Every finding on record at Ark Healthcare & Rehabilitation at St. Camillus

Based on record review, facility documentation review, observation of facility video, and staff interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure a resident with dementia that was dependent for personal care and mobility and had no physician orders for opioids was free from exposure to opioids. The resident was identified unresponsive to verbal or tactile stimulation with pinpoint pupils, and was transferred to the hospital where he/she was diagnosed with suspected opioid intoxication, received Narcan, and had two (2) laboratory tests that were positive for opioids, resulting in a finding of Jeopardy. The findings include: Resident #1 had a diagnosis of vascular dementia and history of a stroke (CVA) with hemiparesis and hemiplegia (one sided weakness/paralysis). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 6 indicating severely impaired cognition, and was dependent with toileting, personal care, and transfers, and was non-ambulatory. The Resident Care Plan (RCP) dated 4/20/26 identified a self-care deficit. Interventions directed Resident #1 was non-ambulatory and dependent for wheelchair mobility, transfer with two (2) assist via mechanical lift, and provide personal care. Nursing Situation Background Assessment Recommendation (SBAR) note dated 5/22/26 at 11:02 AM identified a change in condition. Resident #1 was found in his/her wheelchair unresponsive to verbal or tactile stimulation with flaccid extremities with pinpoint pupils. Nursing note dated 5/22/26 at 11:31 AM identified the APRN was notified Resident #1 was unresponsive to verbal or tactile stimulation with pinpoint pupils with new orders were obtained to transfer Resident #1 to the hospital. APRN note dated 5/22/26 at 7:51 PM identified Resident #1 was unresponsive with a blood pressure of 80/51, respiratory rate of eight (8), oxygen saturation of 88 percent (normal 90% and above), and oxygen was applied via a non-rebreather mask. Resident #1 was transferred to the hospital. Facility Reportable Event (RE) dated 5/26/26 at 12:33 PM identified Resident #1 was in his/her room when noted unresponsive, and was transferred to the hospital for altered mental status on 5/22/26. Reports from the hospital confirmed urine testing was positive for opiates. Resident #1 was not prescribed any opioid medications. Hospital Discharge summary dated [DATE] at 8 AM identified upon admission Resident #1 had myotic (abnormally constricted) pupils. Resident #1 improved after two (2) doses of Narcan, and was started on Bilevel Positive Airway Pressure (BIPAP, ventilator used to assist with breathing). Toxicology results were positive two (2) times for opioids. Resident #1 was admitted for Acute Hypercapnic Respiratory Failure (AHRF) and suspected opioid intoxication despite no opioid prescriptions in the resident's medication list. Reportable event summary dated 6/1/26 identified on 5/22/26 about 8:30 AM Resident #1 was noted to be sleepy and was unable to eat breakfast, mental status worsened and a decision was made to send to the resident to the hospital for evaluation. The facility was notified Resident #1 had been treated with Narcan two (2) times and on initial urine screen was positive for opiates. Upon the facility's Medical Directors request, the urine test was repeated and the results remained positive for opiates. Resident #1 was not prescribed any opioid medications at the facility. The summary indicated, based on interviews and surveillance (video review) there was a possibility that the 11 PM to 7 AM shift nurse (LPN #1) assigned to Resident #1 may have administered narcotic opioid medication that was not ordered by the physician for Resident #1. During an interview with LPN #2, she stated that LPN #1 had indicated to LPN #2 that she had administered Trazadone (used to treat depression/not an opioid) to Resident #1 during the night for agitated behavior. Resident #1 did not have a physician's order for Trazadone. During an interview with LPN #1 she stated she had administered Tylenol to the patient during the night. Tylenol was not documented in the clinical record as administered; no medications were signed as administered during the 11 PM to 7 AM shift prior Resident #1's transfer to the hospital. Interviews failed to identify any staff reported administration of an opioid. Record review identified Resident #1 returned to the facility on 5/29/26. Review of facility surveillance video identified on 5/22/2026 at approximately 2:30 AM (3 hours and 30 minutes after her shift started), LPN #1 was observed to exit Resident #1's room, go to the medication cart, draw up a medication in a syringe from the medication cart second drawer (non-narcotic drawer). Then LPN #1 obtained a medication from the narcotic box and drew that up in a syringe (using the same syringe), returned the medication box to the drawer and then returned to Resident #1's room with the items she removed from the medication cart in her hands. Record review identified Resident #1 had no medications scheduled for administration during the 11 PM to 7 AM shift, and had no physician orders for any no injections or opioids. Interview and written statement review with LPN #2 on 6/23/26 at 11:18 AM identified she spoke with LPN #1 on 5/23/26 and LPN #1 stated she had enough rest from working 5/21 into 5/22/2026 because she she napped in Resident #1's room during the shift. LPN #2 stated that LPN #1 told her Resident #1 was grunting loudly and interrupting her sleep so bad that she had to give him/her something to sleep. LPN #2 stated that LPN #1 indicated she gave Resident #1 Trazadone 50 milligrams (mg) that belonged to another resident. LPN #2 told LPN #1 that Resident #1 was found unresponsive and LPN #1 stated she did not know nor did she care and that it had nothing to do with her. LPN #2 told LPN #1 that the facility was going to do an investigation and watch the cameras and LPN #1 stated they are going to see me going in and out of the bottle. LPN #2 asked what bottle and LPN #1 stated Risperdal (non-opioid medication used to treat bipolar). LPN #1 further stated she went into the narcotic box to recount because she did not trust the evening shift nurse. LPN #2 advised LPN #1 to come forward, and LPN #1 responded, no and that she was afraid to and she would just say she gave Resident #1 Tylenol. Interview with LPN #1 on 6/22/26 at 2:41 PM identified LPN #1 she was the charge nurse on 5/21/26 into 5/22/26 on the 11 PM to 7 AM shift. LPN #1 stated Resident #1 was agitated and kept trying to climb out of bed by putting his/her feet off the bed so she sat with Resident #1 so he/she would not fall. LPN #1 then stated she told the DNS she gave Resident #1 Tylenol, but stated she did not actually give Resident #1 any medications during her shift, and she stayed in Resident #1's room until 5 AM. LPN #1 stated she was aware the facility had surveillance video and when the video showed her go to the medication cart, she took Morphine (an opioid pain medication) out of the narcotic box. LPN #1 stated she removed the syringe out of the box containing the Morphine bottle because the box was wet from Morphine leaking, and she used the syringe to draw up the Morphine that was in the box, and she then injected it back into the Morphine bottle - LPN #1 stated it was approximately 0.5 to 0.75 milliliters (ml) that she drew up from the bottom of the box. LPN #1 denied administering any medications to Resident #1 and stated she did not remember what she took out of the first medication cart drawer that she had opened, and she did not remember taking any items with her into Resident #1's room. Interview with LPN #4 on 6/23/26 at 12:46 PM identified she worked 5/21/26 from 3 to 11 PM and Resident #1 was at his/her baseline and was not unresponsive. Further, when she counted the narcotics at 11 PM on 5/21/26 with the on-coming nurse, the Morphine bottle was not leaking and the box was not wet. Interview with Person #2 on 6/23/26 at 3:10 PM identified he/she visited Resident #1 on 5/21/26 and left at approximately 8 PM. Person #2 stated that Resident #1 was talkative and awake when he/she left Resident #1. Record review identified Resident #3 was Resident #1's roommate and had no order for any injectables or liquid Risperdal or liquid Morphine. Resident #3 had a physician order that directed to administer Trazadone 50 mg, half a tablet every morning, and Risperdal 3 mg one (1) tablet at bedtime daily. Interview with the DNS on 6/23/26 at 4:40 PM identified the only two (2) liquid medications in the medication cart on 5/21/26 into 5/22/26 during the 11 PM to 7 AM shift were Risperdal and Morphine, and Resident #1 did not have a physician order for either of those medications. Resident #1 did not have any physician orders for any opioid medications. The facility surveillance video showed LPN #1 drew up one (1) non-narcotic liquid medication into a syringe and one (1) narcotic liquid medication into the same syringe and then went into Resident #1's room with the items from the medication cart in her hands. Interview with MD #1 on 6/24/26 at 1:57 PM identified he was Resident #1's primary care physician and was aware of the incident on 5/22/26. MD #1 stated Resident #1 did not have any active order during the time of the incident for any injections, Risperdal, Morphine, Trazadone, or any opioids. MD #1 did not instruct LPN #1 to give any medications to Resident #1 during her shift. MD #1 stated if Resident #1 received Risperdal and Morphine together, the effects of the medication would be obtunded (drowsy and require repeated verbal or light physical stimuli to awaken), drowsiness, potentially unresponsive, pinpoint pupils, decreased respiratory rate, and low blood pressure. MD #1 stated having those signs indicated an opioid overdose. Review of facility Medication Administration Policy (no date) directed staff medications must be administered only with a valid physician order and document in the Medication Administration Record (MAR) immediately after giving the medication. Review of facility Narcotic Count Policy (no date) directed all removals, additions, and remaining balances must be recorded immediately in a perpetual inventory log. Review of facility undated Medication Dispensing Policy directed in part, to confirm the medication dose and name are correct, verify each medication preparation that the medication was the right drug, at the right dose, the right route, the right rate, the right time, for the right resident, and verify the Medication Administration Record (MAR) reflects the most recent medication order. Facility documentation review identified education was initiated on 5/26/26 for all nursing staff and included education on medication administration, physician orders, wasting medication (non-narcotic and narcotic), narcotic count at change of shift, Narcan policy, and signs of opioid toxicity. Medication administration audits were initiated on 5/23/26, narcotic counts and procedure audits were initiated on 5/27/26, and a QAPI meeting was held on 5/27/26. Based on review of facility documentation, past non-compliance was identified.

Based on observations, record review, and facility documentation review for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure staff followed accepted medication administration practices administration practices. The findings include: Review of facility surveillance video identified on [DATE] at approximately 2:30 AM (3 hours and 30 minutes after her shift started), LPN #1 was observed to exit Resident #1's room, walk down the hallway toward the nursing station with her medication cart keys in her right hand and a black item the size of a cell phone in her left hand. LPN #1 went to the medication cart, placed the cell phone sized item on top of the left side of the med card and she unlocked the cart and placed her keys on top of the right side of the medication cart. Without unlocking or referring to the laptop on the medication cart (med cart) or the Medication Administration Record (MAR), LPN #1 then opened a large non-narcotic drawer and removed an item that appeared to be a small box inside a clear plastic bag and drew up a liquid medication into a syringe. She placed the syringe on the top right side of the med cart and appeared to screw a top onto the medication bottle, replace the bottle into the box and plastic bag, dropped it into the drawer and pushed the drawer shut using her right knee. LPN #1 then opened the top right drawer of the med cart, removed keys from the drawer and closed the top drawer. She then opened the second drawer (under the drawer where she obtained the keys) and used the keys to unlock the drawer. She then pushed medication cards forward in the drawer and reached to the back of the drawer, again without referring to the computer MAR. LPN #1 then removed a box from the drawer and removed a bottle from inside the box and placed the box on the top of the med cart. Using the syringe that was on the top of the med cart she then tipped the bottle upside down and appeared to remove liquid from the bottle. She then looked at they syringe, placed the syringe on the top of the med cart, appeared to screw a cap onto the bottle, placed the bottle into the box, and placed the box in the back of the drawer. LPN #1 then pushed the medication cards so they were leaning towards the back of the drawer and she locked and closed the drawer. LPN #1 then returned the keys into the top right drawer of the med cart, and picked up the syringe and the cell phone sized item and walked down the hall away from the med cart without locking the cart. Interview with LPN #1 on [DATE] at 2:41 PM identified LPN #1 she was the charge nurse on [DATE] into [DATE] on the 11 PM to 7 AM shift. LPN #1 stated she was aware the facility had surveillance video and when the video showed her go to the medication cart, she took Morphine (an opioid pain medication) out of the narcotic box. LPN #1 stated she removed the syringe out of the box containing the Morphine bottle because the box was wet from Morphine leaking, and she used the syringe to draw up the Morphine that was in the box, and she then injected it back into the Morphine bottle - LPN #1 stated it was approximately 0.5 to 0.75 milliliters (ml) that she drew up from the bottom of the box and re-inserted into the medication bottle. LPN #1 denied administering any medications to a resident at that time, and stated she did not remember what she took out of the non-narcotic medication cart drawer that she had opened, and she did not remember taking any items with her into a resident's room at that time. LPN #1 stated she should not have drawn up the Morphine that she stated leaked from the bottle and she should not have put it back into the bottle. LPN #1 stated the narcotic keys should be on her at all times and she did not remember taking them out of the right top drawer of the med cart. Interview failed to identify if she should have referred to the MAR or the narcotic proof of use sheet/disposition record, or if she should have signed for any medications removed from the med cart. Interview with LPN #4 on [DATE] at 12:46 PM identified she worked [DATE] from 3 to 11 PM and when she counted the narcotics at 11 PM on [DATE] with the on-coming nurse (LPN #1), the Morphine bottle was not leaking and the box was not wet. Review of the CT Department of Consumer Protection Drug Control Division Extended Care Facility Recommendations directed in part, the keys to the controlled substance drawer of the medication cart shall be carried personally by the nurse responsible for the required controlled substance audit during each nursing shift. b. Statement from LPN #6 identified on [DATE] at 3 PM while conducing the shift change narcotic count with LPN #1, LPN #6 noted the Morphine box appeared wet with a green-looking solution. LPN #6 informed LPN #1, the off-going nurse who then secured the cap to stop the leak and RN #1 (supervisor) was made aware of the situation. LPN #6 stated RN #1 told LPN #5 and LPN #6 to document the left-over medication and to sign and cosign it. Statement from LPN #5 on [DATE] identified on [DATE] at approximately 3:25 PM while completing narcotic count the Morphine box for Resident #2 was wet and leaking medication. Upon examining the bottle, it was observed the cap to the bottle was not fully secured. LPN #5 secured the cap and notified RN #1 of the situation. RN #1 instructed LPN #1 to document the medication loss as a waste and RN #1 cosigned the documentation. Interview with RN #1 on [DATE] at 2:37 PM identified LPN #5 informed him the box for the Morphine bottle was wet because the cap was loose. After RN #1 checked the Morphine the box was wet, he cosigned the narcotic sheet to indicate what was left in the bottle. RN #1 stated he did not put the amount that was wasted or the time the medication was wasted and just put the amount that was left in bottle. RN #1 stated the reason why he did not put the time or amount wasted because in his mind he was just looking at the amount wasted and it was a busy shift and had admissions to do. RN #1 stated he should have noted the time, and made a notation as to why only 10 ml remained in the bottle. Interview with the DNS on [DATE] at 4:40 PM identified she did not see an amount identified on the narcotic sheet that was wasted or a time that the waste occurred. The DNS stated she did not know why nursing did not document the time or amount wasted but stated it should have been documented c. Review of the proof of use sheet/disposition record serial #1325225 for Morphine solution identified 30 millimeters (ml) were received on [DATE], and the orders were to administer 0.25 ml every three (3) hours as needed for shortness of breath. An entry dated 4/15 and indicated 0.25 ml was administered, with 28 ml left in the bottle. The next entry was dated 5/23 with no time or amount given noted, the nurse signature was illegible, and the amount left was 10. To the right of the #10 was written wasted with a signature that was illegible. Additional review failed to identify the time the medication was wasted, and the amount that was wasted. Interview and record review with the DNS on [DATE] at 4:40 PM identified when a narcotic medication is wasted/discarded, two (2) nurses are required to sign, and the time and amount that is wasted are required to be noted. Interview identified the illegible signatures belonged to RN #1 and the second nurse was unable to be identified. Review of the facility undated Narcotic Count Policy directed all removals must be recorded immediately on the inventory log. d. Interview and record review with the DNS on [DATE] at 4:40 PM identified when controlled medications are received from the pharmacy they come with a white disposition record that the nurses on the unit use to sign that they administered a medication. In addition, a copy (yellow proof of use sheet) is received at the same time. The DNS stated she performed narcotic audits bi-monthly (twice a month) using a facility made/created form. Review of the form identified it listed the unit and the medication cart audited. The audit included the following seven (7) yes or no questions:1.Was the med cart locked before audit?2.All meds have a proof of use sheet.3.Current count correct.4.All change of shift count sheets signed without blanks.5.All med labeled correctly.6.Expiration dates checked.7.No expired meds.Additional review of the audit form failed to identify the individual controlled medication sheets/disposition sheets were compared and reconciled to the yellow copy proof of use sheet received when the medication was delivered from the pharmacy to ensure all controlled medications were present in the box and the individual counts were accurate. The DNS stated she did not reference and/or compare the white disposition sheets to the original copy of the proof of use/disposition record when completing the audits to compare or note what the original drug amount was that was received and what the prior audited amount was, and to ensure no controlled medications were missing from the narcotic box. Interview failed to identify why narcotic audits did not include reconciliation with the pharmacy provided copy of the proof of use sheets to ensure all medications were accounted for. Interview with the DNS on [DATE] at 4:40 PM identified the facility surveillance video showed LPN #1 drew up one (1) non-narcotic liquid medication into a syringe and one (1) narcotic liquid medication into the same syringe and then went into Resident #1's room with the items from the medication cart in her hands. The DNS stated staff should sign for controlled medications when they are removed from the narcotic box, and the narcotic box keys should be carried by the charge nurse, physician orders and the MAR should be checked to verify orders prior to medication administration, medications should be signed for when they are administered by the nurse, the time and amount of any narcotic medication should be noted when wasted, and bi-monthly audits should include verification that all controlled medications are in the narcotic box. Review of the CT Department of Consumer Protection Drug Control Division Extended Care Facility Recommendations directed in part, the keys to the controlled substance drawer of the medication cart shall be carried personally by the nurse responsible for the required controlled substance audit during each nursing shift. The Director of Nursing or designee shall conduct bi-monthly audits of all controlled substances. Required destruction records shall be maintained whenever partial or individual doses of controlled substance stock are discarded by nursing personnel and must indicate: a. Name, form, strength and quantity of the controlled substance b. Signature of another nurse witnessing such destruction. Review of the undated facility Medication Administration Policy directed staff medications must be administered only with a valid physician order and document in the Medication Administration Record (MAR) immediately after giving the medication. Review of the undated facility Narcotic Count Policy directed all removals, additions, and remaining balances must be recorded immediately in a perpetual inventory log. Review of facility undated Medication Dispensing Policy directed in part, to confirm the medication dose and name are correct, verify each medication preparation that the medication was the right drug, at the right dose, the right route, the right rate, the right time, for the right resident, and verify the Medication Administration Record (MAR) reflects the most recent medication order. Review of undated facility Narcotic Count Policy directed all removals, additions, and remaining balances must be recorded immediately in a perpetual inventory log.

Based on observations, record review, and facility documentation review for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation of resident property. The findings include: Resident #1 had a diagnosis of vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 6 indicating severely impaired cognition. The Resident Care Plan (RCP) dated 4/20/26 identified a self-care deficit. Interventions directed Resident #1 was non-ambulatory and dependent for wheelchair mobility, transfer with two (2) assist via mechanical lift, and provide personal care. Record review identified Resident #1 had no physician orders that directed administration of Risperdal (non-opioid medication used to treat bipolar), Trazadone (used to treat depression/not an opioid), Morphine (opioid medication used to treat pain or shortness of breath), or any opioids. Resident #2 had a diagnosis of dementia and was receiving palliative care. Record review identified Resident #2's payment source was Medicaid. Physician order directed liquid Morphine Sulfate (concentrate) oral solution 20 milligrams (mg) per milliliter (ml) give 0.25 ml sublingual (under the tongue) every three (3) hours as needed for shortness of breath. Facility Reportable Event (RE) dated 5/26/26 at 12:33 PM identified Resident #1 was in his/her room when noted unresponsive, and was transferred to the hospital for altered mental status on 5/22/26. Reports from the hospital confirmed urine testing was positive for opiates. Resident #1 was not prescribed any opioid medications. Reportable event summary dated 6/1/26 identified on 5/22/26 about 8:30 AM Resident #1 was noted to be sleepy and was unable to eat breakfast, mental status worsened and a decision was made to send to the resident to the hospital for evaluation. The facility was notified Resident #1 had been treated with Narcan two (2) times and on initial urine screen was positive for opiates. Upon the facility's Medical Directors request, the urine test was repeated, and the results remained positive for opiates. Resident #1 was not prescribed any opioid medications at the facility. The summary indicated, based on interviews and surveillance (video review) there was a possibility that the 11 PM to 7 AM shift nurse (LPN #1) assigned to Resident #1 may have administered narcotic opioid medication that was not ordered by the physician for Resident #1. During an interview with LPN #2, she stated that LPN #1 had indicated to LPN #2 that she had administered Trazadone (used to treat depression/not an opioid) to Resident #1 during the night for agitated behavior. Resident #1 did not have a physician's order for Trazadone. During an interview with LPN #1 she stated she had administered Tylenol to the patient during the night. Tylenol was not documented in the clinical record as administered; no medications were signed as administered during the 11 PM to 7 AM shift prior Resident #1's transfer to the hospital. Interviews failed to identify any staff reported administration of an opioid. Hospital Discharge summary dated [DATE] at 8 AM identified upon admission Resident #1 had myotic (abnormally constricted) pupils. Resident #1 improved after two (2) doses of Narcan, and was started on Bilevel Positive Airway Pressure (BIPAP, ventilator used to assist with breathing). Toxicology results were positive two (2) times for opioids. Resident #1 was admitted for Acute Hypercapnic Respiratory Failure (AHRF) and suspected opioid intoxication despite no opioid prescriptions in the resident's medication list. Record review identified Resident #1 returned to the facility on 5/29/26. Review of facility surveillance video identified on 5/22/2026 at approximately 2:30 AM (3 hours and 30 minutes after her shift started), LPN #1 was observed to exit Resident #1's room, go to the medication cart, draw up a medication in a syringe from the medication cart second drawer (non-narcotic drawer). Then LPN #1 obtained a medication from the narcotic box and drew that up in a syringe (using the same syringe), returned the medication box to the drawer and then returned to Resident #1's room with the items she removed from the medication cart in her hands. Record review identified Resident #1 had no medications scheduled for administration during the 11 PM to 7 AM shift, and had no physician orders for any no injections or opioids. Interview and written statement review with LPN #2 on 6/23/26 at 11:18 AM identified she spoke with LPN #1 on 5/23/26 and LPN #1 stated she had enough rest from working 5/21 into 5/22/2026 because she she napped in Resident #1's room during the shift. LPN #2 stated that LPN #1 told her Resident #1 was grunting loudly and interrupting her sleep so bad that she had to give him/her something to sleep. LPN #2 stated that LPN #1 indicated she gave Resident #1 Trazadone 50 milligrams (mg) that belonged to another resident. LPN #2 told LPN #1 that Resident #1 was found unresponsive and LPN #1 stated she did not know nor did she care and that it had nothing to do with her. LPN #2 told LPN #1 that the facility was going to do an investigation and watch the cameras and LPN #1 stated they are going to see me going in and out of the bottle. LPN #2 asked what bottle and LPN #1 stated Risperdal (non-opioid medication used to treat bipolar). LPN #1 further stated she went into the narcotic box to recount because she did not trust the evening shift nurse. LPN #2 advised LPN #1 to come forward, and LPN #1 responded, no and that she was afraid to and she would just say she gave Resident #1 Tylenol. Interview with LPN #1 on 6/22/26 at 2:41 PM identified LPN #1 she was the charge nurse on 5/21/26 into 5/22/26 on the 11 PM to 7 AM shift. LPN #1 stated Resident #1 was agitated and kept trying to climb out of bed by putting his/her feet off the bed so she sat with Resident #1 so he/she would not fall. LPN #1 then stated she told the DNS she gave Resident #1 Tylenol, but stated she did not actually give Resident #1 any medications during her shift, and she stayed in Resident #1's room until 5 AM. LPN #1 stated she was aware the facility had surveillance video and when the video showed her go to the medication cart, she took Morphine (an opioid pain medication) out of the narcotic box. LPN #1 stated she removed the syringe out of the box containing the Morphine bottle because the box was wet from Morphine leaking, and she used the syringe to draw up the Morphine that was in the box, and she then injected it back into the Morphine bottle - LPN #1 stated it was approximately 0.5 to 0.75 ml (10 to 15 mg dosage) that she drew up from the bottom of the box. LPN #1 denied administering any medications to Resident #1 and stated she did not remember what she took out of the first medication cart drawer that she had opened, and she did not remember taking any items with her into Resident #1's room. Record review identified the only liquid medication in the narcotic box was the Morphine concentrate that belonged to Resident #2; Morphine Sulfate (concentrate) oral solution 20 mg per ml. Interview with LPN #4 on 6/23/26 at 12:46 PM identified she worked 5/21/26 from 3 to 11 PM and Resident #1 was at his/her baseline and was not unresponsive. Further, when she counted the narcotics at 11 PM on 5/21/26 with the on-coming nurse, the Morphine bottle was not leaking and the box was not wet. Interview with Person #2 on 6/23/26 at 3:10 PM identified he/she visited Resident #1 on 5/21/26 and left at approximately 8 PM. Person #2 stated that Resident #1 was talkative and awake when he/she left Resident #1. Interview with the DNS on 6/23/26 at 4:40 PM identified the facility surveillance video showed LPN #1 drew up one (1) non-narcotic liquid medication into a syringe and one (1) narcotic liquid medication into the same syringe and then went into Resident #1's room with the items from the medication cart in her hands. The DNS stated nursing staff should not be taking narcotics out of the narcotic box unless they are going to give the medication to the resident which it was prescribed for; residents should not be given any medication that a physician did not order. Review of facility Medication Administration Policy (no date) directed staff medications must be administered only with a valid physician. Review of facility undated Medication Dispensing Policy directed in part, to confirm the medication dose and name are correct, and verify the right resident. Review of facility Abuse Policy dated 7/23/23 directed Abuse to be defined as misappropriation of resident property which means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a residents belongings without the residents consent.

Based on clinical record review, observations, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #23) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure a resident was provided and or offered showers. The findings include: Resident #23 was admitted on [DATE] with diagnoses that included depression and schizophrenia.The admission MDS assessment dated [DATE] identified Resident #23 had moderately impaired cognition, had not exhibited refusal of care, and required moderate assistance with bathing. The MDS assessment further identified it was very important for the resident to choose her/his preferred bathing method including a shower, tub bath, bed bath, or sponge bath.The RCP dated 3/4/2026 identified Resident #23 required assistance with activities of daily living (ADLs). Interventions included providing supervision for bathing and dressing. An undated nurse aide care card also indicated the resident required supervision for bathing and dressing.Review of nurse aide bathing flowsheets from 2/26/2026 through 4/21/2026 identified since admission, Resident #23's bathing task was signed off and documented on only three occasions on 3/31/2026, 4/7/2026, and 4/10/2026. The flowsheets did not specify whether bathing provided was a shower or a sponge bath.Review of nursing progress notes from 2/26/2026 through 4/21/2026 failed to identify any documented refusal of care or refusal of showers by Resident #23.Review of the undated facility shower schedule identified Resident #23 was scheduled to receive showers twice weekly, every Tuesday and Friday on the 3:00 PM to 11:00 PM shift.Observation on 4/20/2026 at 2:15 PM noted Resident #23 was dressed in a grey sweatshirt and sweatpants, with hair noted to be uncombed and raised upward. Resident #23 identified he/she had been admitted to the facility approximately six weeks prior. Resident #23 stated he/she had been receiving sponge baths and had only received one shower approximately three weeks ago, with none since. Resident #23 identified he/she would prefer showers and would accept them if offered.Interview with LPN #11 on 4/23/2026 at 12:28 PM identified Resident #23 required the assistance of one for showers. LPN#11 indicated Resident #23 was scheduled to receive showers on Tuesday and Friday evenings during the 3:00 PM to 11:00 PM shift and was not aware of any care refusals.Interview with NA #10 on 4/23/2026 at 2:24 PM identified she regularly is assigned to care for Resident #23 on the evening shift. NA#10 indicated she thinks Resident #23's shower day was Tuesdays. NA #10 indicated she could not recall the last time she assisted Resident #23 with a shower. NA identified approximately 2 weeks ago Resident #23's shower schedule was changed from the day shift to evening shift, but she was unable to recall the specific day or reason for the change. NA#10 indicated she documents showers in the electronic medical record but does not typically document sponge baths. NA #10 stated Resident #23 has not refused care.Interview with the Director of Nursing Services (DNS) on 4/24/2026 at 10:33 AM identified the nurse aides are expected to document showers and baths in the nurse aide flowsheets in the resident's electronic medical record. The DNS identified the documentation in the flowsheets does not distinguish between a shower or sponge bath, so it is not possible to determine from the record what type of bathing was provided on a given day to Resident #23.Review of the undated facility Bathing/Shower Policy identified that each resident would be offered a full bath/shower at least weekly.Review of the undated facility ADLs Policy identified that staff should document all care given as well as document care refusals in the electronic medical record.

Based on clinical record reviews, review of the facility Infection Control Program, facility documents facility policy and interviews, the facility failed to provide education regarding the Covid Vaccine to staff members offering to provide the vaccine or inform where staff could obtain a Covid vaccination, and the facility failed to ensure documentation of screening residents for the eligibility to receive the Covid vaccine was completed, and residents and responsible parties received copies of Covid Vaccination educational materials prior to deciding to vaccinate or decline vaccination. The findings include: An interview and facility document review with the Assistant Director of Nursing Services (ADNS/Infection Preventionist(IP) on 4/23/2026 at 10:15 AM identified she/he was unable to locate specific staff education regarding the Covid Vaccine and offering the vaccine or indicate where they could receive the vaccine. The Staff Development Nurse, RN#2 identified she/he provided staff training on the Covid infection and staff members roles within the facility as it pertains to the infection control process. However, she/he indicated she/he was not specific with education regarding the Covid 19 vaccine and did not offer it to the staff. An interview with the Assistant Director of Nursing Services (ADNS)/Infection Preventionist on 4/23/2026 at 10:15 identified Resident #63's refusal to consent to vaccination form dated 8/15/2024 was signed to indicate the receipt and review of the CDC Vaccination statement but the IP could not provide evidence of what educational materials were provided and who obtained the verbal consent. A review of Resident # 1's clinical record identified on 10/23/2024 a verbal consent was provided by the Conservator of Person for Resident #1 to receive the influenza and Covid 19. However, a review of the consent form identified no page 2 which identified the conservators signature attesting to the receipt of the vaccination information sheet. Additionally, the form noted no documentation of the screening process to determine eligibility to receive the vaccine. The ADNS / IP further indicated s/he screens every resident before providing the Covid 19 vaccine but does not document it. S/he further indicated obtaining verbal consent for the Covid 19 vaccines and education of the vaccine over the phone from the resident's responsible party is done by the party responding yes or no to the understanding of education. The ADNS/IP further indicated that there was a check-off in the electronic vaccination system for each resident, the nurse can check yes or no if education was provided and they all are checked yes. The ADNS/IP could not provide any information of any type of educational source that's/he provided, reading material over the phone or faxed to responsible parties or to residents. On 4/27/2026 at 10:40AM an interview and facility document review with ADNS/IP identified she/he utilized an education form from the Centers for Disease Control and Prevention that was provided by the previous IP. The ADNS/IP further indicated she/he would be using the CDC educational sheets in the future to educate residents and responsible parties. The facility policy labeled Covid 19 Vaccine given onsite indicated all residents who have no medical contraindications to the vaccine will be offered the Covid 19 vaccine based upon CDC guidance and the facility would provide the Vaccination Information Sheet outlining the benefits and risks to the resident or legal representative in conjunction with obtaining the consent for the vaccination.

Based on a tour of the Dietary Department, observations, review of facility documentation, facility policy, and interviews the facility failed to ensure food temperatures were consistently obtained and logged prior to serving meals, refrigerator and freezer temperatures were consistently monitored and documented, dishwasher temperatures were consistently monitored and documented prior to washing dishes, sanitizer solution was consistently tested and logged prior to use to disinfect pots and pans and kitchen surfaces per manufacturer recommendations, and dietary staff wore a beard guard when preparing and serving food. The findings include: A tour of the Dietary Department on 4/20/26 at 8:00 AM with the Food Service Director (FSD) identified the following:1. Food temperature for breakfast, lunch, and dinner meal log sheets for 2025 were not completed. 2. Refrigerator and freezer log sheets for 2025 were not completed. 3. Dishwasher temperature log sheets for 2025 were not completed.4. Sanitizer parts per million (PPM) log sheets for 2025 were not completed.Interview with the FSD on 4/20/26 at 8:10 AM identified he did not have any log sheets for 2025. The FSD indicated the only daily log available were from 1/1/2026 to 4/20/2026. The FSD indicated he is new to the facility and is working with staff to ensure all compliance with food service and kitchen protocols. On 4/22/26 at 8:02 AM, the Administrator provided completed daily log sheets for January through April 2026 for food temperatures, refrigeration/freezer temperatures, dishwasher temperatures, and sanitizer concentrations.Interview with the Administrator on 4/22/26 at 10:32 AM identified she was aware that the daily log sheets for food temperatures, refrigerator/freezer temperatures, dishwasher temperatures, and sanitizer PPM levels were not consistently completed during 2025. The Administrator indicated a Quality Assurance and Performance Improvement (QAPI) plan was implemented on 2/17/2026 to address the concerns and completed on 3/17/2026. 5. Observation on 4/22/26 at 8:18 AM during breakfast meal service in the first-floor kitchenette identified [NAME] #1 was at the steam table preparing and serving food with visible facial hair and was not wearing a beard guard. Foods observed on the steam table included scrambled eggs, bacon, sausage, toast, and bread.Interview with the Admissions Director on 4/22/26 at 8:22 AM identified she was the manager assigned to the meal service in the dining room. The Admissions Director identified that all dietary staff are required to wear hair restraints, including beard guards, at all times while preparing or serving food. The Admissions Director indicated [NAME] #1 must have taken his beard guard off and forgot to put a new one on. Subsequent to surveyor inquiry, [NAME] #1 exited the kitchenette and returned wearing a beard guard. Review of the undated facility Food Temperature Check Policy, directed in part, prior to delivery focuses on ensuring time/temperature control for safety foods are safe adhering to the FDA Food Code and CMS regulations. Policies require checking food temperatures before placing them into the transportation carts or on the tray line.Review of the undated facility Refrigeration Temperature Recording Policy, directed in part, record keeping for temperature control refrigeration equipment is necessary to ensure foods are maintained at optimum quality and to prevent spoiling and/or foodborne illness. It is the FSD responsibility to have protocols in place where temperatures are monitored and logged.Review of the undated facility Storage of Frozen and Refrigerated Foods Policy, directed in part, the Food and Nutrition Service Department would adhere to all guidelines and regulations concerning the refrigeration and freezing of foods. Keep temperatures for freezers at 0 degrees Fahrenheit or below, record all unit temperatures daily on the refrigerator/freezer temperature record and retain per state regulation.Review of facility Sanitizer Bucket Policy dated 3/27/20, directed in part, the proper sanitizer bucket use in order to maintain sanitary conditions of work areas and equipment. Prepare sanitizer solution using QUAT and follow manufacture instructions and levels of chemicals. Test PPM using a test strip made for QUAT ensure test strips are in good condition (not previously wet) and not expired. After checking sanitizer level is accurate, log and verify level on PPM log. Review of facility Dish Machine Policy dated 5/8/20, directed in part, ensure proper sanitary dishwashing with hi-temp and low temp dish machines. Dietary staff will record dish machine temperatures on a dish machine temperature log before they begin the dishes from each meal service. Any unusual or substandard readings should be reported immediately to the FSD or Maintenance Department.Review of facility Hair Restraint Policy dated 1/20/17, directed in part, anyone within the kitchen, who will have close contact with the preparation or service of food, food storage areas, equipment will keep hair effectively/appropriately restrained to include facial hair. The purpose of the hair restraint is to prevent hair from contacting food and food equipment surfaces and to deter food service employees from touching their hair.

Based on clinical record review and interviews for 1 of 1 resident ( Resident #52) reviewed for personal funds, the facility failed to ensure quarterly statements were consistently provided to the resident. The findings include: Resident #52 diagnosis included ulcerative colitis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact. An interview, clinical record review, and facility document review with Business Office Manager (BOM) #1 on 4/27/2026 at 11:51 AM identified she was covering the position due to a vacancy and that Business Office Managers from sister facilities were assisting. BOM #1 identified Resident #52 had a personal account with the facility and was responsible for himself/herself. BOM #1 indicated Resident #52 would be the person to receive quarterly account statements from the facility. BOM #1 identified the procedure was quarterly statements are provided to residents or responsible parties with personal funds account. BOM #1 indicated residents residing in the facility who are responsible for themselves are expected to receive statements in person and sign to acknowledge receipt, while statements for individuals not residing in the facility are mailed. BOM #1 indicated she was unaware of the prior process used by the previous Business Office Managers and would contact the regional BOM to determine if documentation existed to verify whether Resident #52 had received prior quarterly statements. A follow-up interview and facility document review with BOM #1 on 4/27/2026 at 12:58 PM identified because Resident #52 indicated he/she had not received prior quarterly account statements she provided a copy of the current January 2026 through March 2026 quarterly statement to Resident #52. Resident #52 signed the statement at that time to acknowledge receipt. BOM #1 was unable to provide documentation demonstrating that Resident #52 received quarterly account statements prior to this date.

Based on clinical record review, facility documentation, review of facility policy and staff interviews for 1 of 4 residents (Resident #6) reviewed for abuse, the facility failed to keep the resident safe from physical and verbal abuse. The findings include:Resident #6 a conserved resident was admitted with diagnoses of bipolar disorder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition and exhibited verbal behaviors directed towards others. Resident #6 required substantial/maximal assistance for toileting, was independent in standing from a sitting position, and used a wheelchair for mobility. The MDS assessment further identified Resident #6 did not have any skin problems or wounds.The Resident Care Plan (RCP) dated 1/21/2025 identified Resident #6 was at risk for alteration in mood and behaviors as evidenced by yelling at staff. Interventions included leaving the resident alone and returning later if the resident was being abusive towards staff.A psychiatric evaluation dated 1/21/2025 identified Resident #6 exhibited baseline confusion, delusional thinking, and disorganized thought process with a tendency toward impulsiveness when irritable. Recommendations included close monitoring and behavioral documentation.A weekly skin observation tool dated 1/25/2025 identified no skin issues.A nursing note dated 1/29/2025 identified Resident #6 refused care and refused staff to enter her/his room, even to care for her/his roommate.A nursing note dated 1/31/2025 identified an ongoing investigation of abuse, and a full body audit was performed. The note identified an abrasion to the left arm measuring 4.0 Centimeters (CM) by 2.0 CM, and an abrasion to the right leg measuring 7.0 CM by 0.5 CM. The Advanced Practice Registered Nurse (APRN) was informed and reviewed, no treatment orders, leave abrasion open to air. Additionally, noted Resident # 6 was referred to psychiatry for a telehealth consult which was conducted by an APRN and staff were directed to administer a stat (one time dose) of Seroquel (medication used to treat mood disorders) 50 milligrams (mg) Seroquel to the resident for mood and behavior and escalation. A review of the facility Reportable Incident report dated 1/31/2025 identified that a Nursing Assistant student (Person #1) reported on 1/31/2025, Resident #6 came out of the bathroom when Nurse Aide (NA#11) and Person #1 were going to provide care to Resident #6's roommate. Person #1's statement indicated Resident #6 began to kick NA#11, and NA#11 kicked Resident #6 back on the legs. Person #1 reported that NA# 11 called Resident #6 a crazy bitch. The statement further identified NA#11 pushed the resident's wheelchair and scratched the resident's left arm. A statement by NA#11 identified that when NA#11 and Person #1 were providing care to Resident #6's roommate, Resident #6 entered the room and told NA#11 to leave. NA#11 told Resident #6 she was almost done and then would leave. The statement then indicated Resident #6 threw a soiled brief at NA#11, at which point NA#11asked Person #1 to move Resident #6's wheelchair so NA#11 could leave; however, Person #1 was scared, at which time NA#11 moved Resident #6's wheelchair to leave the room. Additionally, the report indicated that on 1-31-25 NA #11 was immediately placed on administrative leave.A statement by NA#13 and NA#14 identified that they took care of Resident #6 on 1/30/2026 and noted no skin impairment. The facility's Reportable Incident report further indicated after completion of the facility's investigation, NA#11 was terminated.A police report dated 1/31/25 identified NA#11 was interviewed with the help of an interpreter by the police and indicated Resident #6 threw a soiled diaper at NA#11and asked NA#11 to leave. NA #11 continued cleaning Resident #6's roommate after Resident #6 had asked NA#11 to leave and Resident #6 kicked NA#11 on the left and right legs. The report identified NA#11 indicated that it was Person #1 who moved Resident #6's wheelchair out of the way so NA#11 could leave. The police report identified that officers were unable to communicate with Resident #6. The police report further indicated that photographs of the scratches on Resident #6's arm were submitted to the appropriate department by the officers.The social worker note dated 1/31/25 12:30 PM identified the Social Worker (SW) and Administrator met with Resident # 6 regarding reported allegation of abuse. The resident was inconsistent with her/his thoughts and could not recall alleged reported incident. Emotional support was provided and Resident # 6 was encouraged to reach out to staff with any issues /concerns. Appropriate departments were made aware. The Social Worker will update upon new incident.A weekly skin observation tool dated 2/6/2025 identified fading bruises, yellow in color, to the right leg and a fading abrasion to the right lower leg. The skin observation tool further identified fading abraded spots on the left forearm and a fading bruise on the right upper arm.Review of NA #11 employee file noted the summary of the investigation by completed by administration dated 2/11/25 identified NA #11 had been terminated for allegation of witnessed resident abuse , after the resident was found to have skin alteration consistent with alleged incident.On 4/24/2026 at 2:04 PM, an interview with Person #1in their preferred language indicated that Person #1 and NA#11 entered the room to clean Resident #6's roommate when Resident #6 yelled through the bathroom door, which was slightly open to not come in. Person #1 indicated NA#11 opened the bathroom door and NA#11 and Resident #6 began arguing, and NA#11 called Resident #6 a crazy bitch. Resident #6 then threw a soiled diaper at NA#11. Person #1 indicated NA#11 tried to close the bathroom door on Resident #6 and continued calling Resident #6 a crazy bitch. Resident #6 then started kicking NA#11 on the legs, and NA#11 kicked Resident #6 back on Resident #6's right leg. Person #1 further indicated NA#11 was restraining Resident #6 by holding the resident's arm down against the armrest of the wheelchair. Person #1 indicated the main door of the room was closed and she/he was not aware of anybody hearing the incident.On 4/27/2026 at 9:12 AM, an interview with NA#11 using an interpreter of NA#11's choosing (Person #2) indicated NA#11 and Person #1 were changing another resident when Resident #6 came into the room from the bathroom and told NA#11 to get out. NA#11 indicated that she did not leave, and Resident #6 began fighting, stood up from her/his wheelchair, and threw a soiled diaper at NA#11's face. NA #11 indicated Resident #6 was kicking and cursing and she/he (NA#11) sat Resident #6 back in the wheelchair. NA#11 indicated that she/he brought the wheelchair close to Resident #6's and Resident #6 sat her/himself back down while NA#11 held Resident#6's hand for assistance. NA#11 could not recall which of Resident#6's hands she/he held. NA#6 denied calling Resident #6 a crazy bitch, denied kicking Resident #6 on the legs, and denied pushing Resident #6's arms down against the armrests of the wheelchair. NA#11 further indicated that she/he did not ring the call bell or call for help when Resident #6 was agitated and the main door of the room was closed.On 4/27/2026 at 12:34 PM, an interview with the Director of Nursing Services (DNS) identified Person #1 did not have anything to gain from making a false accusation, and Resident #6's injuries did not have another clear cause. The DNS indicated that, out of an abundance of caution, NA#11 was terminated at the conclusion of the facilities investigation.Attempts to interview Resident #6 were unsuccessful as Resident #6 was on medical leave.Resident #6's roommate at the time of the incident (Resident #117) was unable to be interviewed due to severe cognitive impairment.A review of the facility policy for Abuse/ Resident policy updated on 7/23/23 noted abuse shall be defined as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse includes hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment.

Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #21 and Resident# 117) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the state agency was updated subsequent to the residents' new psychiatric diagnoses. The findings include:1. Resident #21 had diagnoses that included anxiety and dementia. a. A PASRR Level 1 screen dated 11/27/24 identified Resident #21 had a diagnosis of dementia with no mental health diagnosis and received a dementia exemption. The outcome identified Resident #21's approval remained valid unless changes occur or additional information suggests a primary mental health illness then rescreening should occur to reassess need for PASRR evaluation.A psychiatric Advanced Practice Registered Nurse (APRN) note dated 12/2/24 identified Resident #21 had diagnoses of anxiety and depression (new diagnoses for Resident #21).A physician's order dated 12/2/24 directed to administer Seroquel (medication used to treat depression or frenzied, abnormally excited or irritated mood) 12.5 milligrams (mg) twice a day as needed for 14 days. The admission MDS dated [DATE] identified Resident #21 had severely impaired cognition, was not currently considered by the state agency as a Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and had active diagnoses that included dementia and anxiety.The Resident Care Plan (RCP) dated 12/24/24 identified Resident #21 had anxiety and used psychotropic medication. Interventions included monitoring the resident's mood and behaviors.A psychiatric APRN note dated 1/28/25 identified Resident #21 had diagnoses of anxiety, dementia, and bipolar disorder (new diagnoses for Resident #21). A physician's order dated 2/26/25 directed to administer Depakote (mood stabilizer) delayed released 250 mg tablet twice a day related to bipolar disorder.b. The quarterly MDS dated [DATE] identified Resident #21 had active diagnoses of anxiety, hypertension, dementia, and bipolar disorder. The RCP dated 4/18/25 identified Resident #21 was at risk for potential adverse effects related to the use of psychotropic drugs used to treat anxiety and bipolar disorder. Interventions directed to monitor mood and behaviors because they may fluctuate due to diagnoses.Review of the clinical record identified Resident #21's diagnosis of bipolar disorder was added on 5/19/25 and a diagnosis depression was added on 5/27/25.A psychiatric APRN note dated 5/27/25 identified Resident #21 had diagnoses of anxiety, depression, and bipolar disorder. The physician's order dated 6/9/25 directed to administer Trazodone (medication used to treat depression) 50 mg every day in the afternoon for depression and Valproic Acid (mood stabilizer) oral solution 250 mg/5 milliliter (ml) give 2.5 ml by mouth one time a day and 5.0 ml at bedtime for bipolar disorder. Review of the clinical record failed to identify the PASSR contracted agency was notified of the new psychiatric diagnoses of depression and bipolar disorder from 2/26/25 through 4/22/26 in order to conduct an additional Level 1 and Level 2 screen.Interview with Social Worker (SW) #2 with the Director of Social Services (SW #1) present on 4/22/2026 at 9:40 AM identified she had worked at the facility for approximately a year. SW #2 identified she is responsible for reviewing PASRRs for all new admissions and ensuring updates are submitted to the state agency when a resident receives a new mental health diagnosis. SW #2 indicated she completed an audit of all residents to ensure documented diagnoses matched the PASRRs. SW #2 stated that Resident #21's most recent PASRR, dated 11/27/24, did not include diagnoses of anxiety, depression, or bipolar disorder. SW #2 indicated she must have missed the discrepancy during her audit. Subsequent to surveyor inquiry, a PASRR Level I Screen submission request dated 4/22/26 was made to the PASSR contracted agency to report that Resident #21 had new diagnoses of anxiety, depression, and bipolar disorder. 2. Resident #117 had diagnosis that included dementia, conversion disorder with seizures, major depression disorder, and anxiety.a. A PASRR Level 1 screen dated 11/18/22 identified Resident #117 had no mental health diagnosis known or suspected and not on any medication. The outcome identified Level 2 is not required there is no evidence of a PASRR condition or a serious behavioral health condition. If changes occur or new information refutes these findings a new screen must be submitted. Review of the clinical record identified that Resident #117's diagnosis of major depression was added on 8/8/24, which was a new diagnosis added after completion of the PASRR dated 11/18/22.The quarterly MDS dated [DATE] identified Resident #117 had moderately impaired cognition and active diagnoses that included dementia, seizure disorder, anxiety, depression, and bipolar disorder. A psychiatric APRN note dated 9/5/24 identified Resident #117 had diagnoses of anxiety, depressive disorder, and dementia.b. The quarterly MDS dated [DATE] identified Resident #117 had moderately impaired cognition and active diagnoses that included dementia, seizure disorder, anxiety, depression, and bipolar disorder.The RCP dated 2/24/26 identified Resident #117 used psychotropic medications for anxiety and depression. Interventions directed to administer psychotropic medication and antidepressants as ordered by the physician.A psychiatric APRN note dated 2/20/26 identified Resident #117 had diagnoses of anxiety, depressive disorder, and dementia.A physician's order dated 3/1/26 directed to administer Depakote (mood stabilizer) sprinkles delayed release 500 milligrams (mg) every 12 hours. Interview with SW #2 on 4/22/26 at 9:55 AM identified she was responsible for updated the PASRR contacted agency when there was a new psychiatric diagnosis. SW #2 indicated during recent chart audits she noted Resident #117's most recent PASRR, dated 11/18/22 did not include diagnoses of anxiety, major depressive disorder, or bipolar disorder. SW #2 identified Resident #117's diagnoses of anxiety, major depressive disorder, and bipolar disorder occurred after Resident #117's admission to the facility and had not been communicated to the PASRR state agency. SW #2 identified although she was aware the PASRR state agency should have been updated she was unable to identify the reason why she had not updated the PASRR state agency.Subsequent to surveyor inquiry, a PASRR Level I Screen submission request dated 4/22/26 was made to the PASSR contracted agency to report that Resident #117 had new diagnoses of anxiety, major depression disorder, and bipolar disorder. Although requested, a facility PASRR policy was not provided.

Based on clinical record review, observations, review of facility policy and interviews for 1 of 4 residents (Resident #1) reviewed for pressure ulcers, the facility failed to revise the resident plan of care regarding pressure ulcer interventions to prevent skin breakdown. The findings include: Resident #1 was admitted on [DATE] diagnosis includes pneumonia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact, was at risk for pressure ulcers, and had an unstageable deep tissue injury. The care plan (not dated) indicated Resident #1 had a pressure ulcer classified as a deep tissue injury (DTI) on the right buttock which was present on admission to the facility. Interventions included checking skin at least weekly, providing good nutrition and providing incontinent care. A Health Status Note dated 3/26/2026 at 12:17 PM identified during an observation of Resident # 1's left heel the heel was noted to be boggy with skin intact; no complaints of discomfort and bilateral heel boots were applied. The note further indicated that the Advanced Practice Registered Nurse (APRN) was notified and no new orders . The 3/26/2026 wound consultant documentation identified Resident # 1's left heel was boggy, directed skin prep to the heels leaving heels open to the air and to offload the heels. The physician's orders dated 3/26/2026 directed to offload heels every shift and to apply skin prep to the heels and leave open to air. The physician's orders dated 4/16/2026 directed to check the air mattress for functioning every shift adjusting to the resident's weight or comfort level. An observation on 4/22/2026 at12:20 PM identified Resident #1 in bed with blue booties on both feet. On 4/22/2026 at 12:26 PM an interview and record review with the Registered Nurse (RN) supervisor (RN #2) indicated the Nurse Aide Care cards are on the computer, the nurse aides can access them on the tablets they use to document care. RN#2 indicated the information on the care card flows from the information placed in the care plan. However, upon review of Resident # 1's care plan identified the care plan had not been updated (for 22 days) with the development of a left heel pressure ulcer or the interventions to prevent further skin breakdown which included offloading of the heels. RN#2 indicated the care plan identified a pressure ulcer of the buttock from admission and did not reflect Resident #1's skin status. RN #2 further indicated the physician's orders did flow over to the Treatment Kardex for the licensed nurse to view and sign off after completion. RN #2 also indicated it would be up to the licensed nurse to inform the nurse aides of the need to offload Resident #1's heels. The Assistant Director of Nursing Services (ADNS ) approached RN#2 and the surveyor on 4/22/2026 at 12:34 PM to reviewed Resident # 1's care plan. RN #2 further indicated she/he could not find the care plan revised with the left heel ulcer or the need to offload the heels. The facility policy labeled Resident Profile/Care Cards given onsite indicated in part the purpose is to inform staff who assist the residents on a daily basis of the resident plan of care. The policy further indicated the care card will be updated as needed with changes to the resident plan of care. After surveyor inquiry, Resident # 1's care card and care plan was updated on 4/27/2026 at 10:31 AM to include offloading heel boots and the application of heel boots to both feet while in bed and the wheelchair.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #3) reviewed for dining, the facility failed to ensure a dignified dining experience. The findings include:Resident #3 had diagnoses that included dementia and end-stage renal disease. The physician's order dated 3/1/26 directed a regular renal diet and thin liquids. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #3 had severely impaired cognition and required setup or cleanup assistance for eating.The Resident Care Plan (RCP) dated 3/19/26 identified Resident #3 was at risk for further decline in ADL self-care related to increased weakness, fatigue, and continuous deconditioning. Interventions included the use of adaptive equipment, built-up utensils, scoop plate, double- handled sippy cup, and assistance of one with eating.Observation on 4/22/26 at 8:50 AM noted Resident #3 seated in a wheelchair at a round table in the lounge while Nurse Aide (NA) #1 fed him/her breakfast. NA #1 stood to the left side of the wheelchair, standing over Resident #3 while feeding him/her. NA #1 fed Resident #3 scrambled eggs with a spoon from a scoop dish, followed by fortified cereal, and periodically offered sips of liquid from a two-handled cup between bites. No chair was available for NA #1 to sit.Interview with NA #1 on 4/22/26 at 9:00 AM identified she had worked at the facility for approximately one year. NA #1 indicated she fed Resident #3 while standing because the resident would be out for several hours and needed to eat beforehand. NA #1 stated she remained standing because no chairs were available and she needed to monitor the area.Observation on 4/22/26 at 9:04 AM noted Licensed Practical Nurse (LPN) #1 (MDS Coordinator) exit the elevator, enter the lounge, and retrieved a wheeled chair from the nurse's station. LPN #1 brought the chair into the lounge and instructed NA #1 to sit. NA #1 stated she did not need to sit. LPN #1 again directed NA #1 to sit while feeding Resident #3. NA #1 responded that she was almost finished. LPN #1 then left the lounge. At 9:06 AM, NA #1 sat down and offered Resident #3 the remaining liquid from the two-handled cup. At 9:09 AM, NA #1 completed feeding Resident #3.Interview with LPN #1 on 4/22/26 at 9:09 AM identified she had just arrived on the unit and observed NA #1 standing while feeding Resident #3. LPN #1 indicated she retrieved a chair for NA #1 so she could sit while feeding Resident #3. LPN #1 identified nurse aides should sit while feeding a resident to promote dignity.Interview with the Director of Nursing (DNS) on 4/22/26 at 9:22 AM identified that nurse aides must sit while feeding residents, maintain eye contact, and engage in conversation to promote a dignified dining experience. The DNS stated that NA #1 should not have stood while feeding Resident #3.Review of facility Feeding Policy (undated) identified the purpose was to provide adequate nutrition to residents unable to feed themselves. The procedure is to wash hands, explain procedure to the resident, and assist resident to a comfortable position. While feeding the resident make sure assistance is provided in a dignified and respectful manner during feeding. Staff are to talk to the resident, alternate bites of food with types of food on the plate, feed the resident slowly, and do not stand while feeding a resident.

Based on review of the clinical record, facility documentation, facility policy, observation, and interviews for 1 of 3 residents (Resident #59) reviewed for pressure ulcers, the facility failed to ensure a physician's order was obtained to included appropriate parameters for as needed wound treatment which resulted in the resident receiving inconsistent wound treatment. The findings include: Resident #59 was admitted with diagnoses of dementia and diabetes mellitus.The admission MDS assessment dated [DATE] identified Resident #59 as severely cognitively impaired and required substantial/maximal assistance for toileting, and supervision/touching assistance for bathing.A physician's order dated 4/17/2026 directed to cleanse the sacral wound with vashe, apply Medi honey gel, and to cover with a dry dressing daily.A review of the Treatment Administration Record from 4/17/2026 through 4/23/2026 identified the sacral dressing had been changed as per order on the 7:00 AM to 3 :00 PM (day) shift.On 4/24/2026 at 1:23 PM, an observation of the sacral dressing change by LPN#3 identified there was no old dressing over Resident #59's sacral wound. Resident #59 was in bed and dressed in white underwear, grey pants, and a grey shirt. LPN#3 looked for the old dressing in the resident's clothes and bed but could not locate the dressing. After the new sacral dressing was applied, a record review was conducted with LPN#3. A review of the physician's orders failed to identify a when needed ( PRN) order for dressing changes. LPN#3 indicated that if a dressing fell off, he would notify the nursing supervisor to obtain a PRN order. LPN#3 indicated he was not aware of Resident #59 not having a sacral dressing on and or that the dressing had fallen off.On 4/24/2026 at 1:30 PM, an interview with NA#9 identified she helped Resident #59 wash and dress before breakfast around 8:00 AM or 8:30 AM and did not see a dressing on the resident.On 4/24/2026 at 1:46 PM, an interview with the wound care provider Medical Doctor (MD#1) identified the purpose of the Medi honey for Resident #59 was to provide autolytic debridement, provide moisture, and provide a level of antibacterial protection. MD#1 further indicated the foam dressing over the wound would provide a level of moisture, support, and protection from bacteria. MD#1 indicated that by not having the dressing in place, the wound would be at higher risk for infection and delayed healing.A review of facility policy for Wound and Skin Care indicated that the interdisciplinary plan of care would address goals and interventions directed towards treatment of pressure ulcers consistent with resident goals.

Based on clinical record review, observation, facility policy and interviews for 1 of 4 Residents (Resident #52) reviewed for nutrition, the facility failed to ensure a resident with a therapeutic diet was provided with food items to meet the needs of the resident. The findings include: Resident #52's diagnoses included ulcerative colitis and diverticulitis.The physician's order dated 10/16/2025 directed a regular diet with regular texture, thin consistency, low fiber, and double portions/double protein with all meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had intact cognition and was not on a therapeutic diet (despite the physician's order for a low fiber diet).The Resident Care Plan dated 4/28/2026 identified Resident #52 was at risk for malnutrition related to multiple chronic diseases and exacerbation of ulcerative colitis. Interventions included providing supplements as ordered, offering preferred foods, and serving the prescribed low fiber diet with double portions.Observation on 4/21/2026 at 12:16 PM identified Resident #52's lunch tray with a meal ticket that noted a protein shake, and assorted sandwiches were provided, however the protein shake and assorted sandwich were not present on the lunch tray.Interview with the Dietary Manager on 4/22/2026 at 10:30 AM identified staff prepare meal trays based on the meal ticket. The Dietary Manager indicated uncertainty regarding which foods are appropriate for a low fiber diet and stated that staff rely on the menu rather than specific dietary guidance. The Dietary Manager indicated consultation with the dietician would be necessary to determine whether certain foods, such as broccoli, are appropriate for a low fiber diet.Interview with Dietitian #1 on 4/24/2026 at 10:41 AM identified a low fiber diet as a therapeutic diet and described the diet as one that excludes foods containing seeds or skins. Dietitian #1 indicated broccoli could be served because it does not contain seeds, but did not clarify whether preparation modifications, such as removal of the stalk skin, were required. Dietitian #1 identified the electronic diet order system does not include a selectable option for a low fiber diet and must be entered in the comment section.Review of facility Diet Manual dated 2022 identified broccoli is not allowed on a low fiber diet.

Based on clinical record reviews, review of the facility Infection Control Program, review of facility documentation and interviews for 3 out 3 sampled residents (Residents # 22, #49 and # 63) reviewed for immunization, the facility failed to ensure the screening process for vaccination eligibility consistently documented dates in the facility vaccination consent forms. The facility did not provide evidence of residents or responsible parties receipt of copies of educational materials to assist with deciding to vaccinate or decline the Influenza (Flu) and pneumovax vaccination. The findings included: 1.Resident #22 diagnosis includes diabetes mellitus. Resident #22's Universal Vaccine Consent and Administration Record dated 10/23/2024 identified a verbal consent from the Conservator of Person (COP) obtained for Resident #22 for the Flu. However, the form above the documented verbal consent where screening for eligibility to receive the vaccine remained blank. Page 2 of the consent was missing another consent form without a date to indicated verbal consent for the Flu Vaccine. The Flu consent form obtained from the attorney had no staff signature and screening for eligibility to receive a vaccine was left blank also on page 2 (which indicated acknowledging the receipt of a copy and educational understanding) of the vaccine was not signed by the attorney. 2. Resident #49's diagnosis includes pyelonephritis (kidney infection). Resident #49's Universal Vaccine Consent and Administration Record dated 10/9/2024 indicated verbal consent was obtained from the patient to receive Flu vaccines. The screening area for eligibility to receive the vaccines was not incomplete. On page 2 there was no evidence of receipt of educational materials prior to receiving the vaccines to assist in deciding and the indication of Resident #49's understanding of the forms.Another Universal Vaccine consent form not dated with resident's name was in print in the signature section of the first page of the form indicating Flu vaccine (written in the guardian or representative section) with the same printed name located in the signature section of page 2 without a date. 3. Resident #63's diagnosis includes Parkinson's Disease. The Universal Vaccine Consent and Administration Record for Resident # 63 was not dated but did indicate verbal consent was obtained from a family member. However, the form did not indicate the staff member who obtained the verbal consent. The screening area for eligibility to receive the vaccines was incomplete on page 2. The form also did not indicate receipt of educational materials prior to receiving the vaccines to assist in decision making and Resident #49's understanding of the forms. An interview with the Assistant Director of Nursing Services (ADNS)/Infection Preventionist on 4/23/2026 at 10:15 AM indicated s/he screens every resident before providing the Flu vaccine but does not document the screening. The ADNS further indicated she/he obtains verbal consent for the Flu vaccines and education over the phone from the resident's responsible party education which is acknowledgement of understanding by them responding yes or no. The ADNS/IP further indicated that there was a check-off in the electronic vaccination system for each resident, the nurse can check yes or no if education was provided and they all are checked yes. The ADNS/IP could not provide any information of any type of educational resources that's/he provided over the phone such as reading materials or faxed documents to responsible parties or residents. On 4/27/2026 at 10:40AM an interview and facility document review with ADNS/IP identified he utilized an education form from the Centers for Disease Control and Prevention (CDD) that was provided by the previous IP. The ADNS further indicated she/he would be using the CDC educational sheets in the future to educate residents and responsible parties. The facility policies and procedures labeled Influenza Vaccine and Pneumococcal Vaccine given on site notes both the Flu or Pneumococcal vaccines will only be given with a physician order and a signed consent form. The resident or responsible party will be provided a copy of the Influenza Vaccine Fact Sheet and the Pneumococcal Fact Sheet, education on the vaccines risks and benefits prior to administration and the resident and or responsible party will have the opportunity to ask questions of the Director of Nursing Services (DNS)or his/her designee.

Based on a review of clinical records, facility documentation, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that staff provided the resident with the required assistance with bed mobility and as a result, Resident #1 fell out of bed and sustained a left femur (thigh bone) fracture. The finding includes: Resident #1 had diagnoses of Parkinson's, dementia, abnormalities of gait and mobility and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1's Brief Mental Interview (BIMS) score of six (6) indicative of severely impaired cognition, was always incontinent of bowel and bladder, and was dependent with bed mobility and Activities of Daily Living (ADLs). A physician's order dated 8/29/24 directed to provide extensive assistance of 2 with bed mobility and 1/4 bed rails as an enabler, to assist with turning and repositioning. The care plan dated 9/10/24 identified Resident #1 at risk for ADL self-care performance deficit with interventions that directed to provide total care for ADLs and required an extensive assistance of 2 with bed mobility with a 1/4 bed rail. Review of the facility's accident and incident report dated 9/23/24 identified at 7:30 P.M. Registered Nurse (RN) #2 was called to Resident #1's room by Nurse Aide (NA) #1 and upon arrival to Resident #1's room she observed Resident #1 laying on his/her left side on the floor in a fetal position (a position when the body is curled up into a ball). RN #2 assessed Resident #1 and no injuries were identified. A nurse's note dated 9/23/24 at 8:00 P.M. written by RN #2 identified she was notified that Resident #1 had a fall, and upon arrival to the room she found Resident #1 on the floor. A NA was providing incontinent care and when she turned Resident #1, the resident rolled out of bed. The nurse's note dated 9/24/24 at 6:30 A.M. written by RN #1 identified NA #2 was providing care to Resident #1 and observed swelling and a deformity to Resident #1's left leg. RN #1 noted that APRN #1 directed to send Resident #1 to the hospital for further evaluation and treatment. Review of APRN (Advanced Practice Registered Nurse) #1's note dated 9/24/24 at 3:01 P.M. identified Resident #1 had a fall on 9/23/24 on the 3:00 P.M. - 11:00 P.M. shift and had subsequent left thigh swelling and a deformity noted. APRN #1 identified when Resident #1's left thigh area was palpated Resident #1 exhibited grimacing. Review of Resident #1's Hospital Discharge Summary dated 9/30/24 identified Resident #1 was admitted to the hospital on 9/24/24. Resident #1 sustained a fracture of unspecified neck of left femur and a displaced (bones no longer aligned) spiral fracture (a fracture that wraps around the bone with a corkscrew appearance) fracture of shaft of left femur requiring intramedullary nailing (surgical nails to provide the bone with stability). An interview with NA #1 on 10/18/24 at 3:30 P.M. identified on 9/23/24 she found Resident #1 in bed incontinent of bowel and prepared to provide incontinent care. NA #1 identified that both 1/4 side rails were up, and although Resident #1 required the assistance of two (2) for bed mobility, NA #1 did not ask anyone to help her because the other NA's on duty were very busy and she thought she could do it by herself. NA #1 identified when she turned Resident #1 on to his/her right-side, Resident #1's foot slid off the mattress and fell out of bed onto the floor. An interview with the Director of Nursing Services (DNS) on 10/18/24 at 10:45 A.M. identified on 9/23/24 at approximately 7:30 P.M. while NA #1 was providing incontinent care to Resident #1, the resident rolled out of bed and fell to the floor. The DNS identified that Resident #1's physician's orders directed to provide extensive assistance of two (2) with bed mobility with the use of the bed rail. The DNS identified NA #1 did not follow Resident #1's physician's orders and NA #1 should not have provided care to Resident #1 alone. The DNS indicated Resident #1's physician orders were in place to prevent Resident #1 from falling out of bed. Review of the facility's Fall Prevention and Management policy; in part, identified residents will be assessed for risk of falling and an individualized care plan will be developed and updated as needed to identify interventions to prevent falls.

Based on observations, review of facility policy and interviews, the facility failed to ensure residents were provided access to posting of contact information for the Office of the State Long-Term Ombudsman Program. The findings include. On 7/8/2024 at 12:57 PM a meeting with 8 residents (Residents, #3, #22, #23, #42, #53, #83, #94 and #105) identified they were unaware of who the State Ombudsman was and where to locate the contact information. An interview with Social Worker (SW) #1 on 7/9/2024 at 10:00 AM indicated the contact information for the State Ombudsman was posted on the bulletin boards located on each elevator. During an observation and interview with Social Worker #1 on 7/9/2024 at 10:15 AM noted the State Ombudsman information posted high on the back wall of the elevator but not posted at the level a person in a wheelchair could view and the information located behind residents as they ride the elevator standing or sitting facing the front of the elevator. Further observations identified the Ombudsman information was not posted on the bulletin board outside the elevator doors or on the units. After inquiry, SW#1 indicated the location of the State Ombudsman information would be adjusted and made accessible to residents. The facility policy labeled Resident Right- Required Postings, indicated in part the facility must post in a form and manner accessible and understandable to residents and resident representatives a list of names, addresses and telephone numbers of all pertinent State agencies and advocacy groups such as the Office of the State Long-Term Care Ombudsman program,

Based on review of the clinical record, observations, and interview for 1 of 2 residents reviewed for pressure ulcers (Resident # 98), the facility failed to ensure staff consistently provided evidence of turning and repositioning the resident prior to the development of a pressure ulcer and the facility failed to ensure physician's orders were obtained for recommendations made by a consulting wound physician contributing to the pressure ulcer's further decline. The findings included. Resident #98's diagnoses included Stage 3 pressure ulcer of the left heel, paraplegia, and diabetes mellitus. A physician's order dated 1/16/2024 directed to provide a pressure redistribution mattress every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 was cognitively intact, at risk for pressure ulcers, had no unhealed pressure ulcers and required extensive assistance of two persons for bed mobility. A physician's order dated 3/6/2024 directed to assist Resident #98 out of bed to an Adaptive Wheelchair (AWC) per the 24-hour positioning plan every shift. The Resident Care Plan (RCP) dated 3/14/2024 indicated Resident #98 was at risk for pressure ulcer development related to functional mobility/paraplegia, incontinence, and diabetes mellitus. Interventions included: to provide treatments as ordered, avoid positioning on the affected region, to monitor the dressing's integrity, monitor nutrition, laboratory work, teach resident/family importance of positional changes, and to provide supplements as ordered to promote wound healing. The RCP dated 3/14/2024 indicated Resident #98 demonstrated poor body alignment requiring the use of a manual adaptive tilt in space wheelchair with headrest, foam cushion, and elevating footrests. The interventions included: to follow the 24-hour positioning plan as outlined by the rehabilitation department, to observe for poor toleration while out of bed in the adaptive wheelchair and to notify the therapy department with any issues. The RCP further indicated Resident #98 had a self-care deficit related to activity intolerance due to back pain, spinal abnormality, and limited mobility. The intervention included in part to assist Resident #98 to apply a Knee Ankle Foot Orthotic (KAFO) on the left lower leg with assistance of 2 persons during morning care and to be removed during evening care, apply a Tubi-grip and or Geri-sleeve to the left lower leg daily prior to the application of the leg brace (KAFO) and when lying in bed, and to place a roll between the knees and to check skin integrity every 4 hours. Additionally, directed Resident #98 required the assistance of 2 persons to turn and reposition in bed and a mechanical lift transfer with 2 persons assist between surfaces. a.A progress note dated 3/26/2024 indicated on examination a new Deep Tissue Injury (DTI) pressure ulcer was observed on Resident #98's left heel. The progress notes further indicated to float the heel, provide skin prep, and indicated the wound team was notified of the new pressure ulcer with resulting physician's orders dated 3/26/2024. A nursing skin/wound care note dated 3/26/2024 at 5:38 PM indicated an Advance Practice Registered Nurse (APRN) visit occurred and in addition to a new order for skin prep every shift to the left heel to the (newly noted DTI left heel) Resident #98 was to wear offloading boots to prevent further injury as left heel was prone to skin breakdown due to uncontrollable leg spasms. A wound physician progress note dated 4/4/2024 indicated a new stage 2 pressure ulcer (Deep Tissue injury progressed to a stage 2 pressure ulcer) with treatment recommendations to apply betadine to base of the wound secure with an ABD pad and rolled gauze to be changed daily with a physician's order obtained on 4/5/2024. A wound care specialist's handwritten progress note dated 4/9/2024 (no time) recommended offloading boots and further indicated the leg brace (AKFO) could be used with occupational and physical therapy evaluation of the brace support surfaces. A wound physician progress note dated 4/23/2024 at 8:14 PM indicated the wound bed of the left heel stage 2 pressure ulcer was found to have slough and a debriding agent, Santyl, was recommended, to apply Calcium Alginate to the base of the wound and to secure with an ABD pad and rolled gauze to be changed daily with a physician's order obtained on 4/24/2024. A wound physician progress note dated 4/30/2024 at 4:00 PM indicated completing a follow up visit finding the left heel pressure ulcer had progressed (worsened) to a stage 3 pressure ulcer with 100% granulation of the wound base. Treatment recommendation included cleansing with normal saline, applying Calcium Alginate to the wound base and secure with bordered foam and to change the dressing daily. Physician treatment orders were obtained. The Nurse Aide documentation sheet dated 4/1/2024 through 4/30/2024 had no documentation of the provision of turning and repositioning between 8:00AM and 4:00PM on 4/1/2024, from 12:00AM-6:00 AM on 4/14/2024, 12:00 AM-6:00AM on 4/20/2024, 4:00PM-10:00PM on 4/28/2024, 8:00AM-4:00PM on 4/29/2024 and 4:00PM-11:00PM on 4/30/2024. An interview on 7/18/2024 at 11:47 AM with MD#3 indicated that although turning and repositioning is a fundamental practice in an effort to prevent pressure ulcers and without it could contribute to pressure ulcer formation, he/she could not say with certainty if the dates and time periods of the missing turning and repositioning documentation directly contributed to the formation of the DTI pressure ulcer found on 4/30/2024. On 7/18/2024 at 1:05 PM an interview and record review with the DNS and the Administrator indicated he/she was unable to explain why there was missing documentation on the nurse aide flow sheet for 4/1,14, 20, 28, and 29/2024 prior to the discovery of the Deep Tissue Injury pressure ulcer on 4/30/2024 and missing documentation on the evening shift of 4/30/2024 for the provision of turning and repositioning. The DNS indicated he/she would have expected documentation to have been completed by the end of the shift, indicated the nursing supervisors were responsible for ensuring the nurse aides documentation of care provided for each resident was completed prior to the end of the shift. The DNS further indicated on 5/29/2024 a QAPI (Quality Assurance Performance Improvement) was initiated to start a process for the nursing supervisors to run a report an hour before the shift end to determine what nurse aides have yet to document then speaking to the staff to ensure completion of the task . The DNS also indicated she has found an improvement in consistent documentation of resident care. The facility policy dated as revised on 9/28/2023 labeled Skin Care Management Pressure Injury Treatment indicated in part the pressure injury treatment program should focus on assessing the resident and the status of the pressure ulcers, the current support surfaces, pressure ulcer care, managing bacterial colonization and infection, education, and quality improvement. The policy further indicated a deep tissue injury (DTI or DTPI) result from intense and/or prolonged pressure and shear forces at the bone-muscle level and may rapidly evolve to reveal the true extent of tissue damage. b.A physician's order dated 5/31/2024 directed the check bed air mattress every shift for functioning and to confirm the setting to be at the resident's current weight or comfort level. On 5/31/224 a care plan entry indicated Resident #98 had a stage 3 pressure ulcer of the left heel with no additional interventions. The quarterly MDS assessment dated [DATE] indicated Resident #98 had a stage 3 pressure ulcer. Resident #98's care plan was updated on 6/24/2024 to consult the dietitian for wound healing. An interview and record review with the DNS on 7/9/2024 at 12:35 PM indicated no physician's orders for offloading boots and no indication of the use of offloading boots could be found in the care plan. An interview and record review with the wound care nurse Registered Nurse (RN#1) on 7/9/2024 at 1:00 PM indicated there was no physician's order to use offloading boots as recommended by the wound physician on 4/9/2024 which must have been overlooked. RN #1 further indicated he/she had seen Resident #98 wearing off-loading booties at times but was unable to indicate how staff would know how and when to apply offloading boots and to evaluate the effectiveness if there was not a physician's order to use them. After surveyor inquiry a physician's order dated 7/10/2024 (90 days later) was obtained directing to check offloading boot placement every shift and the discontinuation of donning the KAFO on the left lower extremity in the am removing it in the evening. After surveyor inquiry physician orders dated 7/10/2024 were obtained directing to use bilateral lower leg foam cushion on bilateral leg rests of the wheelchair for proper leg positioning while out of bed in the adaptive wheelchair, and to discontinue use of the KAFO and tubi-grip/geri-sleeve to left lower extremity and to place the use of the KAFO on hold from 7/10/2024 through 7/17/2024. After surveyor inquiry on 7/10/2024 the care plan interventions were updated to include the use of a bilateral lower leg foam cushion(blue) on the leg rests of the w/c for proper positioning while out of bed in the AWC and to wear bilateral off-loading boots while seated in the wheelchair and while in bed. This intervention was also added to the nurse aide care card on 7/10/2024 (93 days after the recommendation for its use). The care plan was further updated on 7/10/2024 indicating Resident #98 refuses booties and offloading devices at times indicating not needing them and indicated the left KAFO to be on hold until the stage 3 pressure ulcer resolves. On 7/10/2024 at 10:40 AM an observation, interview and record review with Nursing Supervisor, RN #5, during observation of Resident #98 sitting in the AWC with lower legs crossed at the feet wearing socks, and legs in between the footrests and a blue foam cushion just below the knees across both footrests identified areas of pressure to both feet. The areas receiving pressure at the time were the right great toe, left upper ankle, top of the left foot and the right shin above ankle. Although RN #5 indicated there was an order for offloading booties and Resident #98 could be non-compliant RN #5 was unable to find a physician's order prior to 7/10/2024 for the use of offloading boots and was unable to find a care plan indicating Resident #98 was noncompliant with care, and was unable to explain or provide documentation as to how licensed nurses monitored for pressure of the feet and heels while out of bed in the AWC. RN #5 further indicated Resident # 98 had been mostly bed bound per his/her choice until around July 4, 2024. On 7/10/2024 at 11:10 AM an interview with Nurse Aide ( NA #6) with RN #5 present indicated he/she has worked in the facility for years and is familiar with his/her regularly assigned residents but had not worked on Resident #98's unit for some time, had received a verbal report of how to care for the residents on his/her assignment from the off going NA he/she was replacing. NA #6 further indicated he/she had provided AM care for Resident #98 along with the off going NA, and Resident #98 told them what care was to be done. NA#6 indicated no NA care cards were on paper, on his/ her person, in the resident rooms or at the nurse's station and s/he can remember what is needed for all the residents on the assignment but was unaware Resident #98 should have had pressure relieving booties on both feet. On 7/10/2024 an observation and interview at 11:15 AM with RN #5 found the electronic tablets in the work room behind the nurse's station the nurse aides use to document care provided at the end of the day but was unable to find information that described the care needed for each resident. RN #5 further indicated the process the nurse aides are to follow is to review the assignment on the tablet at the beginning of the shift and to document on them at the end of the shift and further indicated this did not occur with NA #6 and the process could use some improvement. On 7/10/24 at 11:30 AM interview and record review with the DNS and RN #5 indicated there were no orders for pressure relieving boots although Resident #98 had some available in his/her room, and both had seen Resident #98 wearing them at times no documentation to show the start date, consistent use or evaluation of the effectiveness of the use of the booties or a care plan indicating the need for offloading booties was found. RN #5 was able to find an area in the nurse aide tablet that would bring up items that have been added to the nursing care plan that electronically produce the nurse aide care card and was unable to find electronic communication within the care card of the need for use of offloading boots. An interview with the wound Medical Doctor (MD) #3 on 7/11/2024 at 11:25 AM indicated Resident #98's left heel pressure ulcer could have been prevented but once discovered were managed. MD #3 further indicated many factors could have contributed to the decline of a DTI as the DTI is making a big process occurring below the surface of the skin caused by unrelieved pressure and could not be sure if not using pressure relieving boots consistently as recommended could have by itself caused the decline as many factors play a part in pressure ulcer development. An interview with the Medical Director (MD #2) on 7/15/2024 at 12:34 PM indicated he/she would have expected the wound nurse to have provided the APRN of the facility with the wound physician's recommendations for Resident #98 for review and written orders. MD #2 further indicated not having a physician's order for the offloading boots and monitoring of its use could have contributed to the decline of the pressure ulcer along with multiple factors that could predispose the development of or decline in a pressure ulcer. The facility policy labeled Prevention of Pressure Injuries indicated in part a Risk assessment would be completed on admission, weekly and with any change of condition, use a standardized screening tool to determine risk factors for developing a pressure ulcer. The policy further indicated preventative skin care, use of a pressure relieving mattress may be recommended to aid in the prevention and or healing of a pressure ulcer.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 7 sampled residents (Resident #13 and Resident #97) reviewed for position and mobility, the facility failed to ensure further evaluation and timely treatment were implemented for resident(s) with newly identified limited mobility to maintain, improve or prevent further decline in range of motion and mobility over time and for 1 of 7 residents reviewed for contractures ( Resident # 86) the facility failed to ensure the application of braces and/or splints as per physician's orders.The findings included: 1.Resident #13 was admitted with diagnoses that included mild cognitive impairment, protein calorie malnutrition and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 as moderately cognitively impaired, had no functional limitations in the upper/ lower extremities, required partial to moderate assist in bed mobility, oral care, and total assist in all other Activities of Daily Living (ADL). The Resident Care Plan, (RCP) dated 12/12/21 identified Resident #13 had an ADL self-care deficit, impaired cognition and potential alteration in discomfort related to compromised functional mobility. Interventions directed to provide total assistance with ADL care, communicate needs and capabilities to the resident and family and evaluate for pain, alleviating symptoms, and impact on functional mobility. An Interdisciplinary Rehabilitation screen dated 1/19/22 identified Resident #13 had a left-hand deformity but refused range of motion for bilateral upper extremities and asked the therapist to leave. A review of the clinical record identified that there were no subsequent rehabilitation screens through 12/2/22 for Resident #13 that further identified the status of the left-hand deformity, the functional restriction to the left hand or any plan to address the limitation. The Physical Therapy evaluation and Plan of Treatment dated 12/3/22 identified Resident #13 as being referred for services for splinting of a right knee for contracture management. However, Resident #13 was not receptive to the device despite education and services being terminated with emphasis on bed positioning with pillows and bilateral foot booties. No other functional limitations to the upper extremities/hands were identified at the time of the evaluation. A Resident Round Screen dated 8/30/23 and 3/1/24 identified Resident #13 now had bilateral hand deformities with no subsequent evaluation or plan to address the functional limitation. An Interdisciplinary Rehabilitation screen dated 5/16/24 identified Resident #13 presented with deformities in both hands with the left hand presenting with severe distal interphalangeal or DIP (contracture at the tips of the fingers) and that the right hand would benefit from a splint. There was no documented evaluation following the screen to identify the extent of the functional limitation. An Advanced Practice Registered Nurse Progress note beginning 3/8/24 through 6/10/24 note bilateral hand contractures with no signs of discomfort. An observation on 7/02/24 at 11:12 AM identified bilateral hand contractions with no splint/brace noted. An interview with the Director of Rehabilitation on 7/08/24 at 11:40 AM identified rehabilitation screens were completed on admission and quarterly for every resident to determine any functional changes. Any change would be fully evaluated to determine the extent of limitation and treatment initiated to prevent further progression. The Director of Rehabilitation identified that although Resident #13 had deformities and contractures on both hands, a full evaluation was never conducted for Resident #13 to determine the extent of the limitation(s) and treatment was not initiated to prevent further progression and should have been. After surveyor inquiry, an Occupational Therapy Evaluation and Plan of Treatment dated 7/8/24 identified Resident #13 was being evaluated for left- and right-hand splints for contractures. Functional limitations were noted to the left and right upper extremity bilaterally. Right hand grip strength was less than 5lbs and left and strength was unable to be tested . Functional limitations were not present due to the contract. Recommendations included contracture management and possible splint for both hands. A second interview with the Director of Rehabilitation on 7/8/24 at 1:33 PM identified Resident #13 demonstrated increased tightness during the evaluation indicative of a progression of the contractures. An interview with the Director of Nursing Services (DNS) on 7/10/24 at 11:41 AM identified residents should be screened on admission by rehabilitation staff to determine if an evaluation was indicated. The DNS further identified she would expect the evaluation and treatment to have been initiated at the time an abnormality was identified. An interview with Advanced Practice Registered Nurse (APRN) #1 on 7/11/24 at 9:48 AM identified she began services with the facility beginning December 2023 and Resident #13 was known to her. APRN #1 identified Resident #13 had a functional limitation to one or both hands that was likely unavoidable. However, whether a contracture or deformity, APRN #1 would expect staff to complete screening at regular intervals and further evaluate and implementation of any measures to prevent the progression of the limitation. APRN #1 further identified that not implementing preventative measures at an earlier time could have led to further decline in Resident #13's contracture(s). An interview with the Medical Director on 7/11/24 at 1:26 PM identified she was employed by the facility beginning May 2024 and was not completely familiar with Resident #13 and any limitations. The Medical Director identified that she would expect that once an abnormality was identified, a treatment plan should be discussed interdisciplinary with rehabilitation providing any necessary services to prevent further decline. A review of the Clinical Services Policies and Procedures dated 1/2018 directed that a screening process is used to identify the need for a rehabilitation evaluation and determine a resident's ability to perform in either skilled or restorative nursing. 2. Resident #97 had diagnoses that included cerebral infarction (stroke) with hemiplegia (paralysis) and hemiparesis (weakness) unspecified and breakdown of skeletal muscle due to direct or indirect muscle injury. The MDS assessment dated [DATE] identified Resident #97 as severely cognitively impaired and dependent with all ADL skills. The RCP dated 5/19/23 identified Resident #97 had an ADL self-care deficit related to stroke and impaired cognitive function. Interventions directed to cue and reorient and supervise as needed. a. An Occupational Evaluation and Plan of Treatment dated 5/19/23 identified Resident #97 presented with impairments in balance, dexterity and fine/gross motor coordination, mobility, strength, and attention resulting in limitations/restrictions in self-care which required services to increase functional activity tolerance and maximize independence with ADL's. Impairments limited in the right and left upper extremity with inability to flex or extend at the elbow in the left extremity. The Occupational Treatment notes dated 5/22/23 through 6/28/23 identified Resident liked to keep the left upper in a flexed position and that passive range of motion (completed by therapist) was performed for those areas for improved range of motion. The Occupational Discharge Summary dated 7/3/23 identified Resident #13 allowed the therapist to range muscles of the bilateral upper extremities but fought against upper body dressing. Resident #97 was discharged to the care of nursing without any further recommendations to prevent further loss of limitation to the right upper extremity. The Interdisciplinary Rehabilitation Screens dated 1/29/24, 2/8/24 identified Resident #97 demonstrated increased tone throughout the body with no further evaluation/intervention. A Contracture Splint Rounds dated 5/16/24 identified Resident #97 as being referred for contractures of the left knee, left hip and left elbow. An Interdisciplinary Rehabilitation Screen dated 5/24/24 identified Range of motion was unable to be completed due to increased tone but also noted that range of motion was unable to be performed to the upper extremity (unidentified) due to increased tone with no further evaluation. An interview with the Director of Rehabilitation on 7/08/24 at 11:40 AM identified rehabilitation screens were completed on admission and quarterly for every resident to determine any functional changes. Any change would be fully evaluated to determine the extent of limitation and treatment initiated to prevent further progression. After surveyor inquiry, an Occupational Therapy Evaluation and Plan of Treatment dated 7/9/24 identified Resident #97 presented with contractures of the left upper and left extremity and was trialing splints for the left upper extremity and hand. A second interview and clinical record review with the Director of Rehabilitation on 7/10/24 at 3:27 PM identified Resident #97 should have been discharged from rehabilitation services with a range of motion program to prevent the development of contractures. The Director of Rehabilitation further indicated, once the increased tone was identified, a full evaluation should have been completed to determine the extent with interventions to prevent further progression at the time identified. Resident #97 was referred for splinting on 5/16/24. b. A Physical Therapy Evaluation and Plan of Treatment dated 5/19/23 identified Resident #97 presented with new onset or reduced dynamic balance and decrease in functional mobility. The right and left lower extremities presented within functional limits for strength and range of motion with recommended services to increase activity tolerance and left extremity range of motion/ strength. The Physical Therapy Treatment notes dated 5/22/23 through 6/23/23 identified Resident #97 tended to maintain the left lower extremity and hip in a flexed/abducted position. Therapy included passive range of motion to the left lower extremity and tapping/stroking to the left hip to facilitate muscle relaxation and promote left hip range of motion. The Physical Therapy Discharge Summary dated 6/23/23 identified skilled services included range of motion exercises to maintain joint mobility and prevent contracture. Resident #97 was discharged to the unit with nursing assistance, pressure relieving booties and repositioning every two hours to prevent pressure ulcers with current level of function prognosis identified as good with consistent staff follow through. The summary did not include any further recommendations to maintain or prevent further contractures. An APRN progress note dated 9/14/23 identified a request was made to see Resident #97 to approve a request for a knee splint/brace. Resident #97 was noted to have a left knee contracture and abnormalities of gait and mobility and needed a splint as medically necessary to aid in providing patient with potential to complete ADL's. The case was discussed with nursing and rehabilitation. A review of the clinical record did not include a documented physician's order for the splint/brace or its implementation. Subsequent Interdisciplinary Rehabilitation Screens dated 1/29/24, 2/8/24 identified Resident #97 demonstrated increased tone throughout the body with no further evaluation/intervention. An Interdisciplinary Rehabilitation Screen dated 5/24/24 identified Range of motion was unable to be completed due to increased tone extremity (unidentified) due to increased tone in the lower with no further evaluation. An interview and clinical record review with the Director of Rehabilitation on 7/11/24 at 12:02 PM identified she had never received the referral for a brace/splint for Resident #97 and was unaware s/he had contractures prior to completion of a recent evaluation dated 7/8/24. An interview and facility documentation review with the Director of Nursing Services, DNS on 7/11/24 at 9:27 AM identified any concerns related to changes in a resident's function was discussed at a weekly risk meeting that included the medical provider. The DNS identified that Resident #97 was not documented as having been discussed at any risk meeting dated 6/30/23 through present. The DNS further identified she was unaware that a brace/splint had been recommended and would have expected a physician order to have been transcribed to facilitate the implementation of the brace. An interview with APRN #1 on 7/11/24 at 9:29 AM identified she began services with the facility beginning December 2023 and that Resident #97 was known to her. APRN #1 identified Resident #97's contractures were unavoidable second to h/her stroke. However, APRN #1 would expect staff to complete screening at regular intervals and further evaluate and implement any measures to prevent the progression of the limitation. APRN #1 further identified that not implementing preventative measures at an earlier time could have led to further decline in Resident #97 contracture(s). An interview with APRN #2 on 7/11/24 at 1:45 AM identified she stopped providing services for the facility effective December 2023. APRN #2 identified she would have provided a prescription directly to rehabilitation services when ordering a splint and they would initiate the process of acquisition with an outside vendor for fitting. APRN #2 believed she had written the prescription for the brace but understood it took a while to obtain so did not recall ever actually seeing the brace. An interview with the Medical Director on PM 7/11/24 at 1:26 PM identified she started working at the facility on May 202024 and was not completely familiar with Resident #97 and any limitations. The Medical Director identified that although contractures in a resident with a history of stroke was unavoidable, she would expect that once an abnormality was identified, a treatment plan should be discussed interdisciplinary with rehabilitation providing any necessary services to prevent further decline. A review of the Clinical Services Policies and Procedures dated 1/2018 directed that a screening process is used to identify the need for a rehabilitation evaluation and determine a resident's ability to perform in either skilled or restorative nursing. Although requested, a policy for implementing rehabilitations services for a splint/brace was requested. None was provided. 3. Resident #86's diagnoses included Hemiplegia and Hemiparesis, Cerebral Infarction, and Metabolic Encephalopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #86 as severely cognitively impaired and required maximum assistance for personal hygiene, and was dependent for toileting, and showering. The Resident Care Plan dated 7/8/24 identified the resident had limited physical mobility and a left knee contracture. Interventions included application of a left elbow splint after AM care and remove before PM care, application of a left knee splint after AM care and remove before PM care, and application of left palm roll splint after AM care and remove before PM care. A physician's order dated 7/10/24, subsequent to surveyor inquiry, directed to wear left elbow splint after AM care and remove before PM care, wear left knee splint after AM care and remove before PM care, to wear left palm roll splint after AM care and remove before PM care, and to wear left knee splint after AM care and remove before PM care. A Social Services note dated 7/2/24 at 6:49 PM identified in an IDT meeting that resident received a left knee brace, left elbow, and hand brace per rehab. The Treatment Administration Record (TAR) for the month of June 2024 indicated that the left elbow splint was applied after AM care and removed prior to PM care. The Treatment Administration Record (TAR) for 7/1/24 - 7/10/24 did not indicate that the left elbow splint, left knee splint and left palm roll splint were applied. Further the TAR identified that the orders for the left knee splint, left palm roll splint, and the left elbow splint were pending confirmation subsequent to surveyor inquiry. Splint application instructions for the elbow splint, hand splint, were taped to the Residents closet door with the aide care plan. An Occupational Therapy Evaluation and Plan of Care dated 5/22/24-7/16/24 identified that Resident #86 had functional limitations due to contractures, further identified that Resident #86 had a resting hand splint, an elbow extension splint, and a knee extension splint. An Occupational Therapy discharge summary dated 6/18/24 at 4:11 PM written by OT#1 identified that Resident #86 was being discharged from therapy and staff were trained for donning and duffing left-hand splint, left elbow splint, and left knee splint. Further the documentation identified that a splint/brace program was established and prognosis was good with consistent follow through. Observations on 7/10/24 at 12:00 PM, identified Resident #86 sitting in a custom wheelchair without any splints on her elbow, knee, or hand. Interview with LPN # 1 on 7/10/24 at 12:10 PM identified that he was unaware that Resident #86 was supposed to be wearing splints, further he stated that it was not indicated on the TAR to apply any splints. Interview with OT #1 on 7/10/24 at 12:45 PM identified that Resident #86 was to have a left elbow splint, left wrist splint, and left knee splint to be applied after am care and removed at bedtime. Further she stated that she was applying them until resident was discharged from therapy, then she educated the NAs and included diagrams and instructions. Written instructions with diagrams were found on the closet door. Interview and observation with RN #2 on 7/10/24 at 1:00 PM identified that the splints were not on the resident, and they were in the closet drawer. Further she identified that she did not know what the order was for the application of the splints, she would have to confirm with the MD. Interview with NA#1 on 7/10/24 at 1:43 PM identified that application of the splints is not part of the care she provides. Someone else comes in sometimes and puts them on but not her, further she stated that the nurse tells her in the morning what to do for each resident and was not told to apply the splints. Review of the splinting policy dated 1/18 directed, in part, the treating therapist is to provide instruction to the nursing staff regarding the wearing schedule, application and removal of the splint, precautions, and when to contact the therapist. 48792

Based on observation of Resident Information, review of policy and interviews, the facility failed to inform residents of how to complete a grievance and ensure forms were accessible and available to residents and visitors. The findings include. On 7/8/2024 at 12:57 PM a meeting with 8 residents identified they were unaware of how to complete a grievance or where the forms were located. An interview with Social Worker #1 on 7/9/2024 at 10:00AM indicated the grievance forms were located in the nursing office behind the nursing station on both floors. During an observation and interview with Social Worker #1 on 7/9/2024 at 10:15 AM identified the grievance policy was noted to be posted on a bulletin board to the right when exiting the elevator on the 3rd floor prior to needing to use a code to enter the 3rd units. Further observations and interview with SW#1 identified s/he was unable to locate the grievance forms on the paper wall file in the nursing office behind the nurse's station. SW #1 could not provide any other location for forms but indicated the forms had been provided to the nursing unit in the past and could not explain why the grievance forms were not available. A review of the grievance policy indicated the forms should be easily accessible if the person using wants to remain anonymous. SW #1 indicated the forms are not easily accessible and further indicated the location would be changed to meet the needs of the residents and residents will be informed of the change. Although a copy of the facility grievance policy was requested one was not received.

Based on clinical record reviews, facility policy and interviews for 2 of 7 sampled residents for (Resident #13) who were reviewed for range of motion, the facility failed to ensure the comprehensive care plan was revised for a resident with identified with physical limitations of the hands and for (Resident # 98), the facility failed to develop a care plan to address the residents skin integrity to prevent further skin break down and for 1 of 2 residents reviewed for accidents for (Resident # 54), the facility failed to revise the resident's care plan timely post fall. The findings included: 1. Resident #13 was admitted with diagnoses that included mild cognitive impairment, protein calorie malnutrition and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired, had no functional limitations in the upper/ lower extremities, required partial to moderate assist in bed mobility and oral care and total assist in all other activities of daily living (ADL). The Resident Care Plan, RCP dated 12/12/21 identified Resident #13 had an ADL self-care deficit, impaired cognition and potential alteration in discomfort related to compromised functional mobility. Interventions directed to provide total assist with ADL care, communicate needs and capabilities to resident and family and evaluate for pain, alleviating symptoms, and impact on functional mobility. An Interdisciplinary Rehabilitation screen dated 1/19/22 identified Resident 13 had a left-hand deformity but refused range of motion for bilateral upper extremities and asked the therapist to leave. The Physical Therapy evaluation and Plan of Treatment dated 12/3/22 identified Resident #13 was being referred for services for splinting of a right knee for contracture management. However, Resident #13 was not receptive to the device despite education and services were terminated with emphasis on bed positioning with pillows and bilateral foot booties. No other functional limitations were identified at the time of the evaluation. A Resident Round Screen dated 8/30/23 and 3/1/24 identified Resident #13 now had bilateral hand deformities with no subsequent evaluation or plan to address the functional limitation. An advanced Practice Registered Nurse Progress note beginning 3/8/24 through 6/10/24 note bilateral hand contractures with no signs of discomfort. The Resident Care Plan did not include the deformity/contracture with any interventions for management to prevent progression. An interview with the Director of Nursing on 7/11/24 at 9:11 AM identified the development and revision of the care plan was an interdisciplinary effort and s/he would have expected the care plan to be revised once the physical limitation for Resident #13 was identified. 2. Resident #98's diagnoses included stage 3 pressure ulcer of the left heel, paraplegia and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 was cognitively intact, at risk for pressure ulcers, had no unhealed pressure ulcers and required extensive assistance of two persons for bed mobility. The care plan dated 3/14/2024 indicated Resident #98 was at an increased risk of pressure ulcer development related to functional mobility/paraplegia incontinence and diabetes mellitus. Interventions included: to provide treatments as ordered, avoid positioning on the affected region, monitor dressing to ensure intactness and integrity, monitor nutrition, laboratory work, teach resident/family importance of positional changes, provide supplements as ordered to promote wound healing. The care plan indicated Resident #98 demonstrated poor body alignment requiring the use of a manual adaptive tilt in space wheelchair with headrest, foam cushion, and elevating footrests. The interventions included to follow the 24-hour positioning plan as outlined by the rehabilitation department to observe for poor toleration while out of bed in the adaptive wheelchair and to notify the rehab department with any issues. The care plan further indicated Resident #98 had a self-care deficit related to activity intolerance due to back pain, spinal abnormality and limited mobility. The intervention included in part to assist Resident #98 to apply a knee, ankle, foot orthotic (KAFO) on the left lower leg with assistance of 2 persons during morning care and to be removed during evening care, apply a tubi-grip and or geri-sleeve to left lower leg daily prior to the application of the leg brace (KAFO) and when lying in bed, and to place a roll between the knees and check skin integrity every 4 hours. The interventions further indicated Resident #98 required the assistance of 2 persons to turn and reposition in bed and a mechanical lift transfer with 2 person assist between surfaces. A nurse practitioner provider progress note dated 3/26/2024 identified on examination a new Deep Tissue Injury (DTI) pressure ulcer on Resident #98's left heel. The progress not further indicated to float the heel, provide skin prep and notification of the wound team of the new pressure ulcer with a resulting physician's order dated 3/26/2024. A nursing skin/wound care note dated 3/26/2024 at 5:38 PM indicated an APRN visit occurred and in addition to a new order for skin prep every shift to the left heel (newly noted DTI left heel) Resident #98 was to wear offloading boots to prevent further injury as left heel is prone to skin breakdown due to leg spasms Resident #98 cannot control. A wound physician progress note dated 4/4/2024 indicated a new stage 2 pressure ulcer (Deep Tissue injury progressed to a stage 2 pressure ulcer) with treatment recommendations to apply betadine to base of the wound secure with an ABD pad and rolled gauze to be changed daily with a resulting physician's order obtained on 4/5/2024. A wound care specialist's handwritten progress note dated 4/9/2024 (no time) recommended offloading boots and further indicated the leg brace (AKFO) could be used with occupational and physical therapy evaluation of the brace support surfaces. A wound physician progress note dated 4/23/2024 at 8:14 PM indicated the wound bed of the left heel stage 2 pressure ulcer was found to have slough and a debriding agent, Santyl, was recommended and to apply calcium alginate to the base of the wound secure with an ABD pad and rolled gauze to be changed daily with a physician's order obtained on 4/24/2024. A wound physician progress note dated 4/30/2024 at 4:00 PM indicated completing a follow up visit with findings the pressure ulcer had now progressed to a stage 3 pressure ulcer with 100% granulation of the wound base. Treatment recommendation included to cleanse with normal saline, apply Calcium Alginate to the wound base and secure with bordered foam and to change the dressing daily. A physician's order dated 5/31/2024 directed the beds air mattress every shift for functioning and to confirm the setting to be at the resident's current weight or comfort level. On 5/31/224 an entry into the care plan was made to indicate Resident #98 had a stage 3 pressure ulcer of the left heel but no additional interventions were added at that time. The quarterly MDS dated [DATE] indicated Resident #98 had a stage 3 pressure ulcer. Resident #98's care plan was updated on 6/24/2024 to add consulting the dietitian for wound healing. An interview and record review with the DNS on 7/9/24 at 12:35 PM indicated no physician's orders for offloading boots and no indication of the use of offloading boots could be found in the care plan. An interview and record review with the wound care nurse RN#1 on 7/09/24 at 1:00 PM identified there was no physician's order to use offloading boots as recommended by the wound physician on 4/9/2024 and may have been overlooked. RN #1 further indicated he/she had seen Resident #98 wearing off-loading booties at times but was unable to indicated how staff would know how and when to apply offloading boots and to evaluate the effectiveness if there was not a physician order to use them. RN #1 further indicated the care plan did not reflect the recommendation for use of offloading boots and should have been revised by the MDS nurse who would have been updated in morning report of any changes. After surveyor inquiry a physician order dated 7/10/2024 was obtained directing to check offloading boot placement every shift and the discontinuation of donning the KAFO on the left lower extremity in the am removing it in the evening. After surveyor inquiry a physician's orders dated 7/10/2024 were obtained directing to use bilateral lower leg foam cushion on bilateral leg rests of the wheelchair for proper leg positioning while out of bed in the adaptive wheelchair, and to discontinue use of the KAFO and tubi-grip/geri-sleeve to left lower extremity and to put the use of the KAFO on hold from 7/10/2024 through 7/17/2024. After surveyor inquiry on 7/10/2024 the care plan interventions were updated to include the use of a bilateral lower leg foam cushion on the leg rests of the w/c for proper positioning while out of bed in the AWC and to wear bilateral off-loading boots while seated in the wheelchair and while in bed. This intervention was also added to the nurse aide care card on 7/10/2024 (93 days after the recommendation for its use). The care plan was further updated on 7/10/2024 indicating Resident #98 refuses booties and offloading devices at times indicating not needing them and indicated the left KAFO is on hold until the stage 3 pressure ulcer is resolved. A review of the facility policy for Care Planning directed a comprehensive care plan will be developed for each resident to guide care givers and assist residents to achieve or maintain their highest practical level of wellbeing. The care plan will be reviewed quarterly and as necessary to reflect changes in the resident status. 3.Resident #54's diagnoses included muscle weakness, acute respiratory failure with hypoxia and vascular dementia. A physician's order dated 3/24/24 directed to have bed on Lower Position and scoop mattress. The significant change MDS assessment dated [DATE] indicated Resident 54 had impaired cognition and requires partial assist with bed mobility and bed to chair transfers and maximal assistance with toilet transfer. The care plan dated 4/26/24 indicated Resident 54 is at risk for falls. Interventions include adjusting height of bed as needed to promote safe transfers out of bed, analyze previous falls to determine whether pattern/ trend can be addressed, anticipate residents needs and follow facility fall protocols. The focus section of the 4/26/24 care plan was revised on 6/24/24, however, it did not show where the interventions were updated. A nurse's note dated 6/24/24 at 7:20 PM identified Resident 54 was found on the floor inside her/his room. The charge nurse responded to yelling coming from the resident's room but Resident 54 was unable to provide account of the events. Interview with DNS 07/11/24 11:00 AM indicated that post fall, staff are expected to see what interventions are in place and add new interventions to prevent injuries. The DNS reports nurses and care plan coordinator are responsible for updating the care after falls. DNS requested for the Care Plan Coordinator to print the most recent/ revised care plan. Interview with DNS at 12:26 PM indicated that the care plan we reviewed together earlier, is the most updated version available. Facility's policy indicates Each time a resident experience a fall, an interdisciplinary fall assessment will be completed . The care plan will be revised with any interim interventions to minimize the risk of injuries. 46046 49100

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 sampled residents, (Resident #1) reviewed for accidents, the facility failed to implement adequate supervision for a resident known to wander and/ or exhibit exit seeking behaviors, who was on enhanced monitoring to prevent an elopement, failed to ensure all staff were trained on the door security system, which resulted in Immediate Jeopardy when Resident #1 was able to exit the facility through two alarmed door, missing for approximately 5 hours and traveled 2.9 miles from the facility. The finding includes: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 resided on a secure dementia unit located on the second floor of the facility. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition, was independent with supervision for walking, utilized a cane, and did not exhibit wandering behavior. The care plan dated April 2020 identified Resident #1 was at risk for elopement related to one or more attempts to leave the facility at this facility and other facilities, cognitive loss and dementia. Interventions included the use of a Wanderguard secured to the residents left ankle, check the function daily during the night shift, maintain a photo of the resident at the front desk reception area, and divert the resident by giving alternate objects or activities. An Elopement Evaluation dated 6/30/20 identified Resident #1 was able to walk, had a [DIAGNOSES REDACTED]. A physician order [REDACTED]. Review of the Q15 Minute Check (every)Monitoring Roster dated 7/4/20 identified Resident #1's whereabouts were checked every 15 minutes between 8:00 AM and 7:45 PM. Review of the electronic video surveillance of the secure dementia unit located on the second floor of the facility, dated 7/4/20 from 6:00 PM to 9:45 PM identified the following; Between 5:20PM-5:28PM, Resident #1 observed walking up and down the hall with the assist of a cane. At 5:28PM NA#1 observed going into Resident #1's room with a meal tray. At 5:40PM Resident #1 observed walking up the all towards the nurse's station. Between 5:42PM-5:49PM LPN #2 observed taking resident #1 vital signs and administering medications. At 5:51PM, Resident #1 was observed heading back to his/her room. At 5:58PM, Resident #1 walked up the hall towards the nurse's station. At 5:59PM Resident observed walking onto a separate unit momentarily, then turn around and head towards his/her room. No other residents were observed in the area. At 6:03 PM, Resident #1 was seen walking up and down the hall between the nurse's station and his/her room at the end of the hallway, which was adjacent to the fire door, which lead to a stairway At 6:04PM Resident #1 was again observed walking up the hallway and enter onto an alternate unit. No other residents were observed in the area. At 6:05 Resident #1 was observed leaving the alternate unit with LPN #2. At 6:07 PM, LPN #2 was observed gesturing (no audio) to Resident #1, and pointing down towards the resident's room, and Resident #1 walked into his/her room. At 6:08 PM, Resident #1 was observed at the fire door next to his/her room. NA #2 approached the door and Resident #1 went back to his/her room. At 6:09 PM, Resident #1 was observed in front of the fire door. The electronic video monitoring skipped from 6:09PM - 6:12 PM and Resident #1 was no longer viewed on the screen. At 6:13 PM, LPN #1 was observed walking down towards the fire door where the visual at the end was unknown. Resident #1 was not seen on video surveillance after 6:09 PM on 7/4/20. At 6:47 PM, NA#1 was observed going to the entryway of Resident #1's room, then headed back up the hall. At 7:26 PM, LPN #2 was observed going down to Resident #1's room with the medication cart, used the phone in the middle of the hallway, and then walk to the nurse station to use the phone at the front desk. At 7:38 PM, RN #2 is observed entering onto secure dementia unit located on the second floor of the facility but then exits. At 9:39 PM, multiple staff are observed walking in and out of rooms secure dementia unit located on the second floor of the facility. A nursing progress note dated 7/4/20 at 8:49 PM identified Resident #1 was not in his/her room during a room check, the supervisor was made aware and the facility policy for missing person was initiated, including a search of the entire building and premises. Additionally, the resident representative was made aware, and the local police were notified. A Reportable Event Form dated 7/5/20 at 12:46 PM identified Resident #1 had a history of [REDACTED]. On 7/4/20 at 8:00 PM, Resident #1 was last identified to be seen in the facility. All areas were searched, police, physician and family were notified. Resident #1 was found 2.9 miles away in a residential area and returned to the facility by police on 7/4/20 at 11:55 PM. Resident #1 had no injuries noted and the Wanderguard was in place and functioning upon the resident's return. Resident #1 denied pain and a skin assessment was completed upon return. Resident #1 was placed on 1:1 monitoring until a facility investigation was completed. A statement dated 7/5/20 written by LPN #2 identified s/he was the assigned nurse for the 3:00PM-11:00PM shift on 7/4/20. LPN #2 indicated s/he observed Resident #1 talking with other residents on a separate wing of the secured unit and obtained his/her vital signs at 8:00PM. Resident #1 asked how s/he could get back to his/her room and LPN #2 directed Resident #1 down the hall back to his room. LPN #2 indicated when s/he went to administer Resident #1 his medications at 9:00PM, s/he was discovered missing. LPN #2 checked Resident #1's usual spots on the unit and could not locate him/her. Observation on 7/7/20 10:20AM on the third floor identified Resident #1 on 1:1 supervision, on an observational unit located on the third floor, in bed sleeping, with no roommate. Interview with the Administrator on 7/7/20 at 10:50 AM identified she received a call on 7/4/20 at approximately 10:00 PM that Resident #1 was missing, and that staff completed a room/building/ premise search and were driving the streets to search for the missing resident. The Administrator indicated the facility protocol for a missing resident was activated and all parties had been notified. According to the Administrator, LPN #2 administered Resident #1 his/her medications and obtained vital signs at 8:00 PM that night. The assigned nurse's aide, NA #1, indicated she had last seen the resident around dinner time (dinner determined to be at 5:10PM by video surveillance). Resident #1 was found by police at 11:55 PM, fully clothed and brought back to the facility. An assessment was completed and there were no injuries. Resident #1 was placed on 1:1 supervision and on observation for Covid 19 due to unknown exposure during the elopement. The Administrator indicated the facility had surveillance cameras which identified at 6:07PM, Resident #1 was observed walking back and forth from his room to the nurse's station. LPN #1 was seen responding to a door alarm around dinner time at the end of the hallway on the 2nd floor. According to the Administrator, LPN #1 looked down the stairway and didn't see anyone, nor was the resident seen at the door by LPN #1, and she reset the alarm. The facility did not realize Resident #1 was missing until after 9:00 PM. The Administrator indicated the investigation was still in progress and that while Resident #1 had wandering behaviors, he/she had not demonstrated any exit seeking behaviors for a year. An interview with LPN #1 on 7/7/20 at 12:10 PM identified while she was not the assigned nurse for Resident #1, she did observe Resident #1 on secure dementia unit located on the second floor of the facility talking with another resident on the opposite side of the unit sometime before dinner, but did not see Resident #1 any other time. LPN #1 indicated Resident #1's room was at the end of the hallway, next to an alarmed fire door. LPN #1 indicated that the fire door alarm at the end of the hall on secure dementia unit located on the second floor of the facility was sounding sometime around dinner. LPN #1 responded to the sounding alarm by putting a code in the alarm pad next to the door to deactivate the alarm. LPN #1 looked down the stairs at the time the alarm was deactivated and did not see anyone however she did not walk through the area to further investigate. Observation 7/7/20 at 12:30 PM, of the door leading to a stairwell on the second floor where Resident #1 was believed to have exited identified when the alarm was intentionally activated to determine function and response times, once the fire door was deactivated, there was a brief 2 second delay where the door is left unlocked to allow passage. The fire door would also automatically unlock if pushed for 15 seconds. The door exiting to the outside of the building was intentionally alarmed, which sounded at the front entrance, and at the 2nd floor nurse station. While staff from the second floor physically responded to the alarm, staff from the reception area failed to respond to the alarm. An interview on 7/7/20 at 12:30 PM with Receptionist #1 identified that although she heard the alarm to the door exiting the building at the time of activation by surveyor, s/he did not respond as receptionist coverage was being turned over to other staff. Receptionist #1 instead, deactivated the alarm. An interview with the Maintenance Director on 7/7/20 at 12:30PM identified that it is the resposibility of all staff to respond to alarms. A second review of video surveillance dated 7/4/20 between 6:00 and 6:15PM on the secure dementia unit at 6:11 PM, LPN #1 was observed at an alarm panel located at the nurse's station with his/her hand on the panel but undetermined if s/he was activating buttons. A subsequent interview with LPN #1 on 7/7/20 at 1:21 PM identified while s/he was observed at the alarm panel at the nurses station appearing to be pushing buttons on the panel, she did not know how to reset the alarm at the nurse's station alarm panel, did not understand the meaning of the codes, and would not know how to reset any alarm from the nurse's station alarm panel. Video surveillance of the only alternate alarm panel able to be accessed was located at the reception area and was not being accessed by staff at that time. Interview with NA #1 on 7/7/20 at 2:00 PM, and 7/8/20 at 10:15 AM identified she was assigned to Resident #1 during the 3:00 PM - 11:00 PM shift and was responsible for the every 15 minute enhanced supervision monitoring. NA #1 indicated staff must physically verify that a resident is present when placed on every15 minute enhance monitoring. NA #1 indicated Resident #1 was observed periodically in the hallway up until what she believed to be approximately 7:45 PM and based the 15 Minute Check Monitoring Roster dated 7/4/20. NA #1 indicated although she was observed on video surveillance walking to the entryway of Resident #1's room at 6:47 PM, she indicated she was looking for the resident's roommate and did not actually look to see if Resident #1 was in the room. An interview with LPN #2 on 7/7/20 at 3:02 PM identified s/he was the assigned nurse for Resident #1 on 7/4/20 during the 3:00 PM -11:00 PM shift. LPN #2 indicted she obtained vital signs and administered medications at around 5:00 PM to Resident #1(in direct conflict with his/her statement which noted vital signs were obtained at 8:00PM). Video surveillance identified Resident #1's vital signs and medications were obtained between 5:42PM and 5:49PM. LPN #2 believed she had seen Resident #1 at 8:00 PM and redirected the resident back to his/her room for medications. This is in direct conflict with video surveillance that showed Resident #1 being redirected back to his room by LPN #2 between 6:04PM and 6:07PM when LPN #2 was observed gesturing to Resident #1, and pointing down towards the resident's room, LPN #2 indicated s/he did not administer medications to Resident #1 at 8:00 PM and had forgotten to indicate on the MAR indicated [REDACTED]. This is in direct conflict with LPN #2's written statement indicating s/he last saw resident #1 at 8:00PM and later to administer medications at 9:00PM. LPN #2 indicated she was not aware the resident was missing until sometime after 9:00 PM. But in an amended written statement dated 7/7/20 where LPN #2 indicated s/he went to give Resident #1 his medications, that s/he was not in his/her room, so s/he did not administer the medications. Video surveillance noted LPN #2 was observed in front of Resident #1's room with his/her medication cart at 7:26PM. Video surveillance also identified Resident #1 was not observed on any hallway on the unit after 6:09PM. The Administrator directed LPN #2 to amend his/her statement on his/her next scheduled day to the conflict in times of what was previously reported. Attempts to reach LPN #2 for additional information was unsuccessful. Interview with NA #2 on 7/7/20 at 3:21 PM and 5:39 PM identified she was working on secured unit located on the second floor on 7/4/20 during the 3:00 PM - 11:00 PM shift. NA #2 indicated while Resident #1 was not her assigned resident, she responded to a sounding alarm on that unit around dinner time. NA #2 indicated s/he observed Resident #1 standing in front of the fire door at the end of the unit attempting to enter codes into the keypad located adjacent to the fire door. NA #2 indicated she reset the code to deactivate the alarm and while doing so observed Resident #1 enter back into his/her room. NA #2 indicated the alarm activated a second time, and again, s/he observed Resident #1 at the door pushing on the keypad. NA #2 reset the alarm again but did not recall if Resident #1 went back into his/her room a second time. NA #2 indicated she did not report to anyone that Resident #1 was actively displaying exit seeking behaviors, believing resetting the keypad was enough and then left the area. Interview on 7/7/20 at 3:50 PM with Receptionist #2 identified she was assigned to work on 7/4/20 from 3:00 PM - 8:00 PM. Receptionist #2 recalled there was some activity with staff exiting through the right side door (cannot exit through front door in evening hours) and a resident was returning from [MEDICAL TREATMENT]. Receptionist #2 recalled an alarm sounded around or after dinner and that she called the nursing supervisor to reset the alarm. Receptionist #2 indicated she had not received any training on the alarm system and did not know what to do when the alarm sounded so she notified the supervisor. Interview with RN #2 on 7/7/20 at 4:08 PM and 7/9/20 at 10:00AM identified she received a call from the receptionist for a sounding alarm around dinner. RN #2 checked to see the location on the panel located on the second floor. The location indicated the door was open at the loading dock, which would be expected as it was around dinner, and the large doors to the loading dock would be open. After learning what happened, RN #2 thought it was strange in hindsight because the door Resident #1 was believed to have exited through was checked the following day with the Administrator and read DNS stairway door which described the location of the door Resident #1 was believed to have exited through to the outside of the building. RN #2 indicated LPN #2 went to give Resident #1 his/her 9:00 PM medications and discovered the resident was not there. RN #2 indicated she was not notified until 9:30 PM, at which point she activated the policy for a missing resident, and notified the Administrator and DNS. The alarm for the fire door on secured unit on the second floor was also checked and determined to be functioning, noting the fire door would open after being pushed for 15 seconds. RN #2 thought the Resident #1 may have gone down the back stairs and through the exit door at the bottom of the stairwell. Video surveillance dated 7/4/20 identified RN #2 pressing buttons on the alarm panel located at the nurse's station on the second-floor of the secured unit at 6:40 PM. A subsequent interview with the Director of Maintenance on 7/8/20 at 9:30AM identified while each alarm panel identifies the location of the sounding alarm, the alarm will default to the loading dock location once cleared if the door is open, which it often is as it is near the kitchen. Interview with the DNS on 7/9/20 at 9:20 AM identified Resident #1 constantly exhibited exit seeking behaviors. Additionally, the DNS indicated she had no idea the alarmed panel located on the secured unit on the second floor at the nurse's station and reception area could deactivate alarms to the outside of the building. The policy for an Elopement of a Patient dated 5/15/20 notes elopement occurs when a resident leaves the premises without authorization. For any unwitnessed elopement, staff are to search room to room and all areas of the center as well as the outside perimeter and grounds. If the patient is not found, law enforcement, nurse supervisor, Center Executive Director (Administrator) and Center Nurse Executive (DNS) is notified. All staff are to be trained on the center's door security system and required response to the sounding alarm. The policy further directs staff witnessing a confused patient or identified elopement risk patient attempting to leave the center, will intervene as appropriate to redirect the patient to a safe area and prevent elopement. The facility failed to implement adequate supervision for a resident known to wander or exhibit exit seeking behaviors to prevent an elopement, failed to visualize the resident during 15 minute checks and failed to ensure all staff were trained on the door security system including identified location, and required response to alarms.

Based on clinical record review, interviews and review of facility policy and procedure for one of three residents reviewed for pressure ulcers (Resident #82), the facility failed to implement interventions for the prevention of pressure ulcer development and/or initiate treatment orders with a change in skin condition. The findings include: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified the resident with very limited mobility - unable to make significant changes in position independently, needs extensive assistance, no skin impairments including foot problems, surgical wounds and/or burns, lower extremities normal color, warm to touch and no [MEDICAL CONDITION] present. The Admission history and physical examination [REDACTED]. The admission MDS assessment dated [DATE] identified the resident with cognitive impairment, no behaviors were exhibited, required extensive assistance with bed mobility, transfers, toilet use and personal hygiene, a risk for pressure ulcer development and currently no pressure ulcer, no other skin problems were identified, and utilized a pressure reducing device for the bed and chair. The RCP dated 5/2/19 identified a risk for skin breakdown related to frail fragile skin and limited mobility. Interventions included to assist the resident with turning and repositioning as per facility protocol, and to evaluate for any localized skin problems, i.e. dryness, redness, or pustules. The care plan failed to reflect interventions were implemented for the offloading of bilateral heels for the prevention of pressure ulcer development. The weekly skin check form dated 5/23/19 identified no skin injury/wounds identified. The associated integumentary care plan noted interventions to assist resident with turning and repositioning as per facility protocol. The weekly skin check form dated 5/30/19 identified a new skin injury/wound stage 2 to left heel and a non blanchable area to the right heel. Interventions included to off load/float heels while in bed. The Skin Integrity Report dated 5/30/19 identified a stage 3 pressure area on the left heel with 75% slough and 25% granulation tissue measuring 2.0 Centimeter (CM) x 1.0 CM x 0.2 CM, and a stage 2 pressure area on the right heel with 75% slough and 25% [MEDICATION NAME] tissue measuring 0.5 CM x 1.0 CM x 0.1 CM. The clinical record failed to reflect physician treatment orders were obtained when the resident was identified with bilateral heel stage 2 and stage 3 pressure ulcers on 5/30/19. The Skin Integrity Report dated 6/3/19 identified a stage 3 pressure ulcer on the left heel with 75% slough and 25 % granulation tissue measuring 2.3 CM x 1.2 CM x 0.2 CM, and a stage 2 pressure ulcer on the right heel with 75% slough, and 25% granulation tissue. The wound measured 1.0 CM by 1.2 CM with 0.1 CM depth. The clinical record failed to reflect physician treatment orders were obtained when the resident was identified with bilateral heel stage 2 and stage 3 pressure ulcers. physician's orders [REDACTED]. The clinical record failed to reflect physician orders [REDACTED]. The nurse's note dated 6/5/19 noted significant change in status related to new wounds and suspected weight loss. Additionally, the nurse's note identified bilateral heels between toes appear free from redness, maceration and breakdown. Bony prominences appear free from redness, maceration or breakdown and noted air mattress heel offloading devices review: Helix boots. Interview and review of the clinical record with the DNS 7/11/19 at 11:36 [NAME]M. identified Resident #82 utilized a pressure relieving bed and was assisted by staff with turning and repositioning which allowed the resident to have his/her heels offloaded. The DNS was unable to determine why a dependent resident who was turned and repositioned per facility policy developed a stage 2 and stage 3 pressure ulcer on his/her bilateral heels. Additionally, the DNS identified when a resident is noted with a change in skin condition the physician is notified and treatment orders are obtained and documented on the Treatment Administration Record (TAR), The clinical record failed to reflect physician treatment orders were obtained on 5/30/19 when the resident was identified with facility acquired stage 2 and stage 3 pressure ulcers on his/her bilateral heels. The clinical record failed to reflect interventions for offloading were implemented for a dependent resident at risk for pressure ulcer development prior to 5/30/19 and/or failed to reflect physician orders [REDACTED]. The facility skin care management program identified the facility will provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and to promote healing of all wounds. A complete comprehensive evaluation of the resident upon admission will be done, followed by a comprehensive interdisciplinary plan of care developed including prevention and wound treatments as indicated. Additionally, the skin care management program noted the staff will determine the need for support surfaces for the bed and chair and will determine the need for heel protectors and/or heel lift devices in accordance with manufacturer's guidelines.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents reviewed for falls (Resident #1 and Resident #2), the facility failed to ensure the bed wheels were locked for a resident at risk for falls, and/or failed to provide adequate supervision for a resident who had multiple falls and/or failed to provide interventions to prevent an accident. The findings include: Resident #1's [DIAGNOSES REDACTED]. Review of a nurse's note dated 8/31/17 identified that the resident was readmitted to the facility for long term care and had a fall risk score of 10. The care plan dated 9/1/17 noted that the resident was at risk for falls related to cognitive loss, lack of safety awareness, and [MEDICAL CONDITION]. Interventions included to place resident in front of nurses station when awake, utilize low bed, medication evaluation as needed, call bell in reach, when in bed place all necessary personal items in reach, and monitor for and assist with toileting needs. The admission MDS assessment dated [DATE] identified R #1 was severely cognitively impaired, and required extensive assist of one staff for transfers. a. Review of a facility incident report dated 9/13/17 at 6 AM identified R #1 was observed sitting on the floor next to the bed. Further review of the report identified the bed wheels were not locked. Interview, clinical record review, and facility documentation review with the DON on 12/27/18 at 3:55 PM identified R #1 fell from his/her bed onto the floor, and the bed wheels were not locked. The DON further stated the wheels on the bed should have been locked. Further interview with the DON identified there was no facility policy regarding locking bed wheels for surveyor review, however the expectation was that the wheels should be locked. b. Review of the facility incident report dated 10/20/17 at 12 PM identified R #1 was observed lying on the floor in front of the nurse's station with a 2 x 0.5 centimeter (cm) cut on the right eyebrow with bleeding noted. A nurse's note dated 10/20/17 at 12:16 PM identified R #1 was transferred to the hospital for evaluation. Review of the hospital record dated 10/20/17 identified that the resident had a head CT scan that noted a small subarachnoid hemorrhage along the posterior right temporal lobe; suspect associated mild hemorrhagic contusion. The hospital discharge summary dated 10/21/17 directed a follow up appointment with a neurosurgeon in one month. A nurse's note dated 10/21/17 at 12:15 PM identified R #1 was readmitted to the facility. Review of the APRN note dated 10/23/17 identified R #1 was status [REDACTED]. Interview, facility documentation review, and clinical record review with the DON on 12/27/18 at 3:55 PM identified R #1 was at the nurse's station when he/she fell on [DATE], and stated the staff were busy with lunch and not watching R #1 during the time R #1 fell . the DON further stated it was hard to watch R #1. The DON stated her expectation was that when R #1 was at the desk, per the plan of care, that staff would monitor him/her. 2. R #2's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #2 was unable to recall words, was unable to identify the correct day, month, or year, had no behavior symptoms, and required extensive assist of one staff for transfers. The Resident Care Plan (RCP) dated 6/14/18 identified the resident was a fall risk, and resistive during care, ambulation and transfers. Interventions directed to assess for changes in mental status and report to physician as indicated, ensure bed wheels are locked, place glasses in reach, call light in reach, and monitor conditions that may contribute to resistance (e.g. [MEDICAL CONDITION], delusions, and hallucinations. Review of the facility incident report dated 6/17/18 at 1:50 PM identified R #2 was observed lying on the floor next to his/her bed. R #2 was confused with no recollection of the fall, complained of right hip pain, stated a tall man pushed him/her, and was observed with limited right hip movement. The right leg was shorter than the left, and R #2 was transferred to the hospital. Review of NA #4's written signed statement dated 6/17/18 identified she was passing by R #2's room and observed R #2 lying on the floor. Review of NA #2's written signed statement identified from the morning R #2 was very agitated stating that there was a man in his/her room. Additional review of the facility incident report failed to identify what R #2 was wearing on his/her feet, if the bed was locked, if the call bell was in reach, and if R #2 had his/her eyeglasses. A nurse's note dated 6/17/18 at 7:35 PM identified R #2 was admitted to the hospital with [REDACTED]. Review of nurse's notes dated 6/17/18 failed to identify any resident behaviors were exhibited on that day. Review of the behavior tracking form dated 6/17/18 identified that R #2 did not exhibit any behaviors, and no interventions were noted on the form. Interview and review of facility documentation with NA #2 on 11/30/18 at 11:25 AM identified she was the NA assigned to R #2, and stated she had notified the nurse that s/he was more agitated on 6/17/18 (before the fall). Interview, facility documentation review, and clinical record review with the DON on 12/3/18 at 9:05 AM identified R #2 had been agitated during the day, refused to get out of bed, was yelling and screaming all morning and had fallen from his/her bed onto the floor. The DON was unable to provide documentation that the resident was evaluated and/or interventions were provided when R #2 exhibited behaviors of increased agitation, yelling, screaming and/or hallucinations as described by NA #2 on 6/17/18. In addition, the DON stated the fall investigation was not comprehensive to include identifying what R #2 was wearing on his/her feet, if the bed was locked, if the call bell was in reach, and if R #2 had his/her eyeglasses. Review of facility Falls Management Policy, directed in part, patients experiencing a fall will receive appropriate care and investigation of the cause.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents reviewed for dehydration (Resident #1), the facility failed to monitor the resident's fluid intake and urinary output when noted with decreased intake resulting in dehydration. The finding includes: R #1's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission MDS assessment dated [DATE] identified R #1 was severely cognitively impaired and required set up for meals. The Resident Care Plan (RCP) dated 9/15/17 identified a nutritional risk related to inadequate intake. Interventions directed to monitor intake at all meals and provide diet as ordered. Review of the Registered Dietician's (RD) assessment dated [DATE] identified that R #1 required 1,887 cubic centimeters (ccs) of fluid daily to maintain hydration, that the residents intake was inadequate, and staff to continue to encourage intake at meals. The quarterly MDS assessment dated [DATE] identified R #1 was severely cognitively impaired and required total assist with meals. The APRN note dated 12/18/17 identified dysphagia, continue aspiration precautions and dysphagia diet with a plan to obtain a complete blood count (CBC) on 12/19/18. Review of lab results dated 12/19/17 identified a sodium level of 148 mEq/L (normal 132-146), BUN of 23 mg/dL (normal 9-23) and creatinine of 0.7 mL/min (normal 0.5-1.3). Review of lab results dated 12/23/17 identified a BUN of 30, increased from 12/19/17, creatinine of 0.7, and sodium of 153, increased from 12/19/17. Review of the APRN's order dated 12/24/17 directed to administer [MEDICATION NAME] NaCl solution IV at 50 cc hour for two (2) days. Review of the RD note dated 12/24/17 identified R #1 was receiving IV fluids due to dehydration. The APRN note dated 12/26/17 identified R #1 was not eating or drinking well, increased BUN and sodium level, and plan IV fluids. On 12/26/17, the APRN ordered D5 ½ Normal Saline IV at 75 cc per hour for one (1) liter. Review of the APRN note dated 12/27/17 identified that somnolence was somewhat improved, not due to persistent pneumonia, question due to medications or hypovolemia. Hypovolemia improved, will check labs on 12/28/17, urine culture pending. Review of lab results dated 12/28/17 identified the resident's BUN was 19, creatinine was 0.6, and sodium level was 151 (normal 132 to 146). The APRN note dated 1/2/18 identified worsened dysphagia, pocketing of food and somnolence, with plan to downgrade R #1's diet to puree, decrease [MEDICATION NAME] dosage, and repeat a swallowing evaluation. Review of the APRN note dated 1/5/18 identified increased somnolence, decreased responsiveness, decreased intake, lips dry, breath sounds decreased, [MEDICAL CONDITION], plan to administer oxygen to keep oxygen saturation greater than 92%. Review of the APRN order dated 1/5/18 directed to obtain a CBC and basic metabolic panel (BMP) on 1/6/18. Review of lab results dated 1/6/18 identified the resident's BUN was 52 (normal 9-23), creatinine was 1.0, and sodium was 170, critical high result (normal 132-146). Review of the APRN order dated 1/6/18 directed D5 ½ Normal Saline at 75 cc per hour for two (2) liters, and BMP on 1/7/18. Review of lab results dated 1/7/18 identified BUN 54 (normal 9-23), creatinine was 0.9 and sodium was 170, critical high result (normal 132-146). Review of the APRN order dated 1/7/18 directed to transfer R #1 to the hospital. Review of the clinical record failed to identify that staff monitored the residents fluid intake and output (I & 0) during the period of 12/7/17, when the RD noted the resident's intake was inadequate through 1/7/18, when the resident was transferred to the emergency room and diagnosed with [REDACTED]. Review of hospital history and physical dated 1/7/18 identified R #1 presented with severe toxic metabolic [MEDICAL CONDITION] in the setting of severe dehydration. During an interview and clinical record review with the DON on 12/28/18 at 2:07 PM the DON was unable to provide documentation that R #1's fluid intake was monitored, and/or that R #1 met his fluid needs in accordance with dietician recommendation. The DON further stated she was aware R #1 became dehydrated, and stated the intake should have been monitored. Review of facility Fluid Balance Policy directed in part, the facility will provide patients with sufficient fluids based on individual needs. The Policy further directed that intake and output will be monitored and documented for residents with a [DIAGNOSES REDACTED].

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1), who had acknowledged full Cardio-Pulmonary Resuscitation (CPR) in the Advanced Directive and physician's orders [REDACTED]. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time. The Resident/Patient health care instructions sheet dated [DATE] identified Resident #1's request to have CPR, transfer to hospital, artificial ventilation and artificially administer fluids. The sheet further identified a physician's signature dated [DATE]. A physician's orders [REDACTED]. The nurse's note dated [DATE] at 5:20 AM identified the charge nurse was approached by a nurse aide at 5:20 AM and reported that Resident #1 was sitting on the floor. The note identified the resident was non-responsive to verbal or tactile stimuli, no respirations were observed and the carotid pulses were absent. The note identified the Nursing Supervisor was notified, the resident's code status verified and CPR was initiated after the Registered Nurse assessment. Review of the facility's video footage regarding care and services provided to Resident #1 on [DATE] identified that from 6:26 PM on [DATE] through 5:19 AM on [DATE] the staff did not open the resident's room door to visualize the resident, staff did not enter the room, and/or provide any care. The video footage identified the following activity on [DATE]: -at 5:19 AM, an 11PM-7AM nurse aide, Nurse Aide (NA) #1, entered the resident's room, exited the room and proceeded to walk down the hallway at a steady pace with no sense of urgency. -5:20 AM, the 11PM-7AM charge nurse, Licensed Practical Nurse, (LPN) #1 and NA #1 entered Resident #1's room. -5:21 AM, LPN #1 and NA #1 leave the resident's room and appear to have a conversation in the hallway. LPN #1 then proceeds to use the telephone in the hallway. LPN #1 and NA #1 then walk down the hallway towards the nurses' station. -5:24 AM, LPN #1 was noted to be walking in the hallway towards Resident #1's room donning a gown and gloves. -5:26 AM, LPN #1 entered the resident's room and two staff members stood in the hallway by the room door. -5:28 AM two (2) nurse aides were observed to don gowns and gloves and enter the resident's room. -5:29 AM, a nurse aide stood at the room door with the Automated External Defibrillator (AED). -5:30 AM, the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #2 entered the resident's room. -5:32 AM the crash cart was brought into the room. The video footage identified that CPR was initiated ten (10) minutes after Resident #1 was first noted to be pulseless by LPN #1. Upon further review, the video footage identified at 5:36 AM the emergency response team (fire department) arrived, 5:39 AM identified the Emergency Medical Services (EMS) arriving with stretcher and at 6:10 AM the EMS left with Resident #1. The Reportable Event Form dated [DATE] identified Resident #1 was found unresponsive on [DATE] at 5:20 AM in his/her room sitting on the floor in front of his/her wheelchair by NA #1. The investigation identified that when LPN #1 entered the resident's room at 5:20 AM, CPR was not initiated. The investigation substantiated failure to initiate CPR, RN #2, LPN #1 and NA #1 were suspended and subsequently terminated. The EMS documentation dated [DATE] identified upon arrival at 5:38 AM Resident #1's skin was warm and pale, there was no rigor or lividity, and the resident was noted to be in asystole. CPR and advanced cardiac life support (ACLS) was performed, the resident was transferred to the hospital and pronounced expired as the hospital. In an interview on [DATE] at 1:45 PM, the Director of Nursing (DON) identified if a resident was found unresponsive and determined to be a full code, CPR would be initiated immediately and that an overhead page code blue to be announced three times. Subsequent to the incident the DON identified the facility developed an action plan and implemented the plan on [DATE]. The plan included in-service education for all license staff and shifts, review of emergency response procedures, review of how to call and conduct a code blue, review of the CPR protocol and code blue drills. Interview with LPN #1 on [DATE] at 1:50 PM identified at 5:20 AM, NA #1 came to the nurses' station and informed her to check on Resident #1 who was on the floor in his/her room. LPN #1 identified as she entered the resident's room she noted Resident #1 was sitting on the floor on top of the wheelchair footrests with his/her back against the wheelchair. LPN #1 stated she called out the resident's name and the resident did not respond. LPN #1 identified upon exam there was no palpable carotid pulse, no respirations and the resident was cold and stiff to touch. LPN #1 identified she left the room, paged the Nursing Supervisor, RN #2, and informed RN #3, an orienting Supervisor, who was at the nurses' station that Resident #1 was dead. LPN #1 stated while she was waiting for the RN #2 to response she retrieved a gown to put on because she had noted blood on the front of the resident's body and then returned to the Resident #1's room accompanied by other staff. LPN #1 could not recall if she had instructed staff to bring the AED and/or crash cart. LPN #1 could not explain why she did not stay in the room when she first assessed the resident with no pulse. LPN #1 recalled she had difficulty moving the resident into a supine position and recalled RN #2 assisted her with applying the AED pads while the resident was in the seated position. LPN #1 stated after the AED directed no shock, the resident was repositioned with assistance from RN #2 and she began chest compressions while RN #2 provided rescue breathing. In an interview on [DATE] at 1:28 PM the Nursing Supervisor, RN #2, identified on [DATE] she had made rounds and checked the third floor unit at approximately 1:30 AM to 2:00 AM and recalled Resident #1's room door was closed. RN #2 identified at 5:17 AM she went for a break and heard the page notification beeping, the page was not a verbal overhead page and the pager does not identify which unit the page is coming from. RN #2 identified as she proceeded to check which unit the page was from, RN #3 approached her and stated that Resident #1 was found unresponsive. RN #2 stated when she arrived to the third floor unit she immediately checked Resident #1's code status as full code, dialed 911 and directed staff to take the AED (which was at the nurses' station) to the resident's room. RN #2 identified when she approached the resident's room she realized the crash cart was absent and directed staff to bring it to the room. RN #2 stated when she entered the room she noted Resident #1 was in a sitting position with his/her back and arms wedged against the wheelchair. RN #2 stated after the AED indicated no shock she assisted with repositioning the resident flat onto the floor and began CPR. RN #2 identified that she provided rescue breaths and LPN #1 did the chest compressions. RN #2 stated that the resident's body was not stiff and she had to position herself to support his/her body to prevent him/her from flopping onto the floor. RN #2 stated they continued CPR until the fire department personnel arrived, who then took over. Review of the Cardiac and/or Respiratory arrest policy identified in part for an unwitnessed arrest for patient without a DNR the RN or LPN will evaluate the patient for conclusive signs of death, if at least one conclusive sign of death is present i.e. lividity of blood in dependent parts of body do not initiate CPR and if there are no conclusive signs of death initiate CPR. Review of the facility's plan of correction identified an action plan was developed and implemented on [DATE]. The plan included in-service education for all license staff and shifts, review of emergency response procedures, review of how to call and conduct a code blue, review of the CPR protocol and code blue drills. Review of the facility's documentation identified correction on [DATE].

Based on clinical record reviews and staff interview for two of four residents in the survey sample reviewed for dehydration while receiving gastrostomy tube feedings (Resident #30, #64), the facility failed to initiate intake and output monitoring and/or assess for signs and symptoms of dehydration when residents with tube feedings had laboratory indicators of dehydration and/or repeated episodes of dehydration and/or licensed staff failed to document and verify the amount of tube feeding and water that had infused. The findings include: 1. Resident #30's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had short and long-term memory problems, required total care for eating, and had a feeding tube. A resident care plan dated 5/15/17 identified a problem with dysphagia, nothing by mouth and enteral feedings. Interventions included check patency of gastrostomy tube daily and administer feedings and free water as ordered. A physician's orders [REDACTED]. A review of laboratory documents, APRN notes, and physician's orders [REDACTED]. On 1/10/17 the resident's BUN was 63 (normal 9-23). The APRN ordered an IV of D51/2 NS at 75cc/hour for 3 liters. On 1/12/17 the BUN was 43. An APRN note dated 1/19/17 indicated the resident receives 600 cc of water every 6 hours via the gastrostomy tube to prevent dehydration. On 1/24/17, the resident's BUN went down to 35. On 2/7/17, lab results noted the BUN was 44. On 3/7/17 the BUN had risen to 60 and on 3/12/17 the BUN was 66. The APRN ordered an IV of D51/2 NS at 50 cc/hour for 3 liters. On 4/18/17 the resident's BUN was 65 (9-23). The APRN ordered D5 1/2 NS at 75 cc/hour for 2 liters. On 4/20/17 the resident's BUN was 44. An interview on 5/23/17 at 1:45 PM with LPN # 4 indicated he/she was unable provide documentation of fluid monitoring for the gastrostomy tube, and/or output for the [MEDICAL CONDITION], and/or nephrostomy. Review of the medication administration records dated January 2017 through April 2017 noted the only documentation related to the tube feeding was when it is started and when the tube feeding is ended every day. The records did not verify that the amount of tube feeding ordered by the Physician was actually administered. An interview on 5/24/17 at 10:00 AM with MD #1 indicated that although most patient's will respond to fluids provided, the resident should have had ongoing monitoring of his/her fluid status via having his/her intake and output monitored. An interview on 5/24/17 at 10:53 AM with LPN # 6 indicated although he/she verified the resident received the necessary amount of tube feeding at the beginning of the shift and the end of the shift by clearing the machine to zero at the start of his/her shift, s/he did not document the amount the resident received anywhere in the clinical record. An interview on 5/24/17 at 10:59 AM with LPN # 7 indicated he/she did not verify the resident received the necessary amount of tube feeding. He/she signed the MAR indicated [REDACTED]. An interview on 5/24/17 at 11:00 AM with RN # 3 indicated he/she would verify the amount of tube feeding the resident received by looking at the bottle at the start and the end of his/her shift and document it in on an intake and output sheet. An interview on 5/24/17 at 11:10 AM with RN # 4 indicated he/she would verify the amount of tube feeding the resident received visually by looking at the bag at the start of the shift and at the end of the shift. He/she would document the amount in the nurse's notes. An interview and clinical record review on 5/24/17 at 12:10 PM with RN # 2 indicated he/she was unable to provide any documentation to indicate that the resident was assessed for dehydration or put on intake and output monitoring after multiple episodes of dehydration requiring IV fluid rescue. Review of a facility policy on fluid balance indicated patients identified as being at risk for dehydration or needing acute re-hydration will be monitored to identify appropriate care plan interventions for promoting adequate hydration. 2. Resident #64's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that the resident had both long and short term memory impairment and was totally dependent on staff for transfers and eating. The care plan dated 1/12/17 identified the resident exhibits or is at risk for dehydration as evidence by insufficient intake and has an enteral feeding tube to meet nutritional needs related to dysphagia. Interventions included to administer IV fluids for hydration, monitor for signs/symptoms of dehydration (increased temperature, decreased output, mental status changes, dry mucous membranes, [MEDICAL CONDITION], and/or [MEDICAL CONDITION]. a. A nurse's note dated 11/9/16 at 3 PM identified the resident was hot to touch with a temperature of 99 and diaphoretic. The APRN was notified of the change at 1 PM and ordered lab work, chest x-ray and urinalysis, culture and sensitivity. At 9:59 PM lab results identified an elevated sodium level. The APRN ordered water flushes, 500 cc three times and repeat lab work in the AM. Review of laboratory values dated 11/10/17 identified the resident with a BUN of 66 (9-23), creatinine of 1.2 (0.5 -1.2), and BUN/Creatinine ratio of 55 (10-20), Sodium 158 (132-146) and urinalysis identified a large amount of blood and many bacteria. A physician's orders [REDACTED]. A nurse's note dated 11/11/16 at 3:06 AM identified that the resident's temperature was 102.5, Tylenol was administered and the APRN was notified of the change in condition. A new order for [MEDICATION NAME] 500 mg via [DEVICE] stat and perform lab work (CBC/BMP) on 11/11/16. Review of laboratory values dated 11/11/16 identified a BUN of 61 (9-23), Creatinine of 1.2 (0.5-1.3), BUN/Creatinine ratio 50.8 (10-20) and Sodium 158 (132-146). A physician's orders [REDACTED]. b. A nurse's note dated 1/11/17 at 12:36 PM identified the resident was having dyspnea on exertion, and had a temperature of 100.9 and pulse of 117. Lab work identified a BUN of 108 and Creatinine of 1.9 and Sodium of 167. A physician's orders [REDACTED]. A nurse's note dated 1/11/17 at 10:36 PM identified that the Gastrostomy tube was flushed with an extra 250 ml and that an IV was running at 100 ml per hour. A nurse's note dated 1/12/17 at 4:36 AM identified that the right hand peripheral IV hydration was in progress. A nurse's note dated 1/12/17 at 3:27 PM identified that the resident had an unplanned transfer to the hospital. A nurse's note dated 1/19/17 at 8:45 PM identified the resident was readmitted to the facility. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Monitor intake and output for continuous infusion and document on I&O sheet every shift. Review of the I&O documentation dated 1/20/17 identified tube feeding administered as 400 cc on the night shift with a 150 cc water flush and 250 cc and 60 cc were administered [MEDICATION NAME] (IV), no documentation was identified for the day shift and tube feeding administered was identified as 490 cc and no water flushes. An APRN readmission note dated 1/23/17 identified that the resident, during the hospital stay had an acute kidney injury and was given IV fluids to resolve the kidney function and tube feedings and free water bolus were adjusted. Additionally, the resident returned to the facility on [MEDICATION NAME] to complete treatment for [REDACTED]. A physician's orders [REDACTED]. A Nurse's note dated 1/24/17 at 11:59 PM identified Glucerna was infusing at 75 ml per hour. A Nurse's note dated 1/25/17 at 11:06 PM identified Glucerna was infusing at 75 ml per hour and that the resident was on antibiotics for [MEDICAL CONDITION]. A physician's orders [REDACTED]. Then, taper [MEDICATION NAME] 125 mg every 12 hour via PEG tube for 7 days, then taper [MEDICATION NAME] again to 125 mg via PEG tube daily for 7 days. Continue isolation until the resident has formed stools for 48 hours, then discontinue isolation. c. A nurse's note dated 3/7/17 at 1:28 PM identified that the PEG tube dislodged during AM care. A Foley catheter was inserted to keep the ostomy patent. The APRN ordered IV fluids until the PEG tube was reinserted. An APRN order dated 3/7/17 directed facility staff to infuse ½ Normal Saline at 50 cc per hour for one liter. A late entry nurse's note dated 3/8/17 at 2:19 AM identified that the resident was scheduled for reinsertion today in the Radiology Department and an IV of 0.45 NS was infusing via peripheral line in the left forearm. A nurse's note dated 3/8/17 at 8:18 AM identified that the resident left via stretcher for [DEVICE] replacement. A nurse's note dated 3/9/17 at 6:19 PM identified that Normal saline was started at 11 PM until the next day and that the [DEVICE] was scheduled to be re-inserted. In an interview and clinical record review with RN# 1, RN #2 and the Medical Records Coordinator on 5/24/17 at 11:10 AM it was identified that there were no I&O records during the changes of condition/dehydration episodes on 11/11/6 or 1/12/17. RN#2 identified that the facility staff were recording I&O's by signing off the MAR indicated [REDACTED]. Additionally, RN#2 noted that I&O records that were available were noted to be incomplete and/or incorrect both for January and March. RN#2 identified that the facility policy for fluid balance identified that I&O should be monitored when a resident was at risk for dehydration. Interview with the MD on 5/24/17 at 10:00 AM identified that residents who are unstable should have I&O's monitored.

Based on review of the clinical record and interviews for one sampled resident reviewed for fracture (Resident #1), the facility failed to ensure timely care and services were provided when the resident's leg was identified out of proper alignment. The finding includes: Resident #1's [DIAGNOSES REDACTED]. The readmission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment and total dependence for transfer from the bed to the chair. The Resident Care Plan dated 1/8/14 identified the resident required a Hoyer mechanical lift for transfer with the assistance of two staff. The nurse's note dated 2/8/14 at 9:30 AM identified the resident was found with a painful and swollen right knee. The physician was notified and directed to obtain an x-ray of the right knee. The x-ray report dated 2/8/14 identified an impacted metaphyseal [MEDICAL CONDITION] femur with knee arthroplasty. The physician was notified and directed to transfer the resident to the hospital for evaluation and treatment. The hospital discharge summary dated 2/9/14 identified the resident was not a candidate for surgical intervention and a knee immobilizer was applied to keep the right leg in extension. Physician orders [REDACTED]. The nurse's note dated 2/9/14 at 7:30 AM identified the resident returned to the facility at 6:10 AM. A right leg immobilizer was in place from the mid-thigh to the right foot. The right leg was noted to be internally rotated within the immobilizer. The nurse's note indicated the physician was updated on the hospital recommendations, however, failed to reflect the physician was notified that the right leg was internally rotated in the immobilizer. Subsequent nurse's notes dated 2/9/14 at 2:00 PM and 9:00 PM identified the resident's right leg remained internally rotated in the knee immobilizer. The nurse's notes failed to reflect the physician was notified of the continued internal rotation of the right leg. On 2/9/14 at approximately 10:00 PM, 16 hours after return from the hospital, bleeding was noted at the right leg immobilizer site. Upon examination, two small perforations in the skin were noted above the right knee. The resident was transferred to the hospital and required surgical repair of the right femur fracture. Interview on 5/19/14 at 2:15 AM with Nursing Supervisor (RN) #2 identified she/he was aware the resident's right leg was internally rotated in the immobilizer upon return to the facility on [DATE]. RN #2 indicated the physician was notified, however, could not recall the name of the physician notified and/or provide documentation of the notification. Interview on 5/20/14 at 12:02 PM with Licensed Practical Nurse #2 (the charge nurse on duty 2/9/14) identified MD #1 was notified of the hospital recommendations on 2/9/14 and updated on all aspects of the resident's condition when Resident #1 returned to the facility. LPN #2 did not indicate she/he specifically informed MD #1 of the internal rotation of the right leg during the conversation. Interview on 5/20/14 at 1:30 PM with MD #1 identified he/she could not recall being notified that the resident's right leg was out of alignment in the immobilizer upon return to the facility on [DATE]. MD #1 indicated if notified his/her practice is to direct the facility to transfer the resident to the hospital for an evaluation and treatment. Interview on 5/22/14 at 11:00 AM with the Orthopedic Surgeon (MD #2) indicated that although a fracture was identified on 2/9/14, the resident was not a candidate for surgical intervention. Treatment included the application of a knee immobilizer to ensure proper alignment of the fractured right femur. MD #2 indicated any fracture has the possibility to displace and that once the skin is broken, the patient is at risk for infection requiring surgical repair and closure. Numerous attempts to interview RN #3 were unsuccessful.