resident received a $50.00 and $25.00 withdrawal from petty cash.Interview with Resident #3 on 7/14/26 at 10:16 AM identified that he/she had an ongoing issue with missing property at the facility and that approximately 1-2 weeks ago he/she had $100 stolen from his/her room. Resident #3 indicated $100 was received from the facility banker and that the money was placed in an envelope and left under his/her pillow per his/her request while he/she was out of the facility receiving a hemolytic treatment. Upon return he/she found the envelope containing the money. Resident #3 stated the envelope was resealed, placed back under his/her pillow, he/she went to the bathroom, and when he/she returned the envelope containing the money was gone. Resident #3 stated that SW #1 was working on it and he/she was still waiting to hear back for a solution as the facility hadn't provided him/her with a lockbox, hadn't called the police, and hadn't refunded the $100 that had been taken indicating I hope they (the facility) give my money back. Resident #3 indicated that he/she no longer trusted his/her belongings to be left in the room and had resorted to placing valuables in a second pillowcase overnight, transferring the belongings to a backpack in the morning, and then he/she would carry the backpack with him/her during the day for security. Resident #3 did not know why the police had not been called since he/she reported the money was stolen. Interview with SW #1 on 7/17/26 at 10:15 AM and at 11:54 AM identified that when residents reported funds missing, the information was given to her, and she would then ask permission to the search the resident's room. SW #1 further identified that she conducted an investigation from 7/8/26 to 7/10/26 believing that another resident (Resident #17) known to have taken food from Resident #3 had taken his/her money. Upon asking for permission, Resident #17 refused to have his/her room searched so SW #1 was only able to visually inspect the room. SW #1 also identified that she did not investigate if Resident #3 had withdrawn money from his/her personal need account as she didn't work with facility funds and didn't want to appear as if she was accessing the resident's financial account information. SW #1 indicated that Resident #3 insisted that he/she did not want the missing $100 reimbursed from the facility and declined to receive a lock box to place his/her valuables inside which the facility would have provided and that the outcome/findings of her investigation were discussed with Resident #3 verbally but never documented. SW #1 indicated that the written resolution on the resident's Grievance Form was left vague to attempt to protect Resident #3's privacy, and that she didn't call the police to report the missing funds because Resident #3 had insisted that the facility not involve the police, which was also not documented. SW #1 further stated that she had not documented the names of staff or residents' that had been interviewed during the investigation but would do so moving forward. Attempts to conduct and interview the facility's banker were unsuccessful as she was not available during survey and was away.Interview with the Administrator on 7/17/26 at 10:46 AM identified that his signature was at the bottom of Resident #3's Grievance Form, along with SW #1's signature. The Administrator further identified that the procedure for misappropriation of funds was that SW #1 conducted the investigation. The Administrator identified that he did read the Grievance Form prior to signing it and indicated that he did not report the misappropriation of funds to the State Agency. The Administrator further indicated that he wasn't sure why he didn't report the incident but was aware that the occurrence should have been reported to the State Agency and a thorough investigation should have been conducted as well. Subsequent to the interview with the Administrator, a Reportable Event was submitted to the State Agency regarding Resident #3's missing $100. Review of the policy regarding Personal Property and Missing Items directs, in part, allegations of theft, exploitation, or misappropriation of resident property will be investigated in accordance with the facility's Abuse Prevention and Reporting Policy. The policy further directs that investigation activities may include searching resident rooms and common areas; interviewing staff; reviewing recent transfers, appointments, or outings; and other appropriate investigative measures and if theft or misappropriation was suspected, then required reporting, investigation and regulatory requirements will be followed as applicable. The Personal Property and Missing Items policy also directs that for follow-up, the social worker/designee will maintain documentation related to missing property investigations and outcomes and that the resident and/or responsible party will be informed of investigation findings and outcomes. Review of the policy regarding Abuse Prevention and Reporting directed, in part, that any staff member witnessing or suspecting abuse must immediately report it to a supervisor who should then immediately notify the DON and the Administrator; an A/I (Reportable Event) report will be completed for each resident involved; the DON or designee will notify the resident's family, physician, DPH, and local police as needed and submit an online report to FLIS within 2 hours of notification. The Administrator/DON or designee will initiate an investigation and the investigation will include: interviews with all witnesses, including the accused; interviews with any individuals with relevant information; and signed and dated statements from all involved parties.

Based on interviews, review of the clinical record, facility documentation and facility policies for 1 of the 4 sampled residents (Resident #3) reviewed for personal property, the facility failed to investigate a report of a misappropriation of funds per the requirement. The findings include:Resident #3's diagnoses included kidney disease, dependence on kidney hemolytic treatment, depression, and schizoaffective disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status score of 13, indicating intact cognition, and was independent with transferring from chair/bed to chair and bed mobility. The Resident Care Plan (RCP) in effect from 4/7/26 through 7/17/26 identified Resident #3 attended hemolytic treatment 3 times per week. Interventions included ensuring treatments on Monday, Wednesday, and Friday. Additionally, the RCP indicated that Resident #3 may prefer at times to keep his/her clothes/personal belongings in bags in their room, rather than keeping them in his/her closet. Interventions included encouraging the resident to keep their extra belongings in the closet to help decrease clutter as Resident #3 allowed. A physician's order dated 6/30/26 directed to obtain the resident's weight prior to hemolytic treatment on Monday's, Wednesday's, and Friday's. A Social Services progress note dated 7/8/26 at 9:57 AM identified that Resident #3 met with Social Worker (SW) #1 per his/her request to report he/she had $100 missing from his/her room. Resident #3 stated the money was taken from his/her room and that Resident #3 believed another resident (Resident #17) was responsible for taking the money as that resident was previously in his/her room. A draft formal grievance was filed, and the matter was to be investigated. A Grievance Form dated 7/8/26 written by SW #1 identified Resident #3 reported $100 was missing from his/her room and staff and residents were interviewed; all deny seeing any money (and) residents deny entering patient's room or taking money. Under the Summary of Findings, the Grievance Form indicated, that Resident #3's money had not been located, under Actions Taken it indicated that SW #1 worked out a system with the patient to ensure his/her belongings stay safe and the patient (Resident #3) was in agreement with this system. Review of Resident #3's facility personal needs account statement provided by the Administrator identified that on 7/1/26, the resident received two withdrawals of $50.00 from petty cash, on 7/8/26 the resident received a $50.00 and $25.00 withdrawal from petty cash.Interview with Resident #3 on 7/14/26 at 10:16 AM identified that he/she had an ongoing issue with missing property at the facility and that approximately 1-2 weeks ago he/she had $100 stolen from his/her room. Resident #3 indicated $100 was received from the facility banker and that the money was placed in an envelope and left under his/her pillow per request while he/she was out of the facility receiving a hemolytic treatment. Upon return he/she found the envelope containing the money. Resident #3 stated the envelope was resealed, placed back under his/her pillow, he/she went to the bathroom, and when he/she returned the envelope containing the money was gone. Resident #3 stated that SW #1 was working on it and he/she was still waiting to hear back for a solution as the facility hadn't provided him/her with a lockbox, hadn't called the police, and hadn't refunded the $100 that had been taken indicating I hope they (the facility) give my money back. Resident #3 indicated that he/she no longer trusted his/her belongings to be left in the room and had resorted to placing valuables in a second pillowcase overnight, transferring the belongings to a backpack in the morning, and then he/she would carry the backpack with him/her during the day for security. Resident #3 did not know why the police had not been called since he/she reported the money was stolen. Interview with SW #1 on 7/17/26 at 10:15 AM and at 11:54 AM identified that when residents reported funds missing, the information was given to her, and she would then ask permission to the search the resident's room. SW #1 further identified that she conducted an investigation from 7/8/26 to 7/10/26 believing that another resident (Resident #17) known to have taken food from Resident #3 had taken his/her money. Upon asking for permission, Resident #17 refused to have his/her room searched so SW #1 was only able to visually inspect the room. SW #1 also identified that she did not investigate if Resident #3 had withdrawn money from his/her personal need account as she didn't work with facility funds and didn't want to appear as if she was accessing the resident's financial account information. SW #1 stated that Resident #3 insisted that he/she did not want the missing $100 reimbursed from the facility and declined to receive a lock box to place his/her valuables inside which the facility would have provided and that the outcome/findings of her investigation were discussed with Resident #3 verbally but never documented. SW #1 indicated that the written resolution on the resident's Grievance Form was left vague to attempt to protect Resident #3's privacy, and that she didn't call the police to report the missing funds because Resident #3 had insisted that the facility not involve the police, which was also not documented. SW #1 further stated that she had not documented the names of staff or residents' that had been interviewed during the investigation but would do so moving forward. Interview with the Administrator on 7/17/26 at 10:46 AM identified that his signature was at the bottom of Resident #3's Grievance Form, along with SW #1's signature. The Administrator further identified that the procedure for misappropriation of funds was that SW #1 conducted the investigation. The Administrator identified that he did read the Grievance Form prior to signing it indicating that a thorough investigation should have been conducted.Review of the policy regarding Personal Property and Missing Items directs, in part, allegations of theft, exploitation, or misappropriation of resident property will be investigated in accordance with the facility's Abuse Prevention and Reporting Policy. Review of the policy regarding Abuse Prevention and Reporting directed, in part, that the Administrator/DON or designee will initiate an investigation and the investigation will include: interviews with all witnesses, including the accused; interviews with any individuals with relevant information; and signed and dated statements from all involved parties.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #30) reviewed for Resident Care Planning, the facility failed to invite the legal representative to the initial Resident Care Conference and failed to provide the legal representative with a copy of the initial Resident Care Plan. The findings include:Resident #30's diagnoses included schizoaffective disorder, bipolar type, and catatonic schizophrenia. A Resident Care Plan sign-in sheet dated 6/1/26 identified a Resident Care Conference was attended by the Minimum Data Set (MDS) Coordinator, Registered Nurse (RN) #9, social services Social Worker (SW) #1, the Therapy Program Director (PT) #1, and Resident #30. The sign-in sheet failed to identify that the resident's legal representative (Person) #1 was in attendance. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment, and required set-up assistance for oral hygiene, personal hygiene, and upper and lower body dressing, and had a diagnosis of schizophrenia.The Resident Care Plan in effect on 6/5/26 identified Resident #30 had problematic behaviors including yelling and inappropriate comments towards staff. Interventions included providing psychiatric and social services as needed, and administering medications as directed by the physician. Interview with Person #1 on 7/13/26 at 2:43 PM identified Person #1 was the legal representative for Resident #30, and he/she was not invited to the initial Resident Care Conference and did not receive a written copy of the initial Resident Care Plan. Interview with RN #9 on 7/15/26 at 2:40 PM identified that a Resident Care Conference had been held on 6/1/26 and that he was responsible for sending out the invitations to attend. He also stated that it was the normal practice to invite the legal representative to the conference but that he failed to invite Person #1. RN #9 was unable to provide a reason for the failure to invite Person #1 but stated he would ensure an invitation would be sent to Person #1 for the quarterly Resident Care Conference. Interview and medical record review with SW #1 on 7/15/26 at 3:25 PM identified that there was a centralized admissions process that documents certain demographic information including identification of a resident's legal representative, and this was done prior to admission. SW #1 stated she thought that she called Person #1 for the initial Resident Care Conference, but when she reviewed her documentation she failed to identify a record of a phone conversation held with Person #1 or invitation to the initial Resident Care Conference. Review of the Care Planning policy identified a comprehensive interdisciplinary plan of care would be developed, implemented, reviewed, and updated for each resident in accordance with regulatory requirements and resident-specific needs, and that residents and/or responsible parties would be encouraged to participate in the care planning process. The policy directed, in part, that the resident and/or responsible party would be invited to participate in care plan conferences and participant involvement would be documented.

Based on observations, interviews, and review of the clinical record and policy for 2 of 3 sampled residents (Resident #26 and Resident #55) reviewed for Activities of Daily Living (ADL), for Resident #26, the facility failed to provide fingernail care to a dependent resident and for Resident #55 failed to provide assistance with shaving to a dependent resident. The findings include:1. Resident #26's diagnoses included pulmonary fibrosis, type 2 diabetes mellitus, and hyperlipidemia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #26 had a Brief Interview of Mental Status score of 14 indicating intact cognition and was dependent on staff for personal hygiene and showering/bathing. The Resident Care Plan dated 7/2/26 identified Resident #26 required assistance with ADLs due to a self-care deficit. Interventions included assisting with ADLs as needed to meet bathing, dressing, hygiene, and toileting needs. Review of the Physician Order Summary report dated 7/17/26 failed to identify a physician order related to ADL personal hygiene assistance levels. Observation and interview with Resident #26 on 7/14/26 at 10:15 AM identified his/her fingernails on both hands were long with a dark, brown, dirt-like substance underneath. Resident #26 indicated that it had been about 4 weeks since he/she got his/her fingernails trimmed by the hospice nurse and that the facility staff refused him/her on numerous requests. Observation and interview with NA #7 on 7/15/26 at 2:11 PM identified that the NA was responsible for cleaning and trimming resident's fingernails. NA #7 indicated that fingernails should be trimmed and cleaned when observed as long and dirty or per the resident request. NA #7 indicated that she had observed Resident #29's fingernails earlier in her shift but did not remember if they were dirty/long. Observation of Resident #29's fingernails identified that they should not be that long and dirty. NA #7 asked Resident #26 if she could clean and trim his/her fingernails and he/she agreed. Interview with the Director of Nursing (DON) on 7/16/26 at 9:32 AM identified that the NA was responsible for cleaning/trimming resident fingernails and that they should be observing their fingernails every shift. She indicated that resident refusals would be communicated to the nurse and documented in a note in the resident's electronic health record. The DON was unable to identify why Resident #26's fingernails were not trimmed/cleaned per resident request and facility policy and that she would reeducate staff. Subsequent to surveyor inquiry, NA #7 cleaned/trimmed Resident #26's fingernails. 2. Resident #55 diagnoses included diabetes, major depressive disorder, and anxiety. The Nursing admission assessment dated [DATE] at 9:17 PM identified Resident #55 required assistance with grooming. The admission Minimum Data Set assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status of 13 indicating intact cognition and was dependent on staff for personal hygiene, toileting hygiene, and dressing and that Resident #55 had not rejected care. The Resident Care Plan dated 5/1/26 identified Resident #55 needed assistance with activities of daily living related to a self-care deficit. Interventions included assisting with activities of daily living due to cognitive status and assisting them to meet their needs. Review of the electronic health record identified a photograph of Resident #55 taken upon admission, with a clean-shaven face. Observation and interview of Resident #55 on 7/13/26 at 9:45 AM identified him/her in bed, unshaven with a scruffy, unkept beard stating he/she preferred to be clean shaven but that it was hard to find staff to do it even though he/she has asked. Observation on 7/14/26 at 10:00 AM identified Resident #55 in his/her chair wearing a johnny coat without the benefit of being shaved. Interview with Nurse Aide (NA) #1 on 7/15/26 at 9:42 AM identified it was the facility's policy to shave residents upon their request or when it is identified they need to be shaved as part of morning care. Additionally, NA #1 identified she was the regular care giver for Resident #55 and that just that morning he/she requested to be shaved, which she planned to do later, after finishing up the care she was providing for another resident. Interview and observation with the Director of Nurses (DNS) on 7/15/26 at 12:03 PM identified it was the facility policy for NA's to shave residents on shower day and upon request. Observation of Resident #55 identified he/she was still not shaved, with Resident #55 reiterating he/she asked for a shave in the mornings. The DNS identified that Resident #55 should have been shaved with morning care. Subsequent to surveyor inquiry the resident was shaved. Review of the AM Care/ADL Policy directed in part to provide residents with assistance for morning care and activities of living according to their preferences, abilities and plan of care. The procedure included providing incontinent care, skin care, nail care, shaving and range of motion exercises as appropriate.

Based on interviews, observations, and reviews of the clinical record and policy for 2 of the 5 sampled residents (Resident #2 and Resident #52) for Resident #2 reviewed for unnecessary medications, the facility failed to consistently take blood pressures to ensure medication parameters were met prior to medication administration and for Resident #52 reviewed for positioning and mobility, the facility failed to ensure footrests were applied to a wheelchair for a resident dependent on staff for Activities of Daily Living (ADL). The findings include: 1. Resident #2's diagnoses included congestive heart failure, atrial fibrillation, and hypertension. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status score of 15 indicating intact cognition, did not exhibit behaviors, was dependent on staff for transfers, and required partial/moderate assistance with bed mobility. The Resident Care Plan (RCP) in effect on 2/8/26 through 7/17/26 identified cardiovascular disease. Interventions included administering medications and taking vital signs as ordered/per facility policy. A physician's order dated beginning on 3/12/26 and in effect through 7/17/26 directed to administer Losartan 25 milligrams (mg) and Metoprolol Extended Release (ER) 25 mg daily, and to hold both medications for a blood pressure less than 100/50 mmHg. Review of the clinical record from 3/12/26 and in effect through 7/17/26 identified daily blood pressures were missing on 3/7/26 through 3/29/26, 4/9/26 through 5/27/26, 5/29/26 through 6/5/26, 6/18/26, 6/20 and 6/21/26, and 6/23/26 through 7/17/26 for a total of 88 out of 132 opportunities missed. An interview with RN #7 on 7/17/26 at 11:16 AM noted that Resident #2 had not consistently received blood pressure monitoring the for the administration of Metoprolol and Losartan. Nurses were responsible to ensure blood pressures were taken prior to administering medication when there were parameters. The reason blood pressure monitoring was not occurring regularly was that the facility failed to attach the supplemental documentation in the electronic medical record which would have appeared on the Medication Administration Record as a trigger for the nurse to take the blood pressures. Review of the undated Medication Administration facility policy directed to monitor adverse side effects and administer medications according to the physician orders. 2. Resident #52's diagnoses included dementia, depression, anxiety, abnormalities of gait and mobility, and repeated falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #52 had a Brief Interview of Mental Status score of 00 indicating severe cognitive impairment, required mechanical lift for transfers, was totally dependent on staff for bed mobility, and wheelchair use. The Resident Care Plan (RCP) in effect from 6/21/26 through 7/17/26 identified Resident #52 required staff assistance with Activities of Daily Living (ADLs) related to his/her impaired mobility and cognitive deficits related to dementia. Interventions included for staff to assist with the resident's ADLs as needed. A physician's order dated 7/10/25 directed to transfer Resident #52 with a mechanical lift to a tilt in space wheelchair every shift. Multiple observations on 7/13/26 beginning at 10:15 AM and ending at 12:50 PM identified Resident #52 observed in the East unit dining room, seated in his/her wheelchair feet unsupported by footrests, legs dangling, and the residents feet were suspending in the air and not touching the floor. Observations on 7/14/26 at 12:28 PM, and at 12:35 PM identified Resident #52 sitting in his/her wheelchair without the wheelchair's leg rests attached, legs dangling unsupported, and feet not touching the floor. Observations of Resident #52 during lunch in the East Unit lounge on 7/15/26 at 12:10 PM identified his/her wheelchair tilted back approximately 30 degrees with the wheelchair leg rests angled and attached, however, the position of the leg rests was too low, and the legs were dangling suspended above the leg rests unsupported. Observation of Nurse Aid (NA) #6 on 7/15/26 at 12:21 PM identified she adjusted Resident #52's wheelchair to 90 degrees (flat/normal seating position), without adjusting the resident's leg rests. The leg rests remained in the up position and Resident #52's legs were between the calf support and the footrests unsupported, dangling, without his/her feet reaching the floor or footrest. Interview and observation with Rehabilitation Department Director/Occupational Therapist (OT) #2 on 7/16/26 at 12:12 PM identified that Resident #52 was sitting in the East Dining Room with his/her wheelchair tilted back approximately 30 degrees with the wheelchair's leg rests angled and attached to the wheelchair. Resident #52 was observed to have his/her legs dangling, unsupported by the wheelchair leg supports, with the resident's feet not touching the floor. OT #2 indicated that the resident's leg rests were not properly placed to support Resident #52's legs appropriately and stated, the resident should either have padded leg rests if they had a custom wheelchair, but in Resident #52's case they should use a leg strap with their existing leg support. OT #2 further stated that Resident #52 did have leg straps for their leg rest attachments, but she would go to her office to grab a set and educate staff on the importance for this resident to have his/her legs supported. OT #2 further identified that potential ramifications for a resident having their legs dependently hanging off the edge of a wheelchair not properly supported could result in contractures, increased edema, and increased pain. She indicated that it is all staff's responsibility to make sure that the resident's leg rests were attached to their wheelchair, and their legs were appropriately supported by the leg attachments. OT #2 stated she didn't know why Resident #52's legs weren't properly supported and that she would educate the staff. Interview and observation with Nurse Aid (NA) #6 at 7/16/26 at 1:48 PM identified she had Resident #52 on her assignment. Resident #52 was observed sitting in his/her wheelchair with the seat at 90 degrees, with his/her legs hanging from the edge of the wheelchair seat, not touching the floor and both legs unsupported by the attached leg supports on the wheelchair which were rotated outward and were not in the required supports. NA #6 was unable to verbalize what the facility's policy/procedure was regarding wheelchair leg supports or that the resident's feet required support while in the wheelchair since the resident's feet did not touch the floor. NA #6 identified that it was the NA's responsibility to make sure residents' leg rests were on, and that their legs were supported by the attached leg rests. NA #6 stated she didn't know why Resident #52's leg rests weren't properly attached, with their legs supported by the leg rests and stated, it was a mistake. Review of the undated Wheelchairs and Specialized Seating policy directs, in part to ensure appropriate positioning and support of residents' head and neck, upper extremities, lower extremities, and their trunk and pelvis. The policy further directs to utilize positioning devices, cushions, leg rests, arm supports, and other equipment as indicated by the resident plan of care, rehabilitation recommendations, or physician/provider orders.

Based on observations, interviews, facility documentation, and facility policy for 1 of 3 sampled residents (Resident #55) reviewed for activities of daily living, the facility failed to obtain a podiatry consent and failed to provide podiatry services. The findings include:Resident #55 diagnoses included diabetes, major depressive disorder, and anxiety.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status of 13 indicating intact cognition and was dependent on staff for personal hygiene, and lower body dressing and had no rejections of care.The Resident Care Plan dated 5/1/26 identified Resident #55 had diabetes. Interventions included a diabetic foot check every shift, reporting any complaints of foot or nail discomfort, and observing for cuts, blisters, open areas, and long thick toenails.A physician's order dated 5/11/26 directed for consults: wound, vision, dental, podiatry, audiology, physiatry, and psychiatric services as needed.Observation and interview with Resident #55 on 7/13/26 at 9:45 AM identified the resident in bed, feet uncovered, exposing jagged unclipped nails, with both big toenails appearing as yellow, thick and longer than 0.5 inches past the nailbed. Resident #55 stated that although staff trimmed his fingernails, his/her toenails had not been clipped since he/she was admitted (4/30/26).Review of the admission and readmission face sheet identified that Resident #55 was appointed a conservatorship for person (health and daily care decisions ) and the resident was not able to make his/her own decisions for care. Review of the consent form dated (illegible) identified the box for No was checked and that the resident would make alternate arrangements for services. This was followed by unchecked boxes for audiology, dental, eye care, and podiatry. The form was signed by Resident #55.Review of the clinical record from 4/30/26 through 7/15/26 failed to identify that the facility had made attempts to contact the conservator to ensure alternate or any provision of podiatry services.Interview with Registered Nurse Supervisor (RN) #1 on 7/15/26 at 9:46 AM identified it was the facility's policy for resident to have their toenails clipped by the Podiatrist, however there was no formal list, and the Director of Nurses (DNS) was verbally notified of any resident that needed services. RN #1 failed to identify that the DNS was notified of Resident #55's need for toenail clipping/podiatry services.Interview and documentation review with the Director of Nursing Services (DNS) on 7/15/26 at 12:03 PM identified that residents were enrolled in ancillary services, including podiatry, on admission or on request, requiring a signed consent and that podiatry services were provided every 60 days. A review of the Podiatrist Visit Summary list dated 7/13/26 failed to identify that Resident #55 was seen, and the podiatry schedule for the upcoming visit on 8/13/26 failed to identify Resident #55 was scheduled. Review of Resident #55's clinical record (paper and electronic) with the DNS, failed to identify a signed podiatry consent from the resident's conservator completed at admission on [DATE] or at readmission on [DATE]. Although Resident #55 had signed for him/herself on 6/24/26 upon readmission, the DNS indicated that she would have to educate her staff to ensure they were checking for conservatorship prior to document signing as Resident #55 was conserved. The DNS confirmed that consent should have been obtained, but had not been, and that Resident #55 should have been seen by podiatry. Subsequent to surveyor inquiry, the DNS asked Resident #55 if he wanted podiatry services to which he agreed, the conservator was contacted, and a consent was signed as of 7/15/26.Review of the Ancillary Services Policy directed in part that ancillary needs will be evaluated on admission, and as part of ongoing assessments by the interdisciplinary care team and physician. Additionally, ancillary services will be provided by the facility or through coordination with qualified external providers. Residents and/or legal representatives will be informed of available services and assisted in scheduling appointments as needed.Review of the Foot Care Policy directed in part residents with diabetes, vascular disease, wounds or other high-risk conditions may require additional monitoring or provider involvement.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #7) reviewed for nutrition, the facility failed to provide double portions, per the physician order, for a resident exhibiting significant weight loss. The findings include:Resident #7's diagnoses included encephalopathy (a brain disorder), type 2 diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD).A dietitian note dated 2/19/26 identified Resident #7 had a wound to the coccyx and was eating well according to staff reports and review of records. Commercial supplements were not indicated at that time, but the kitchen would be asked to send double portions of meats/eggs at meals for added calories and protein. A Nutritional assessment dated [DATE] identified Resident #7 had a right heel wound stage 3, and a stable coccyx wound stage 2 and improving. The resident's weight was noted to be labile (changing), and Resident #7 was noted to be eating well and receiving larger portions.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment and required set-up assistance for eating with use of suitable utensils. Weight loss was not coded on the 5/15/26 MDS. The Resident Care Plan in effect on 5/19/26 identified Resident #7 had potential for nutritional decline due to multiple medical problems and need for a therapeutic diet with altered consistency and directed to provide diet as ordered including larger portions of meats and eggs. A review of Resident #7's weight from 4/3/26 through 6/25/26 identified the following:On 4/3/26 a weight of 229 pounds. On 5/5/26 a weight of 215 pounds indicated a 14-pound (6.1%) weight loss from 4/3/26. On 6/25/26 a weight of 207.5 indicated a 7.5-pound weight loss from 5/5/26, and a 21.5 pound weight loss from 4/3/26 (9.4%) in 2 months.A Grievance Form dated 6/5/26 written on behalf of Resident #7 indicated a concern that he/she was not receiving enough food and not receiving protein with his/her meals. The action taken by Social Worker #1 was to remind Resident #7 and the person who initiated the grievance that double portions were ordered and that the kitchen would watch protein with each meal ensuring Resident #7 had the correct amount. A Physician's Order dated 6/30/26 directed to provide dysphagia level 3 texture diet with thin liquids, soft sandwiches, and double portions.Resident #7's weight was recorded to be 208.2 pounds on 7/1/26 indicating a 0.7-pound weight gain from 6/5/26 and a significant weight loss of 9.08% in 90 days.A physician's note dated 7/1/26 indicated that Resident #7's condition would continue to decline including weight loss as diseases progressed. Additionally, Resident's diagnosed chronic obstructive pulmonary disease and congestive heart failure were noted to be chronic and stable. A dining observation on 7/13/26 at 12:15 PM identified Resident #7 was initially served a meal of the wrong consistency and provided with pudding and a beverage while waiting for the correct meal. Resident #7 was served the correct meal at approximately 12:30 PM and the portion of entree, starch, and vegetable were similar in size to portions served to another resident seated at the same table, with each of the 3 portions filling 1/3 of the plate. A second dining observation on 7/15/26 at 12:15 PM identified Resident #7 was served a meal including a vegetable, pasta with meat sauce, and a dinner roll. A meal of similar size/proportion was served to another resident seated at the same table and a photograph was taken for comparison. The meal ticket noted a diet order for consistent carbohydrates, with mechanical soft texture and a note was added to indicate that Resident #7 could have soft sandwiches. The meal ticket failed to direct increased protein or to serve double portions. Interview with Nurse Aide (NA) #8 on 7/15/26 at 12:15 PM identified that Resident #7 did not receive double portions as directed by the physician order dated 6/30/26. A review of the meal ticket sent with the meal failed to identify that double portions were to be provided so she did not know that double portions were to be served.An interview with Dietitian #1 on 7/16/26 at 11:10 AM identified she ordered double portions of meat and eggs on 2/19/26 for added calories and protein to promote healing due to a wound to the coccyx, and that Resident #7 should continue with the order as written on 2/19/26. Dietitian #1 ordered house supplement 120 milliliters twice daily for risk for malnutrition on 5/1/26, in addition to the double portions ordered. She additionally had ordered liquid protein 30 milliliters twice daily for 2 weeks on 7/2/26 due to the stalled healing of a stage 3 heel wound. Dietitian #1 stated she expected the order for double portions to have been continued and did not know why the double portions were not being provided by the Dietary Department.An interview with Corporate Food Service Supervisor on 7/16/26 at 12:00 PM identified upon review of diet change slips received and kept in the Dietary Department, a meal ticket had been sent to the kitchen on 2/19/26 for the double portions, and that the system for generating meal tickets had recently been updated. Corporate Food Service Supervisor stated the directions for double portions may have been missed during the change to the new system however she was unable to identify when the change occurred or how long the double portions were missed. An undated copy of Resident #7's meal ticket from the previous system was provided and notations for double eggs and meat at breakfast, and double meat at lunch and supper were notated as ordered by the Dietitian on 2/19/26. The Nutritional Supplementation Program policy directed, in part, that the facility would utilize an interdisciplinary approach to identify residents at nutritional risk, implement appropriate interventions, monitor effectiveness and adjust the plan of care as needed, and the goals of nutritional supplementation may include supporting adequate nutritional intake, supporting wound healing and promoting weight maintenance or weight gain. Additionally, nutritional supplementation could include oral nutritional supplements, nourishments/snacks, or other physician/provider or dietitian-directed interventions.

Based on interviews, observations, reviews of the clinical record, and facility policy for 1 of 2 sampled residents (Resident #20) reviewed for respiratory care, the facility failed to ensure oxygen administration was set according to the physician order. The findings include:Resident #20's diagnoses included chronic respiratory failure, obstructive sleep apnea, and heart failure.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status score of 15 out indicating normal cognitive function, required personal moderate assistance with personal hygiene, used a manual wheelchair, was dependent on staff for wheelchair mobility and was receiving oxygen therapy as a respiratory treatment.The Resident Care Plan dated 5/12/26 identified Resident #20 was at risk for cardiac/respiratory distress and related complications due to heart failure. Interventions included providing oxygen as ordered by the physician.A physician order dated 7/3/26 directed continuous oxygen at 5 liters per minute (lpm) via nasal cannula.Observation on 7/13/26 at 11:10 AM identified Resident #20 was sitting in a chair with a nasal cannula on. The oxygen machine was turned on and set at 3.5 lpm and was noted to be out of reach for the resident so he/she would be unable to adjust the setting.Interview and observation with the Licensed Practical Nurse (LPN) #4 on 7/15/26 at 2:34 PM identified that oxygen administration should be set according to the physician's order, should be checked at least once per shift and that it is the responsibility of the assigned nurse to ensure that it is set correctly. LPN #4 identified that although she had checked Resident #20's oxygen saturation level earlier in the shift, she did not check the setting of the oxygen administration. LPN #4 identified that Resident #20 had a current physician order for continuous oxygen at 5 lpm via nasal cannula, was sitting in his/her chair with a nasal canula on and his/her oxygen administration was set at 3.5 lpm which was incorrect. Subsequent to surveyor inquiry, LPN #4 changed Resident #20's oxygen administration from 3.5 lpm to 5 lpm per physician order.Interview with the Director of Nursing (DON) on 7/16/26 at 10:18 AM identified oxygen administration should be set according to the physician's order and that it was the responsibility of the unit nurse to check at least once a shift. The interview failed to identify why Resident #20 oxygen was set incorrectly.Review of the Oxygen Administration Policy not dated directed in part for staff to verify that that a physician's order is necessary for oxygen administration.

Based on observation, staff interview, and facility policy review, the facility failed to ensure safe storage of medications for 1 of 2 medication carts. The findings include:Observation on 7/14/26 from 9:20 AM to 9:30 AM, identified supervising Registered Nurse (RN) #1 passing medications on the East Unit. After pouring medications, she walked away, out of sight of the medication cart, failing to secure (lock up) medications. At 9:26 AM 2 residents were observed walking by the unlocked medication cart. At 9:30 AM RN #1 returned to the medication cart and was observed opening the top drawer of the cart without using a key to unlock it. Interview and observation with RN #1 at 9:30 AM identified that the medication cart was unlocked upon her return and that she knew the policy required her to ensure medications in the cart were secured by locking the cart when not in use or in direct sight. RN #1 could not state why she left the cart unlocked indicating that she should have locked it before walking down the hallway. A review of the Medication Storage in the Facility policy dated 1/26 directed in part that the medication would be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and that medication rooms, carts and medications supplies would be locked or attended to by persons with authorized access.

Based on observations, staff interviews, and facility policy, the facility failed to ensure food was served/prepared under sanitary conditions. The findings include:During a tour of the kitchen with the Dietary Director on 7/13/26 at 9:05 AM identified the following:Freezer had food debris on the inside bottom shelf2 refrigerators had food debris on the inside bottom shelfShelf in the middle of the kitchen had food debris on 2 bottom shelves.Shelf on the right side of the oven and left side of the deep fryer had food debris; a brown dried substance.Clean adaptive eating equipment on the bottom shelf had food debris throughout the Potatoes and onions were stored in plastic bins under a food preparation counter without the benefit of being covered.Observations and interview with the Director of Dietary on 7/13/26 at 9:10 AM identified that the kitchen counters were cleaned after each meal, shelves were cleaned at the end of each day, and refrigerators and freezers were cleaned weekly by dietary staff. The Director acknowledged the food debris in the refrigerators, freezers, and shelves should not be there, did not know how long the food debris was there, and that they should be cleaned daily. He indicated that the potatoes and onions had been stored under the food preparation counter in the plastic bins, uncovered, since he had been employed (about 2 months) and should have been covered to prevent debris from falling into the bins during food preparation. The Dietary Director noted that a rotten potato was discovered in the bin stating yea that's not good, it should not be there.The Director indicated he was responsible for ensuring the kitchen was clean/sanitary and proper storage of food and that he would have the shelves, refrigerators, and freezer cleaned. Subsequent to surveyor inquiry, the shelves, refrigerators, and freezers were cleaned. Additionally, the potatoes and onions were discarded and the Director indicated they would be stored in a different location with the benefit of a coverReview of the Guidelines for General Cleanliness of the Dietary Department dated 8/17 directed in part that employees are responsible for a thorough cleaning prior to the end of shift at the close of each day but not limited to: cleaning and sanitizing all work surfaces, sweeping/mopping kitchen and dish room floor, proper storage of dishware and overall cleanliness of the entire department.

Based on interviews, review of the clinical records, and facility policy for 1 of 13 sampled residents (Resident #20) reviewed during the Resident Council meeting, the facility failed to ensure medications were administered according to the 5 Rights of Medication Administration, and for 2 of 4 sampled residents (Resident #24 and Resident #60), reviewed for medication administration, for Resident #24 and Resident #60, the facility failed to follow the Five Rights of Medication Administration and for Resident #60, failed to perform appropriate hand hygiene according the infection control principles. The findings include: 1. Resident #20's diagnoses included muscle weakness, type 2 diabetes mellitus, hypothyroidism, venous insufficiency, obstructive sleep apnea and heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status score of 15 indicating intact cognition, required setup or clean-up assistance with eating, and was dependent on staff for transfers. The Resident Care Plan dated 5/12/26 identified Resident #20 had exhibited increased paranoia and agitation surrounding medication administration from nursing staff. Interventions included administering medication as directed by the physician. During a Resident Council meeting on 7/16/26 at 1:30 PM, Resident #20 indicated that he/she was administered his/her morning medications late on 7/15/26. Review of physician orders dated 7/3/26 and currently in effect directed to administer the following medications: Tylenol 325 milligram (mg) oral tablet, give 650 mg 3 times a day at 8:00 AM for pain Metformin HCL 500 mg tablet, give 2 times a day at 9:00 AM for diabetes mellitus Gabapentin 600 mg tablet, give 2 times a day at 9:00 AM for pain Baclofen 10 mg tablet, give two 2 times a day at 9:00 AM for pain Review of Resident #20's Medication Administration Record (MAR) identified that on 7/15/26 his/her Tylenol order was scheduled at 8:00 AM and administered at 11:47 AM. Additionally, the MAR identified that his/her Metformin, Gabapentin, and Baclofen orders were scheduled at 9:00 AM and administered at 12:08 PM Interview with the Director of Nursing (DON) on 7/17/26 at 10:51 AM identified that if medications were being administered late the nurse should have notified the physician, responsible party and documented the information in the resident's electronic health record. The DON indicated that the nurse providing medication administration should notify the supervisor when knowing medications would be administered outside the 1 hour allotted time frame so assistance could have been given. The DON indicated that she was unaware Resident #20's medications were administered late on 7/15/26 and that she and the physician should have been notified. Interview with Licensed Practical Nurse (LPN) #4 on 7/17/26 at 11:37 AM identified that if medications were administered late then the provider should be notified and it was responsibility of the nurse who was administering the medications to make notification. LPN #4 indicated that she did not consider administering Resident #20's medications 3 to 4 hours after the prescribed administration time on 7/15/26 to be late so she did not notify the provider. LPN #4 indicated she was running behind during medication administration due to it being her first day at the facility and was not used to the large number of residents who needed to be administered medications. LPN #4 could not identify an appropriate time frame in which medications needed to be administered or what would be considered outside of the accepted parameters. Additionally, LPN #4 had not notified anyone in the facility so that help could be provided. Interview with the Medical Director on 7/17/26 at 12:43 identified that he should be notified when a resident's medication was administered late to determine if it was appropriate for the next dose to be administered at the scheduled time. Review of the medications administer late for Resident #20 with the Medical Director identified that he didn't know if he would have changed the next dose as it was dependent on the resident's current status when the late medication administration occurred. 2. Resident #24's diagnoses included Down syndrome, Alzheimer's disease and hypotension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #24 had a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment and required total staff assistance of staff with bed mobility, transfer, and eating. A physician's order dated 6/30/26 directed to check Resident #24's identification band (ID) band prior to medication administration, administer: escitalopram oxalate 10 milligram orally 1 tab daily for depression loratadine 10 milligram orally once a day for allergies lorazepam 0.5 milligrams 1 tab orally 3 times a day for yelling, restlessness, anxiety, hold for lethargy Seroquel 50 milligrams orally 2 times a day for agitation, midodrine hydrochloride 10 milligram 1 tab orally 3 times a day for hypotension Senna-S 8.6-50 milligrams 3 tabs orally 2 times a day for constipation bisacodyl delayed release 5 milligrams 1 tab orally once a day for constipation Observations and interview with supervising Registered Nurse (RN) #1 on 7/15/26 at 8:25 AM identified she poured 1 tablet of bisacodyl directly into her hand from the container. RN #1 was stopped by the surveyor due to concerns with infection control practices. RN #1 was unaware that she had not adhered to standardized infection control practices stating, is that bad?. RN #1 discarded the medication, repoured the medication, and entered Resident #24's room. Just prior to administering Resident #24's medication RN #1 was stopped by the surveyor. Resident #24 was not wearing any ID band and RN #1 failed to ask the resident his/her name, failed to have the medication cart (left at the nurses station) to reference a picture, and failed to verify any attempts to ensure the right resident was receiving the right medication. RN #1 indicated that had known Resident #24 known from previous administrations, and that was how she had identified the resident. RN #1 was unable to explain the facility policy/practice of identifying the correct resident (Resident #24) prior to medication administration. 3. Resident #60's diagnosis included diabetes, presence of prosthetic heart valve, and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview for Mental Status assessment score of 15, indicating intact cognition, was independent with bed mobility, required supervision with transfers and ambulation, and set up assistance with eating. A physician's order dated 6/30/26 directed to check the Identification (ID) band prior to medication administration, and administer: anastrozole tablet 1 milligram orally once a day for breast cancer cholecalciferol tablet 50 micrograms 1 tablet orally once a day for bone health fenofibrate 160 milligrams 1 tablet orally once a day related to hyperlipidemia Januvia 100 milligrams 1 tablet orally once a day for diabetes, escitalopram 10 milligrams 1 tablet once a day related to depressive episodes aspirin 81 milligrams orally one tablet once a day for stroke prophylaxis. Observation and interview with supervising Registered Nurse (RN) #1 on 7/15/26 at 9:00 AM identified her pouring the medicine into a medication cup and while doing so, dropped a pill on the floor. She picked up the pill, threw it in the trash can, but failed to sanitize her hands after touching the floor and prior to repouring the medication. RN #1 was stopped just prior to administering medications to Resident due to the failure to identify the resident. RN #1 was unable to explain how she verified Resident #60's identity since the resident did not have an ID band and she had left the medication cart at the nursing station, unable to state the facility policy/practice of correctly identifying residents prior to medication administration. RN #1 then asked Resident #60 to state his/her name and date of birth prior to administering the medication. Interview with Director of Nursing (DON) on 7/15/26 at 11:51AM indicated that residents were identified prior to administering medications by looking at the resident identification band. If the resident did not have an identification band, the identity of the resident would be verified by the picture in the computer, or another staff member would verify the resident's identity. The DON further indicated that the 5 Rights of Medication Administration should be followed as well as hand hygiene and maintaining infection control measures. The DON indicated that a pharmacy representative observed medication administration competencies and the last competency was performed on 4/29/26. Subsequent to surveyor inquiry, a medication competency was conducted with RN #1 on 7/15/26 by RN #10. Review of the medication administration policy undated, directed, in part, 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, right documentation. Routine non-time-sensitive medications may be administered within one hour before or one hour after the scheduled administration time. Additionally, the policy directed staff to report adverse reactions, medication errors, or significant concerns according to facility policy and document all required notifications and interventions. Verify Right resident, right medication, right dose, right route, right time. Preparation for administration performs hand hygiene prior to medication preparation and administration, follow facility infection prevention practices during medication preparation and administration.

Based on observations, interviews, and facility policy during a review of the resident Personal Needs Account (PNA) funds, the facility was unaware of where resident funds could be accessed during off hours when business office personnel were unavailable. The findings includeObservation on 7/15/26 at 2:18 PM, identified although a sign outside the business office door indicated banking hours were between 9:00 AM and 4:00 PM, the door was noted to be locked and unanswered when knocked on. Interview with the receptionist on 7/15/26 at 2:18 PM identified that the Business Office Manager was not available in the building, but that a nursing supervisor would be able to access resident funds. Interview with the Assistant Director of Nursing Services (ADNS) on 7/15/26 at 2:21 PM failed to identify that she knew how residents could be provided with their PNA funds upon request, when business office personnel were not available, or during off hours when the business office was closed outside of the posted 9:00 AM to 4:00 PM banking hours. The Assistant Director of Nursing Services (ADNS) stated she was unaware of a cash box or if there was a location of a cash box indicating she didn't think the facility gave out funds during the off/closed hours. The ADNS went to the East Unit but was unable to locate an available PNA cash box. Interview with Registered Nurse (RN) #1 on 7/15/26 at 2:22 PM (who was working on the East Unit) failed to identify she or other nursing staff were aware there was an available resident PNA cash fund so residents could obtain money during times when the Business Office Manager was not working or available or outside banking hours. RN #1 indicated she worked a total of 8 off shifts during the period from 6/13/26 through 7/12/26 and although no residents had requested personal funds, she would have been unable to provide any money to residents if requested, as she was not aware of a PNA cash box and the resident would have to wait to obtain money. Interview with Corporate Registered Nurse (RN) #7 and the Director of Nursing Services (DNS) on 7/15/26 at 2:25 PM identified that the Administrator would know of the location of the resident PNA cash box.Interview with LPN #1 and the Administrator on 7/15/26 at 2:27 PM on the [NAME] Unit failed to identify the locations of the resident PNA cash box. Observations and interviews on 7/15/26 from 2:25 PM through 2:58 PM with the Administrator failed to initially determine the location of a PNA cash box on either of the 2 units. Subsequent to surveyor inquiry, he called the Business Office Manager and at 2:38 PM when the Business Office Manager returned the call, the Administrator was told the petty cash box was located on the East Unit. A set of keys was obtained by RN #7 and the social worker, but the keys were unlabeled and access to the resident PNA cash was delayed until 2:58 PM (40 minutes after the initial request) when the correct key was determined. At 3:03 PM the Administrator identified that nursing should have known of the existence of a PNA cash box, where it was located, and how to access PNA cash for residents requesting their money during off hours. Review of the Resident Trust Fund Policy and Procedure dated 10/1/20 directed, in part, petty cash be accessible in the off shift, dispersed as requested.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Residents #1) who exhibited behavioral symptoms, the facility failed to notify the provider of medication omissions when the antianxiety medication was not available therefore six (6) doses were omitted. The findings include:Resident #1's diagnoses included catatonic disorder (a neuropsychiatric disorder that presents with abnormal motor, behavioral, and emotional responses which can include immobility, excessive movement and unusual postures or speech), major depressive disorder, anxiety disorder, delusional disorder and unspecified psychosis (psychotic symptoms that don't align with a specific psychotic disorder or mental illness). The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) indicating Resident #1 had some memory recall deficits and received antianxiety and hypnotic medications. The Resident Care Plan dated 12/5/25 identified Resident #1 was receiving antianxiety medication. Interventions included administering medication as directed by the provider and updating the provider of any concerns, complications or changes in condition. A physician's order dated 12/12/25 directed to administer lorazepam tablet 0.5 milligrams (mg), give 0.5 mg by mouth three (3) times daily for restlessness and catatonia. Review of the December 2025 Medication Administration Record (MAR) identified the lorazepam was not administered on 12/18/25 at 4:00 PM and 9:00 PM because the lorazepam was unavailable. Review of nurse's electronic MAR (eMAR) notes dated 12/18/25 failed to reflect documentation a provider was notified the lorazepam was not available and therefore two (2) doses were omitted. A physician's order dated 12/19/25 directed to discontinue the lorazepam three (3) times a day and start lorazepam tablet 0.5 milligrams (mg), give 0.5 mg by mouth four (4) times daily for restlessness and catatonia. Review of the December 2025 Medication Administration Record (MAR) identified the lorazepam was not administered on 12/25/25 at 4:00 PM and 8:00 PM, 12/26/25 at 4:00 PM and 8:00 PM and on 12/27/25 at 8:00 AM and 12:00 PM because the lorazepam was unavailable, therefore six (6) doses were omitted. Review of nurse's electronic MAR (eMAR) notes dated 12/25/25 through 12/27/25 identified the medication was not administered because the medication was not available and was on order, and the notes failed to identify a provider was notified. Interview with the psychiatric Advanced Practice Registered Nurse on 1/7/26 at 2:50 PM identified she was not aware of Resident #1 missing any doses of lorazepam, explaining a provider should have been notified, and another benzodiazepine could have been ordered as an alternative in the meantime due to the frequency the medication was scheduled and Resident #1's diagnosis of catatonia. Interview with the Regional Nurse, Registered Nurse (RN) #7, on 1/7/25 at 3:12 PM identified a provider should have been notified for all the missed doses of lorazepam for a possible alternative order. RN #7 explained the pharmacy should have been contacted to inquire if there were any issues and to require the medication STAT (immediately) and she was unable to find any documentation that had occurred. Review of the Medication Administration policy (undated) directed, in part, that all medications shall be administered safely and accurately in accordance with physician orders, facility protocols, and applicable state and federal regulations. For medications that are unavailable at the time of administration, notify the physician immediately and request guidance or an alternative order, inform the resident or their responsible party about the situation, check with the pharmacy or alternative suppliers to expedite delivery of the medication, document all actions taken in the resident's medical record and notify the supervisor.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had behavioral symptoms of restlessness and impulsiveness, the facility failed to ensure the plan of care was reviewed and revised to address the addition of an anti-psychotic medication when the medication was ordered. The findings include:Resident #1's diagnoses included catatonic disorder (a neuropsychiatric disorder that presents with abnormal motor, behavioral, and emotional responses which can include immobility, excessive movement and unusual postures or speech), major depressive disorder, anxiety disorder, delusional disorder and unspecified psychosis (psychotic symptoms that don't align with a specific psychotic disorder or mental illness). The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) indicating Resident #1 had some memory recall deficits, required staff assistance with activities of daily living and received antianxiety and hypnotic medications. The psychiatric Advanced Practice Registered Nurse's (APRN) note dated 12/23/25 identified there were concerns Resident #1 may have undiagnosed bipolar disorder, depression, or significant trauma history as medical causes for catatonia were ruled out. The note directed that she would trial Abilify (an anti-psychotic medication) at a low dose, and she would be ordering Abilify 2 milligrams (mg) daily. A physician's order dated 12/23/25 directed to administer Abilify 2 mg tablet, give 2 mg bymouth one (1) time a day for delusional disorder (having false beliefs based on an incorrect interpretation of reality). The psychiatric APRN note dated 1/2/26 identified Resident #1 continued to exhibit restlessness and yelling out and the plan was to increase the Abilify to 5 mg daily for psychosis. A physician's order dated 1/2/26 directed to administer Abilify 5 mg tablet, give 5 mg bymouth one (1) time a day for psychosis. Review of the Resident Care Plan (RCP) from 12/23/25 through 1/7/26 failed to reflect documentation a care plan was put into place to address the use of the anti-psychotic medication, Abilify. Interview and clinical record review with both the Director of Nursing (DON) and the Regional Nurse, Registered Nurse (RN) #7, on 1/7/26 at 12:10 PM identified that for any resident on anti-psychotic medications, a care plan was required to guide the resident's plan of care, to include interventions on monitoring the resident for side effects and continued behaviors. They explained both the nursing staff and Minimum Data Set (MDS) Coordinator were responsible for the initiation of care plans and they were unsure why a care plan had not been developed when the Abilify had been ordered fifteen (15) days prior. They identified they discuss residents on psychotropic medications during their weekly risk meetings every Wednesday to ensure care plans and all required orders are put into place but Resident #1 must have been missed. Interview with the MDS Coordinator, RN #6, on 1/7/26 at 2:05 PM identified a care plan should have been developed for Resident #1 to target the use of the anti-psychotic medication. Review of the Care Planning policy dated 10/30/20 directed, in part, that a comprehensive and individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of well-being. A comprehensive care plan based on the identified needs, strengths and preferences of the resident will be developed no later than 7 days after the completion of the admission MDS. The care plan is developed by the Interdisciplinary Team (IDT) in collaboration with the resident and/or family/responsible party and the resident's physician. The care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the residents' status.

Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #1) reviewed for pressure ulcers, the facility failed to ensure a thorough wound assessment was completed and a treatment immediately implemented at the time a new pressure ulcer was identified, failed to ensure weekly wound documentation was consistently performed, and failed to notify the Dietitian when a pressure ulcer developed, which subsequently led to the deterioration of the pressure ulcer and the eventual need for the resident to be hospitalized for [REDACTED]. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nutritional assessment dated [DATE] identified Resident #1 was eating well and was able to make needs known. Resident #1 had no pressure ulcers or other skin injuries at the time of the assessment. The documentation identified the resident gave reports of weight loss and had a recent fracture. Resident #1 was started on 8 ounces of milkshake with all meals for additional calories/protein and fluid. The Admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, required total 2-person assistance with transfers and extensive 2-person assistance with bed mobility, dressing, grooming and toilet use. Additionally, the MDS identified Resident #1 was identified at risk for developing pressure ulcers, had no pressure ulcers at the time of the assessment and had treatments including pressure relieving devices for bed and chair and application of nonsurgical dressing. A physician's orders [REDACTED]. The Care Plan dated 4/14/20 identified Resident #1 was at risk for skin breakdown. Interventions included to encourage the resident to reposition side to side, offload pressure to heels with a pillow, inspect skin when providing care, pressure redistribution mattress and pressure reduction cushion for chair/wheelchair. A Nurse's Note dated 4/19/20 at 10:53 PM, written by LPN #1, identified Resident #1 had a right heel blister with discoloration, no drainage and the supervisor was notified. Further review failed to reflect an RN assessment was completed at that time, including a description of the wound, exact location on the heel, size, stage, appearance of the wound bed, any undermining/tunneling, surrounding skin condition, or drainage and exudate. Additionally, the clinical record failed to reflect that the physician/APRN was notified of the wound, or that a treatment was implemented at that time. The Skin Tracking Sheet dated 4/20/20, and completed by RN #1, identified Resident #1 had a facility acquired right heel blister, stage 2, measuring 3.0cm by 2.0cm by 0.1cm with 4/20/20 as the date of origin, (this date is in conflict with the Nurse's Note dated 4/19/20 when the blister was originally identified). The Tracking Sheet identified the treatment included skin prep followed by Allevyn heel and to change daily. A Nurse's Note dated 4/21/20 by RN #1 identified the right heel blister drying, measuring 3.0cm by 2.0cm by 0.1cm. Additionally, APRN and family were aware, new order for skin prep and Allevyn heel ordered and heels to be offloaded at all times when in bed. A physician's orders [REDACTED]. Change daily. A Skin Tracking Sheet completed by the ADNS identified the following: 4/27/20: right heel blister stage 2; 3.0cm by 2.0cm by 0.1cm, no drainage, improved; treatment: skin prep and allevyn heel dressing daily. A Dietitian progress note dated 4/30/20, identified resident had gradual weight loss since admission, was eating 75-100% of meals and the Dietitian recommended weekly weights for 4 more weeks. Although Skin Tracking dated 4/27/20 identified Resident #1 had a right heel blister stage 2, the dietitian note failed to reflect the right heel blister. Review of the clinical record failed to reflect documentation that the Dietitian was notified when Resident #1 was identified with a stage 2 right heel pressure ulcer on 4/19/20. Skin Tracking Sheets completed by the ADNS identified the following: 5/5/20: right heel blister stage 2; 3.0cm by 2.0cm by 0.1cm, no drainage, improved; treatment: skin prep and allevyn heel dressing daily. 5/14/20: right heel blister stage 2: 2.0cm by 2.0cm by 0.1cm, no drainage, improved; treatment: skin prep and allevyn heel dressing daily. Review of facility documentation and Resident #1's clinical record failed to reflect that any further wound tracking, description or measurements were obtained during the 16 day period from 5/14/20 through 5/30/20. Nurse's note dated 5/30/20 identified the physician ordered Resident #1 to be sent to the clinic for evaluation and treatment of [REDACTED]. Hospital Discharge Summary dated 6/14/20 identified Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with LPN #1 on 6/26/20 at 11:40 AM identified she checked the resident's heel on 4/19/20 because the resident had complained of right heel discomfort. Although LPN #1 indicated she informed the nursing supervisor (RN #2) about the blister, she could not explain why she (LPN #1) did not measure and describe the area or why there was no documentation by the RN supervisor to support that the area was thoroughly assessed including measurements and description. Interview with RN #2 on 6/26/20 at 3:30 PM identified although she usually writes a nurse's note when informed about a new resident concern, or completes an assessment and obtains new orders, she did not remember anything specific regarding Resident #1's new right heel blister which was identified on 4/19/20. RN #2 indicated it was extremely busy during that time due to the pandemic, she only works per diem and could not remember that long ago. Interview with the DNS on 6/29/20 at 10:10 AM identified that LPN's can assess and measure wounds but the RN needs to verify the assessment in order to notify physician/APRN with accurate information and obtain further directions/orders. The DNS identified that Resident #1's pressure ulcer/blister should have been assessed by the RN with a thorough description of the area. Additionally, the physician/APRN should have been notified and an appropriate treatment should have been initiated when the wound was identified. Additionally, the DNS indicated that because there was no infection control nurse/wound nurse during this time, she had delegated other RN's to do the weekly wound tracking. The DNS identified she was not aware Resident #1's pressure ulcer hadn't been tracked for over 2 weeks from 5/14/20 through 5/30/20, indicating the facility was so overwhelmed with the COVID-19 virus that it must have gotten overlooked. Additionally, the DNS indicated there should have been consistent weekly monitoring of Resident #1's pressure ulcer. Further, the DNS identified if there had been an infection control nurse/wound nurse working in the facility and Resident #1 had been receiving weekly consistent wound tracking of the right pressure ulcer, especially during the last 2 weeks (5/14/20 - 5/30/20) the wound deterioration could absolutely have been prevented. Further, the DNS identified that the Dietitian should be notified with any new skin or pressure injury. Additionally, that although the supervisor does most of the notifications, any nurse can update the dietitian of any new wounds/pressure ulcers. Further, the Dietitian should have been notified so the resident could have been evaluated and received nutritional support for wound healing if needed. Interview with LPN #2 on 6/26/20 at 11:00 AM identified she was the regular nurse for Resident #1 and had performed the right heel treatment on 5/27/20, 3 days prior to hospital transfer. LPN #2 identified that although the wound wasn't really improving, it wasn't worse either. LPN #2 identified the area was about quarter sized and the tissue was pinkish red without drainage. LPN #2 identified on 5/30/20, upon performing the dressing change, she found the heel wound to be much worse in appearance than it had been 3 days prior and summoned the supervisor, RN #4. LPN #2 identified the wound looked very black, with no drainage, no odor and resident had no complaints of pain. Interview with RN #4 on 6/27/20 at 11:00 AM identified when he was summoned by LPN #2 to assess Resident #1's right heel, he was shocked at how bad it looked. RN #4 indicated the heel was very black and he knew the resident needed transfer to the hospital for evaluation. Interview with APRN #1 on 6/30/20 at 12:10 PM identified that she was aware of and had seen Resident #1's right heel pressure ulcer early on when it was identified as a blister, however she had not been informed of any worsening nor asked to assess the wound since that time. On 5/30/20, when she was called and informed that the heel now presented with eschar, redness and appeared infected, she was very surprised and shocked that it had deteriorated to this point and that she was not made aware. Additionally, APRN #1 indicated that a decline like that did not occur overnight and someone should have noticed it at least a week prior. Further, APRN #1 identified when nursing has a concern about a resident and wants them to be evaluated they write an entry in the APRN book with the resident's name and what issue or concern that needs to be addressed. APRN #1 indicated there were no entries pertaining to Resident #1's pressure ulcer. Interview with the Dietitian on 6/27/20 at 4:00 PM identified she is only in the building 1.5 days per week. The Dietitian identified that besides the admission nutritional assessment completed on 4/3/20, she had last evaluated Resident #1 on 4/30/20. The Dietitian identified she was only evaluating the resident's weights at that time because she had not been informed that Resident #1 had a right heel pressure ulcer. Had she been notified, the Dietitian indicated she would have evaluated the resident to determine if there were any nutritional needs and made recommendations if needed at that time. If she had determined there were no nutritional deficits or needs, she would have documented her evaluation and findings in the clinical record. The Dietitian identified when the previous infection control/wound nurse was there, she would email her with any resident concerns including new wounds. She identified that any nurse can send her an email for updates, although none do. The Dietitian indicated the facility had not had an infection control nurse/wound nurse for several months and during this time she had not been receiving updates. Additionally, the Dietitian indicated she is unable to attend the At Risk meetings because they are held on a day she is not scheduled in the facility. Review of the Documentation policy identified a complete wound assessment and documentation will be done weekly on each area until healed utilizing the skin/wound tracking record. Include site/location; stage; size including length, width and depth measured in centimeters; appearance of the wound bed which describes the tissue present in the wound bed including color, drainage, odor and periphery; undermining/tunneling; surrounding skin which describes the condition of the surrounding skin noting if it is intact, [DIAGNOSES REDACTED]tous, indurated, [MEDICAL CONDITION], macerated and the temperature if abnormal; drainage/exudate which describes the amount, color, consistency and odor. Review of the facility's Wound Prevention/Interventions for All Residents, identified to encourage adequate nutrition including supplements as recommended by the dietitian. The facility failed to ensure a thorough RN assessment of a new heel blister on 4/19/20, physician notification and a treatment was implemented for Resident #1, who was admitted with intact skin and at risk to develop pressure ulcers. Additionally, the facility failed to notify the dietitian of the wound and complete weekly wound assessments and documentation from 5/14/20 through 5/30/20, at which point the wound had deteriorated and the resident had to be sent to the hospital for treatment of [REDACTED].

Based on a review of clinical records, review of facility documentation, and interviews, for one of three sampled residents (Resident #64) who were reviewed for falls, the facility failed to ensure that the resident was provided with adequate assistance during ambulation in accordance with the plan of care and sustained a fall resulting in a fracture. The finding includes: Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].e. recreation. Review of the nursing admission assessment dated [DATE] identified Resident #64 was without cognitive impairment and required the assistance of one for ambulation. The Physical Therapy Plan of Care dated 7/9/19 identified Resident #64 was at moderate risk for falls, was able to ambulate 20 feet with the use of a rolling walker and provide contact guard due to the Resident's unsteadiness. The Resident Care Plan (RCP) dated 7/12/19 identified Resident #64 was at risk for falls related to weakness and a history of falls with an intervention to transfer per MD orders. A late entry nurse's note dated 7/13/19 at 8:15 AM identified that on 7/12/19 while Resident #64 was ambulating from a recreational activity with the Director of Recreation, he/she tilted to the left, lost his/her balance and fell to the floor hitting the back of the head. Resident #64 complained of left hip pain and a shortening with external rotation of the left leg was noted. The Resident was transferred to the Emergency Department for evaluation. Review of the Hospital Discharge Summary dated 7/16/19 identified the Resident was admitted with an acute mildly displaced left intertrochanteric femur fracture and required surgical repair (open reduction and internal fixation). In an interview on 10/30/19 at 1:30 PM, the Director of Recreation identified that when the recreation program ended, she walked with Resident #64 while she/he ambulated with a rolling walker from the recreation room to the unit's nurse's station, approximately 100 feet. The Director looked away from the resident for a minute and when she looked back, she witnessed the resident tilt to the left and fall to the floor. The Recreation Director indicated that she was not aware that the Resident required contact guard for ambulation or to utilize a wheel chair for long distances, Interview with RN #2 on 10/30/19 at 2:00 PM stated that prior to this incident, residents who were new admissions and residents with a changes in transport/ambulation status were discussed in the facility's morning meetings, however, the Recreation Director was not aware of the resident's ambulation order. Subsequent to this incident the recreation department now has a list of all transport and ambulation orders for all residents in the facility.

Based on observations, interviews, clinical record reviews, and review of facility documentation for three of four nursing units (West, North East and North West), the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections by failing to ensure staff followed manufacturer guidelines on required cleaning and disinfecting of multi-use glucometers to prevent the possible transmission of blood borne pathogens resulting in the finding of Immediate Jeopardy and/or based on observation and review of facility documentation and interview with the Administrator and the Director of Environmental Services, the facility failed to ensure that a water management plan was in place to Reduce Legionella Risk in the Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) as required by 42 CFR §483.80 for skilled nursing facilities and nursing facilities. The findings include: 1. Resident #37's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified moderately impaired cognitive skills and daily insulin injections. The care plan dated 8/4/18 identified a risk for complications of diabetes with interventions which included diabetes medication as ordered and monitor/document/report to MD and APRN for signs and symptoms of [MEDICAL CONDITION]. Physician's orders for the month of (MONTH) (YEAR) directed to obtain a finger stick for blood sugar three times daily at 6:30am, 11:30am and 4:30pm and coverage with Humalog Insulin subcutaneously (SQ) three times daily at 7:30am, 11:30am and 4:30pm according to blood sugar results using a sliding insulin scale. Observation on 9/4/18 at 11:30am identified LPN #1 obtain Resident #37's blood sugar using an Assure Platinum glucometer. LPN #1 identified the glucometer was used for obtaining blood sugars of multiple residents on the unit (2 residents at that time). The blood sugar obtained was 224 dl/mg and Humalog Insulin 8 units SQ was administered per physician's order. Further observation identified LPN #1 cleansed the glucometer using Alcohol Wipes with two to three quick motions across all surfaces of the glucometer. Interview with LPN #1 at the time, identified she always cleaned the glucometer with alcohol wipes and was never made aware that another wipe was necessary for cleaning/sanitizing the glucometer for the prevention of transmission of blood borne pathogens. 2. On 9/4/18 at 11:45am LPN #2 indicated that she had just completed obtaining the blood sugars of 4 residents on another unit using the Assure Platinum glucometer. Observation of cleaning/sanitizing demonstration of the multi-use glucometer by LPN #2 on 9/4/18 at 11:50am identified LPN #2 used an alcohol wipe to cleanse the glucometer with two to three motions across the surfaces. Further observation of the two medication carts of the unit failed to identify the presence of germicidal wipes in the medication carts. LPN #2 identified she was not aware where the germicidal wipes were stored. LPN#2 further identified she was somewhat aware of the need to utilize germicidal wipes for cleaning the glucometers in between resident use however, she had consistently used alcohol wipes in cleaning/sanitizing the glucometers as this was the facility practice. 3. Demonstration of cleansing/sanitizing multi-use glucometer by and interview with RN #1 on 9/4/18 at 12:10pm identified RN #1 used germicidal Clorox wipes with one to two quick swipes on all surfaces of the glucometer with a dwell time of less than one minute. A review of the Clorox Healthcare Germicidal Wipes manufacturer's instructions identified a contact time of one minute for disinfection against blood borne pathogens. RN #1 identified she was unaware of the cleansing/sanitizing procedure for the multi-use glucometer. RN #1 further identified while blood sugars were not obtained on that day on the unit, RN #1 was assigned to care for three residents on the unit who had physician's orders to obtain blood sugars at 6:30 am once a week. Interview and review of the facility policy on blood glucose monitoring with RN #2 and the Staff Development Nurse on 9/4/18 at 12:30pm identified the policy directed to disinfect the glucometer with germicidal wipes after each use. Review of the Reference Manual for the Assure Platinum Glucometer identified disinfecting can be accomplished with an Environmental Protection Agency (EPA) registered disinfectant detergent or germicide that is approved for healthcare settings or a solution of 1:10 concentration of sodium hypochlorite (bleach). Review of a staff development in-service note dated 11/8/17 and signed by a total of 7 staff members indicated the following: Glucometers have been a source of transmission of blood borne diseases. Glucometers must be wiped with bleach wipes between residents. Additionally, a review of the mandatory in-service notes addressed standard precautions and blood borne pathogens which addressed the use of gloves, gowns and mask, but was not specific to the utilization of multi-use glucometers and how to clean/sanitize to prevent transmission of blood borne pathogens. b. The Administrator did not provided documentation to indicate that the facility had a comprehensive water management plan in place as required by S&C 17-30 ALL. The facility did not have a plan that included process flow diagrams, identify dead ends in the water system that were identified during the survey. In addition the plan did not include control measures such as physical controls, temperature management, disinfection level control, visual inspections and documentation to support the lack of an annual environmental testing for Legionella and other opportunistic waterborne pathogens; e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria and fungi that could grow and spread in the facility's water system. The facility lacked documentation to indicate that Staff had received education/training on a comprehensive water management plan.

Based on clinical record review, staff interview, review of facility documentation, and review of facility policy and procedure, for 2 of 4 residents reviewed for accidents (Residents #4 and #45), the facility failed to transfer the resident in a safe manner and/or failed to ensure a resident was provided the necessary care and services to prevent an accident. The findings include: a. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified the resident with severe impaired cognition, required extensive assistance of two staff members for bed mobility, transfers, and toileting. The Resident Care Plan (RCP) dated 12/23/17 identified Resident #4 with [MEDICAL CONDITION] and may have brittle fragile bones and be prone to fractures. Interventions included to administer medications as ordered by physcician, consult the dietician as needed, and to handle resident gently when turning. The Reportable Event (RE) dated 1/13/18 identified while Resident #4 was being transferred by Nurse Aide (NA) #2 and NA #3 via a sliding board transfer from the wheel chair to the bed, Resident #4 complained of right knee pain. The physician was notified and directed to send Resident #4 to the hospital for evaluation. Resident #4 was diagnosed with [REDACTED]. Facility investigation identified NA #2 and NA #3 utilized a sliding board to transfer Resident #4 from his/her wheel chair to bed. As soon as Resident #4 was positioned in bed he/she complained of right leg pain, NA #3 noted the right leg was not in a good position. NA #3 immediately reported the concern to Registered Nurse (RN) #1. RN #1 noted Resident #4 was unable to tolerate any movement of the right lower extremity, the right hip was noted to be externally rotated, had positive pedal pulses, and the APRN was notified and directed to send Resident #4 to the hospital. The facility investigation identified the slide board was positioned under Resident #4's left buttocks, NA #2 was holding Resident #4's lower extremities while NA #3 was holding the upper extremities, under the resident's armpit and slid Resident #4 on to the bed. Interview and review of the RE with Occupational Therapist (OT) #1 on 9/5/18 at 12:20 PM identified that although the facility does not have a written policy for the utilization of a sliding board transfer, the expectation would be that two staff members be present to assist with the transfer. A gait belt should be applied prior to the transfer, one staff member should be positioned on the resident's left side and the other staff member should be positioned on the resident's right side with one hand on the gait belt to assist with the transfer. The facility investigation failed to reflect NA #2 and NA #3 were positioned on Resident #4's right and left side and/or failed to reflect a gait belt was utilized when transferring Resident #4. Additionally OT #1 identified he/she had in-serviced/educated staff on utilizing a sliding board transfer, but was unable to provide documentation of the in-servicing provided. b. Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Care Plan dated 7/27/17 identified that Resident #45 was an assist of two for transfers from bed to wheelchair and wheelchair to bed, with one person holding the wheelchair. A quarterly Minimum Data Set ((MDS) dated [DATE] identified that Resident #45 scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. For transfers, the resident scored a 3/3, indicating extensive assistance with two person physical assist. For toileting, the resident scored a 3/3, indicating extensive assistance with two person physical assist. A review of facility documentation (reportable event with investigation) dated 10/29/17 identified that Resident #45 requested to be taken to the bathroom on 10/29/17 at 4:35 PM. NA #10 assistedResident #45 into shower room and assisted in transfering Resident #45 onto the toilet, which had a raised toilet seat. As Resident #45 was transfering off of the raised toilet, he/she became unbalanced and hit his/her elbow on the toilet, resulting in a skin tear. The facility investigation identified that the toilet with the raised seat was too high for Resident #45 and directed to remove the raised toilet seat from the shower room. An interview with NA #10 on 9/20/18 at 9:30 AM indicated that on 10/29/17 at 4:35 PM, Resident #45 was sitting in his/her wheelchair in the West Wing hallway, outside the shower room. The resident asked NA #10 to be taken to the bathroom. NA #10 assisted Resident #45 into the shower room to use the toilet. NA #10 indicated that a raised toilet seat was in place. NA #10 indicated that Resident #45 was able to stand up from his/her wheelchair and NA #10 assisted in transfering Resident #45 onto the raised toilet. NA #10 then was assisting Resident #45 off of the toilet, when Resident #45 became unbalanced and slipped. NA #10 does not recall Resident #45 hitting his/her elbow. NA #10 indicated that at the time of the transfer, he/she believed that Resident #45 was an assist of one with transfer, indicating that that's how everyone does it. An interview with the DNS on 9/10/18 at 12:30 PM indicated that residents who may require a raised toilet seat, should first be screened by therapy. Standard raised toilet seats may be available at the facility, and any raised toilet seats with special height requirements, may be ordered. In addition, the DNS indicated that all raised toilet seats were removed from shower room toilets. The facility failed to ensure Resident #45 was provided the necessary supervision and services to prevent an accident. c. A quarterly Minimum Data Set ((MDS) dated [DATE] identified that Resident #45 scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. For eating, the resident scored a 0/1, indicating independence with setup only. A review of facility documentation (reportable event with investigation) dated 10/16/17 identified that Resident #45 spilled coffee on his/her lap during breakfast. Upon assessment, there was no redness noted and Resident #45 denied any pain or discomfort. The intervention noted was to have an OT screen and to have a cover/lid placed on hot drinks. A note written by Physical Therapy Assistant (PTA) #5 indicated that the OT screen was not needed, PT had lids for cups, and the kitchen was to apply the lids daily. The Resident Care Plan dated 10/17/17 for the coffee spill identifed as interventions: provide education to the resident, OT screen, and ensure a lid is placed on all hot drinks. A quarterly Minimum Data Set ((MDS) dated [DATE] identified that Resident #45 scored a 10 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. For eating, the resident scored a 1/1, indicating supervision with setup help only. A review of facility documentation (reportable event with investigation) dated 7/10/18 identified that Resident #45 spilled coffee on his/her chest while in bed at 8:45 AM. Upon assessment, there was no redness noted and Resident #45 denied any pain or discomfort. The intervention noted was to have ice applied to chest as needed and to place a lid with coffee while in bed. A review of facility documentation (reportable event with investigation) dated 7/26/18 identified that Resident #45 spilled coffee on his/her lap during a recreation activity. Upon assessment, there was no redness noted and Resident #45 denied any pain or discomfort. The intervention noted education to the recreation staff that Resident #45 required a lid on hot drink cups. A Diet Change Form dated 8/2/18 directed that for Resident #45, a lid was to be placed on all cups with hot beverages. An interview was conducted with the Directer of Dietary Services on 9/6/18 at 2:50 PM. The Director of Dietary Services indicated that the dietary deparment was unaware that Resident #45 required a lid on cups containing hot beverages, and that no staff had contacted him/her regarding adding lids to the resident's hot beverages. The Director of Dietary indicated that when a resident is identified as requiring special adaptive equipment, such as a lidded cup, the dietary department receives the white slip from a Diet Change Form. The special diet order is then entered into the system and printed onto the resident's meal ticket. Any adaptive equipment would be highlighted (in purple) on the meal ticket to alert staff to the special order. The Director of Dietary indcated that lids for cups would be provided through dietary services. A review of Resident #45's meal ticket slip for 9/6/18, did not reflect any adaptive equipment. A review of facility documentation with the Director of Dietary Services identifed that the white slip from the Diet Change form dated 8/2/18 had been attached to the reportable event and investigation for 7/26/18. A review of the facility's policy and procedure titled, Adapative Feeding Equipment, directed that any resident who appears to be a candidate for adaptive feeding equipment should be referred to the rehab department for evaluation. Adaptive feeding equipment will be implemented per the recommendation of rehab. All adaptive feeding equipment will be sent by the dietary department unless otherwise indicted in the resident's care plan. The facility failed to provide Resident #45 with the necessary equipment to prevent an accident.

Based on review of the clinical record, review of facility documentation and interview for one of three sampled residents reviewed for accidents (Resident# 158), the facility failed to ensure safe and appropriate assistance with ambulation resulting in a fall with an injury. The findings include: Resident # 158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified the resident was without cognitive impairment, required extensive assistance with ADLs including 2 person physical assistance with ambulation and toilet use. The October 2016 care plan identified a history of falls with interventions which included non-slip footwear, well-lit/ clutter free environment, and fall prevention program. The nurses' notes dated 10/26/16 at 7:30 PM identified NA# 6 reported while she was assisting the resident to the bathroom, the resident fell sideways, hit the wall and slid to the floor. On assessment the resident's right leg was externally rotated and the resident complained of right groin pain. The physician was notified and the resident was transferred to the emergency room for an evaluation. Resident #158 was admitted to the hospital with [REDACTED]. The facility investigation of the incident dated 10/27/16 identified NA # 6 failed to utilize a gait belt per the facility policy when Resident#158 was ambulated to the bathroom on 10/26/16. Interview on 8/23/17 at 2:00 PM with NA #6 identified she was aware of the facility policy regarding the use of a gait belt during transfers and ambulation, however she refused to answer specific questions regarding Resident #158's fall on 10/26/16. Interview and clinical record review on 8/24/17 at 12:45 with the DNS identified gait belts are utilized to ensure residents are safe while transferring/ambulating and to prevent falls. The DNS further identified the investigation following the 10/26/16 fall determined NA#6 did not follow the facility policy regarding the use of a gait belt resulting in a fall with an injury. The facility gait belt policy identified the use of gait belts is mandatory by all nursing personnel and rehab staff while transferring or ambulating residents.

Based on a review of clinical records, facility documentation, interview, and policy review, for one of three residents with aspiration precautions and/or required supervision with meals (R #2) the facility failed to ensure that the resident was supervised for meals and/or aspiration precautions were implemented in accordance with physician orders. The finding included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission assessment dated [DATE] identified that the resident was disoriented to time and place, was able to understand directives and able to follow commands. The assessment identified that the resident was dependent on staff for transfers, personal hygiene and eating. Review of a physician order [REDACTED]. The order directed aspiration precautions. Review of ADL flow records for the period of 4/25/17 to 4/27/17 identified that the resident was provided assistance and/or supervision with meals. Review of a nurse's note dated 4/28/17 identified that at 8:45 AM, RN #1 (Nurse Supervisor) witnessed the resident with agonal breathing, was unresponsive and appeared to be in the process of eating as food was observed in the resident's mouth. The resident was assessed with [REDACTED]. The resident's oxygen saturation improved to 91% and began to respond as EMS arrived. The resident was transferred to the Emergency Department. Review of the ED record dated 4/28/17 identified that a chest X-ray was performed and was negative. The resident returned to the facility. Review of the ADL flow record dated 4/28/17 failed to identify documentation to indicate that the resident was provided assistance with breakfast and/or the amount that the resident consumed. Interview with RN #1 on 6/19/17 at 2PM stated she was unable to identify when, if, and/or who fed the resident. Review of NA #3's written statement dated 4/28/17 identified that on the morning of 4/28/17 he picked up a plate from resident #4 with 100 % of the food gone. NA#3 stated that the resident showed no signs of distress at that time. NA #3 was not available for interview at the time of the investigation. Interview with NA# 2 (assigned NA) on 6/19/17 at 11:00 AM identified that on the morning of 4/28/17 she went into Resident #2's room to pick up the roommate's breakfast plate she noticed that Resident #2 was having trouble breathing and didn't answer when she called to him/her. NA#1 stated she immediately called to the charge nurse for help. NA#1 stated that at the time she saw the resident sitting up in bed with his/her bed table across his/her lap with no food or plate in front of the resident. Interview with the acting assistant Director of Nurses (RN#2) on 6/16/17 at 10:30 AM, review of the facility's investigation and statements identified that on the morning of 4/28/17, dietary aide #1 delivered a breakfast plate to the resident's room rather than leaving it at the nurse's station. RN #2 identified that the dietary aide should not have delivered the food to the resident's room because the resident required supervision for meals. Subsequent to this incident all dietary aides were educated to leave meals trays at the nurses station Interview with dietary aide #1 on 6/16/17 at 4:30 PM identified that on 4/28/17 she brought the resident's breakfast plate to the room and placed it on the resident's over bed table. Dietary aide #1 stated that the resident was in his/her bed and the over bed table was on the side of the bed out the resident's reach. Dietary aide #1 stated that she knew not to leave in reach of the resident because the resident was to be supervised for meals. Dietary aide #1 stated that she should have left the plate at the nurse's station but surely did not leave it in reach of the resident. In an additional interview on 6/19/17 at 1:00 PM, RN#2 was unable to identify who set the resident up for for breakfast and/or who provided the plate to the resident and/or if the resident was fed and/or supervised for breakfast on 4/28/17. RN#2 stated that at the time of the investigation it was determined that the dietary aide gave the resident the meal as she brought into the resident's room. Interview with APRN #1 on 6/19/17 at 11:30 AM stated she was unsure if the residents unresponsiveness was related to a choking incident as the resident had a compromised cardiac status and had no subsequent signs or symptoms of aspiration. Review of the facility's Aspiration Precautions policy identified, in part, that aspiration precautions are instituted from a physician's orders [REDACTED].

Based on observations, staff interviews, clinical record review, and facility record reviews for one of three residents in the survey sample reviewed for accidents (R # 57) the facility failed to ensure interventions were put in place to prevent falls and/or ensure water temperatures were maintained within acceptable ranges, and/or monitor hydrocollator temperatures per facility policy. The findings include: 1. Resident # 57's [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified a history of falling in the previous six months and a high risk for falls. A care plan dated [DATE] identified osteopenia with approaches that included minimize risks for falling. The care plan also identified an alteration in mobility related to a history of [DIAGNOSES REDACTED] and osteoarthritis with interventions that included provide safety interventions as needed to reduce risk of injury of falls. Nurse's notes dated [DATE] on the 7:00 AM-3:00 PM shift identified that the resident was found sitting on the floor near the bed saying, I need to help Johnny, I heard him yelling. The resident was noted to have a 1.5 centimeter (cm) by 3.0 cm bruise on the left wrist. No other injuries were noted at that time. The staff identified that the resident was reminded to call for assistance when getting OOB (out of bed). No other interventions or change to the plan of care were identified or documented. Nurse's notes between [DATE] and [DATE] documented that the resident complained of back pain. The nurse's notes dated [DATE] and/or [DATE] on the 3:00 PM - 11:00 PM shift noted the resident was complaining of an upset stomach, not feeling well and crying. The nurse's notes further identified that on [DATE] a chest x-ray was obtained and the results were negative. On [DATE], the resident was seen by the APRN and the physician with continued complaints about abdominal pain identified on the 3:00 PM - 11:00 PM shift. At 10:00 PM on [DATE], the resident's temperature was noted to be 100.0 degrees Fahrenheit. The resident received APAP (Tylenol) and was started on an antibiotic for a questionable urinary tract infection. Extra Strength APAP 1000 milligrams was ordered to be administered at 6:00 AM, 2:00 PM and 10:00 PM for 7 days along with urine culture and lab work. Nurse's notes dated [DATE] and/or [DATE] on the 3:00 PM - 11:00 PM shift identified increased lethargy, continued complaints of discomfort in the lower abdomen and left hip area, bruising present in the left inner groin and upper thigh and the resident was anxious and restless. On [DATE] at 6:30 PM, the physician ordered a left hip x-ray and decreased the diet to pureed. The nurse's note dated [DATE] on the 11:00 PM-7:00 AM shift identified that the left hip x-ray was negative and that the resident tried to climb out of bed 5 times to see his/her son, saying I want to go home, I want to see S----- my son. Nurse's notes dated [DATE] on the 7:00 AM-3:00 PM shift noted the resident continued to complain of back pain. At 3:15 PM the resident was found sitting on the floor with no injuries identified. Nurse's notes dated [DATE] on the 7:00 AM-3:00 PM shift identified that the resident was given Tramadol for abdominal pain and Ativan for anxiety. On [DATE] at 2:00 PM, the resident was started on O2, 2 liters for shortness of breath secondary to anxiety. The note further identified increased dyspnea continued despite continued use of O2 and O2 saturation rates were identified at 87%. The resident was noted to have decreased lung sounds in bilateral bases, the heart rate was up, the resident was cold and clammy and was complaining about back and abdominal discomfort. The resident was sent to the emergency department (ED) for evaluation. The resident was subsequently transferred to another hospital after assessment noted that R# 57 had several fractured ribs and a fractured pelvis. The resident expired at the hospital. A review of a medical examiner certificate dated [DATE] identified the resident's cause of death was complications from blunt injury of the torso with pelvic fractures and classified the resident's manner of death as accident. An interview and clinical record review on [DATE] at 1:25 PM with RN#1 failed to provide documentation that interventions were intitiated to prevent further falls after the resident fell and/or when the resident was noted repeatedly attempting to climb out of bed. 2. An observation on [DATE] at 10:15 AM noted the water temperatures in rooms 111, 113, 115 and 117's bathrooms were 134 degrees. The maintenance director was notified at that time. He/she indicated water temperatures were monitored in [DATE] and no water temperature went over 115. He/she further indicated there were 11 hot water tanks serving the facility so it was possible one or more of the tanks were not monitored. An outside licensed plumber (HVAC) was notified and an immediate plan was put in place to prevent injury. 3. A review of facility hydrocollator temperature logs dated [DATE] through [DATE] and interview on [DATE] at 10:15 AM with PT#1 failed to provide documentation that the hyrdrocollator temperatures were monitored daily. PT # 1 indicated that the therapy assistant is assigned to check the temperatures and clean the hydrocollator. The hydrocollator temperatures were not completed daily because the therapy assistant only completed the days that he/she was working. PT#1 further indicated that the hydrocollator packs are used daily for resident treatment and that the temperature in the hydrocollator should be checked and documented daily. Review of the facility's policy on Hydrocollator/Hot Packs directed that the temperature checks will be done once during each treatment day and a record is posted of the inspection.

Based on clinical record review, staff interviews, and review of facility policy and procedure for one of two residents reviewed for pressure ulcers (R #26), the facility failed to assess a change in skin condition related to the use of an ankle-foot orthosis (AFO) brace and/or ensure weekly skin audits were completed in accordance with facility policy and procedure. The findings include: Resident # 26's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident had impaired cognition, required extensive assist with ADL's, had limitation in range of motion of the lower extremity, was at risk for pressure ulcer development, and had no pressure ulcers. A resident care plan dated 4/28/15 identified a risk for skin breakdown. Interventions included body audits weekly on shower days, any changes report to the nurse, and check skin during care for reddened areas or any sign of breakdown. Review of weekly body audit work sheets dated 4/10/15 through 7/30/15 identified 8 out of 17 weekly body audits were noted as blank and not completed. A physical therapy treatment note dated 5/13/15 indicated R #26 was tolerating wearing an AFO on the left lower extremity for four hours. A small < 1 cm red area developed superior to the lateral malleolus. The note indicated will reassess red area tomorrow and will hold the use of the brace pending skin condition to avoid tissue injury. A physical therapy treatment note dated 5/14/15 indicated withheld donning of AFO today following skin inspection of left lower extremity. Skin appears to be developing a pressure ulcer/blister over the left lateral malleolus where red mark was seen at the end of treatment yesterday. Nursing has been notified, will withhold use of the AFO until area is healed. An APRN's progress note dated 5/14/15 noted staff noted a pressure area after application of a brace on the left lateral malleolus. A stage two pressure ulcer measuring 0.25 cm x 0.25 cm superficial, no periwound redness or heat was noted. A physician's orders [REDACTED]. An interview and review of the clinical record on 10/1/15 at 9:50 AM with PT # 2 indicated when trialing an AFO on a resident he/she will assess the skin for redness and/or irritation prior to applying the AFO and immediately when removed. On 5/13/15 when PT # 2 removed the AFO he/she identified a small <1 CM red area superior to the lateral malleolus. On 5/14/15 PT # 2 noted the skin appeared to be developing a pressure ulcer/blister over the patients left lateral malleolus where the red mark was seen at the end of treatment on 5/13/15. Nursing was notified on 5/14/15. Although PT # 2 indicated he/she reports to nursing any changes with the resident identified during therapy, the clinical record failed to reflect documentation that the red area identified on the left lateral malleolus after removing the AFO on 5/13/15 was reported to nursing and/or failed to reflect a nursing assessment of the area. An interview and review of the clinical record on 10/1/15 at 12:10 PM with the DNS identified when the resident was noted with a change in skin condition after removing the AFO on 5/13/15, nursing should have been notified and an assessment should have been completed identifying location, size, stage, condition of the periwound and if there was any pain. Additionally, weekly body audits are to be completed by the licensed nursing staff and documented on the weekly body audit worksheets. The clinical record failed to reflect an assessment and/or treatment was initiated when a change in skin condition was identified and/or weekly body audits were completed. The facility policy for weekly body audits identified weekly body audits will be completed on bath/shower day by the licensed nurse.

Based on clinical record review, for one sampled resident reviewed for pain, (Resident #61), the facility failed to provide timely services necessary to address the pain. The findings include: Resident #61 was transferred from another facility on 4/221/11 with [DIAGNOSES REDACTED]. Transfer medication sheet included [MEDICATION NAME] to be applied every 72 hours to the upper left back, [MEDICATION NAME] as needed every four hours for severe pain, (last given 4/21/11 at 6 AM at the previous facility), and Vicodan every 6 hours as needed for severe pain. Nursing admission notes dated 4/21/11 at 1:40 PM and 3:00 PM indicated Resident #61 was moaning loudly and yelling and attempt to contact the attending physician, (who is also the medical director), was made. Nursing admission assessment dated [DATE] indicated moaning upon repositioning. Nursing note dated 4/21/11 at 11:00 PM indicated the resident was given [MEDICATION NAME] at 6:30 PM with positive effect. Interview with Licensed Practical Nurse (LPN)#2 on 8/25/11 at 3:00 PM identified that of first importance was to have the orders verified by the physician on 4/21/11 so the resident could be medicated for pain. Interview with Registered Nurse (RN)#1 on 8/26/11 at 12:30 PM indicated that the resident's physician was called and the covering physician returned the call. The covering physician, however, refused to verify the admission orders [REDACTED]. Finally, RN#1 located an alternate physician who verified the admission orders [REDACTED]. Interview with the Administrator on 8/26/11 at 2:00 PM indicated the attending physician, or if not available, the covering physician is responsible for verifying the admission orders [REDACTED].