Every finding on record at Autumn Lake Healthcare at Bucks Hill

Based on review of the clinical record, facility documentation, facility policy, and interviews, 5 of 6 residents (Residents #5, Resident #14, Resident #20, Resident #56, and Resident #68) reviewed for unnecessary medications, the facility failed to ensure the pharmacist conducted Medication Regimen Review (MRR) at least monthly. The findings include:1.Resident #5 was admitted to the facility with diagnoses including epileptic seizures, hypercholesterolemia, hypertension, bipolar disorder, hypothyroidism, osteoporosis with pathological fracture, diabetes, and heart failure.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had severely impaired cognition. The MDS further identified Resident #5 received high-risk medications, including antidepressants, antianxiety, diuretics, and anticonvulsants.The Resident Care Plan (RCP) dated 10/31/2025 identified Resident #5 had a mood problem related to bipolar disorder. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, monitor/record/report to MD as needed mood patterns, signs and symptoms of depression, anxiety, or sad mood per facility behavior monitoring protocols, and behavioral consults as needed.Review of the clinical record failed to identify Medication Regimen Reviews (MRRs) for November 2025, January 2026, and February 2026. No pharmacist consultant documentation was present for those months.2. Resident #14 had diagnoses that included heart dysrhythmia, type 2 diabetes, anemia, dementia, insomnia, cardiac pacemaker, asthma, and anxiety. The quarterly MDS dated [DATE] identified Resident #14 had severely impaired cognition. The MDS further identified Resident #14 received high risk medications, including antianxiety, anticoagulants, diuretics, hypoglycemics, and anticonvulsants.The RCP dated 11/4/25 identified Resident #14 used psychotropic medications for insomnia and anxiety. Interventions directed to consult with the pharmacy and provider to consider dosage reduction when clinically appropriate.Review of the clinical record failed to identify Medication Regimen Reviews (MRRs) for November 2025, January 2026, and February 2026. No pharmacist consultant documentation was present for those months.3. Resident #20 had diagnoses that included anemia, chronic obstructive pulmonary disease (COPD), depression, anxiety, hypercholesterolemia, cancer, hypertension, epileptic seizures, heart attack, transient ischemic attack (mini stroke), and chronic pain.The quarterly MDS dated [DATE] identified Resident #20 had intact cognition. The MDS further identified Resident #20 received high-risk medications, including anticonvulsants, antiplatelets, and antidepressants.The Resident Care Plan (RCP) dated 9/15/25 identified Resident #20 used psychotropic medications for depression and anxiety with a history of panic disorder. Interventions included administering medications as ordered and monitoring for side effects and effectiveness, including unsteady gait, difficulty swallowing, suicidal ideation, social isolation, blurred vision, weight loss, and atypical behaviors.Review of the clinical record failed to identify Medication Regimen Reviews (MRRs) for October 2025, November 2025, January 2026, and February 2026. No pharmacist consultant documentation was present for those months.4. Resident #56 had diagnoses that included dementia, hyperlipidemia, encephalopathy, hypertension, and major depression.The quarterly MDS dated [DATE] identified Resident #56 had severely impaired cognition. The MDS further identified Resident #56 received high-risk medications, including antipsychotics and antidepressants.The Resident Care Plan (RCP) dated 7/15/25 identified Resident #56 used psychotropic medication. Interventions directed pharmacy consultation for dose reduction and Abnormal Involuntary Movement Scale (AIMS) monitoring every 6 months.Review of the clinical record failed to identify Medication Regimen Reviews (MRRs) for October 2025, November 2025, January 2026, and February 2026. No pharmacist consultant documentation was present for those months.5. Resident #68 had diagnoses that included diabetes, anemia, hyperlipidemia, major depression, and hypertension.The annual MDS assessment dated [DATE] identified Resident #68 had intact cognition. The MDS further identified Resident #68 received high-risk medications including antidepressant, antiplatelet, diuretic, opioid, and anticonvulsant medications.The Resident Care Plan (RCP) dated 11/7/25 identified Resident #68 was prescribed psychotropic medication with interventions that directed to administer medications per physician orders.Review of the clinical record failed to identify Medication Regimen Reviews (MRRs) for November 2025, January 2026, and February 2026. No pharmacist consultant documentation was present for those months.6. Review of the Admission, Discharge, and Transfer Report dated 11/1/25 to 11/30/25 identified there were 23 admissions and 4 readmissions during this period. Review of the daily census report for the period of 11/1/25 through 11/30/25 identified the daily census ranged from 81 to 88 residents per day. Facility documentation was unable to reflect that MRRs were conducted for newly admitted and readmitted residents. 7. Review of the Admission, Discharge, and Transfer Report dated 1/1/26 to 1/31/26 identified there were 33 admissions and 6 readmissions during this period. Review of the daily census report for 1/1/26 through 1/31/26 identified the daily census ranged from 81 to 89 residents per day. Facility documentation was unable to reflect that MRRs were conducted for newly admitted and readmitted residents.8. Review of the Admission, Discharge, and Transfer Report dated 2/1/26 to 2/28/26 identified there were 21 admissions and 3 readmissions during this period. Review of the daily census report for 2/1/26 through 2/28/26 identified the daily census ranged from 84 to 88 residents per day. Facility documentation was unable to reflect MRRs were conducted for newly admitted and readmitted residents.Review of the Medical Director Rounds dated 2/26/26 identified communication to MD #1 that the facility was awaiting pharmacy services due to a change in pharmacy consultant groups related to inconsistencies with regulations.Interview with the Director of Nursing (DNS) on 6/16/26 at 11:00 AM identified she was aware the pharmacist consultant Pharmacist #1 had not conducted monthly MRRs for November 2025, January 2026, and February 2026. The DNS indicated the facility had contacted the pharmacy and they sent a different pharmacist consultant to the facility in March 2026. The DNS identified the facility initiated Quality Assurance and Performance Improvement (QAPI) due to missing pharmacy reports and changed pharmacy consultants effective April 2026.Interview with Registered Nurse (RN) Regional Director of Nursing on 6/16/26 at 11:38 AM identified she was aware Pharmacist #3 did not conduct monthly MRRs for November 2025, January 2026, and February 2026. RN #4 indicated she contacted Person #2 (owner of the pharmacy consultant group) to inform him/her that Pharmacist #3 had not been coming into the facility. RN #4 identified as of 4/1/26 that the facility had a new pharmacy.Interview with Pharmacist #2 on 6/16/26 at 12:40 PM identified MRRs for new admissions and readmissions should occur within 2 to 3 days of admission and all residents must receive at least monthly MRRs.Interview with Person #2 (owner of the pharmacy consultant company) on 6/16/26 at 12:58 PM identified the pharmacist was required to document in each resident's medical record at least monthly whether recommendations were made or not. Person #2 identified that in February 2026 they determined Pharmacist #3 had not been consistently documenting monthly MRRs or completing documentation for admissions and readmissions. Person #2 indicated all new admissions and readmissions were required to be reviewed by the pharmacist by the next day. Person #2 identified Pharmacist #3 had not consistently documented Medication Regimen Reviews (MRRs) in the resident's clinical record for new admissions and readmissions; however, if a recommendation was made, it was sometimes communicated to the DNS. Person #2 identified the DNS was required to receive a monthly report from Pharmacist #3 documenting all residents reviewed and any recommendations made to nursing and providers. Person #2 further identified Pharmacist #3 was not consistently providing required reports to the DNS. Person #2 identified his/her company stopped providing pharmacy consultant services to the facility on 3/31/26.Interview with the MD #1 (Medical Director) on 6/16/26 at 3:08 PM identified he was not aware that the pharmacist was not conducting monthly MRRs for all residents. MD #1 indicated that the DNS and Administrator had not informed him.Interview with the DNS on 6/17/26 at 7:28 AM identified although she initiated QAPI corrective action plan when she became aware the MRRs were not conducted, she closed it right away because the facility started with a new company. The DNS identified she did not do any education or audits because she did not think it was needed.Interview with the Administrator on 6/17/26 at 7:57 AM identified she was informed by the DNS informed a few months ago that the pharmacist consultant had not come in to conduct monthly MRRs. The Administrator indicated she was unsure which monthly MRRs were not conducted. The Administrator indicated she was not sure if Pharmacist #1 was or was not conducting MRRs for admission and readmissions.Review of the facility Drug Regimen Review Monthly Policy undated directed, in part, the consultant pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician. The attending physician or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly, whenever possible. Any identified irregularities of an urgent nature shall be communicated to the DNS and/or nursing supervisor for immediate notification and action of the attending physician. The facility Administrator, DNS, and Medical Director shall be notified of all findings. The Pharmacist shall document that the monthly drug regimen review has been completed and whether there are any recommendations on the electronic medical record of each resident. The Pharmacist shall provide written documentation of all recommendations and submit monthly to the facility for attending physician review and response. The written documentation and prescriber's response shall be considered a permanent part of the resident's medical record.Review of the facility Drug Regimen Review for New Admissions and Readmissions Policy undated, directed, in part, the consultant pharmacist shall review and perform a drug regimen review for all newly admitted and readmitted residents. The pharmacist shall access the new admission information for residents admitted or readmitted to the facility via the electronic medical record. The pharmacist shall perform a drug regimen review as close to the time of admission as reasonably possible and communicate findings via email to the facility DNS. The consultant pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician. An attending physician or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly, whenever possible. The Pharmacist shall document that the monthly drug regimen review has been completed and whether there are any recommendations on the electronic medical record of each resident. The Pharmacist shall provide written documentation of all recommendations and submit monthly to the facility for attending physician review and response. The written documentation and prescriber's response shall be considered a permanent part of the resident's medical record.

Based on tour of the Dietary Department, observation, review of facility policy, and interviews, the facility failed to ensure dietary staff wore a beard cover while preparing food. The findings include:Observation during a tour of the Dietary Department on 6/14/2026 at 9:25 AM identified Dietary Aide #1 was preparing broccoli for the residents' lunch meal by transferring multiple bags of frozen broccoli into a large metal pan for reheating without wearing a beard cover.Interview with Dietary Aide #1 on 6/14/2026 at 9:25 AM identified he was aware facility policy required a beard cover while preparing food. Dietary Aide #1 indicated he was not wearing a beard cover because he forgot.Interview with the Director of Dietary on 6/15/2026 at 10:27 AM identified facility policy required staff with beards to wear a beard cover while working around food. The Director of Dietary identified preparing broccoli for reheating constituted working around food and Dietary Aide #1 should have worn a beard cover.The facility Environment policy dated May 2014, and revised June 2025 directed, in part, all food preparation areas, food service areas, and dining areas would be maintained in a clean and sanitary condition. The policy did not address the use of beard covers to maintain a sanitary food service area.

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 1 sampled resident identified to self-administer medication (Resident #64), the facility failed to access a resident's ability to safely self-administer medications. The findings include:Resident #64 had diagnoses that included Lewy body dementia, Type 2 diabetes, and blindness of the left eye.A Self Administration Screening Form dated 10/15/2024 identified Resident #64 had not expressed a desire to self administer medications and no approval for self administration was granted.The quarterly MDS assessment dated [DATE] identified Resident #64 had a Brief Interview of Mental Status (BIMS) score of 15 indicative of intact cognition, and was independent with personal hygiene, eating, bed mobility, and ambulating.The Resident Care Plan (RCP) dated 5/2/2026 identified Resident #64 had an Activities of Daily Living (ADL) self-care deficit. Interventions included allowing to have facial hairs if he/she desires, and respecting resident's choice to have personal belongings chained with a pad lock in his/her clothes closet. The RCP failed to identify Resident #64's preference for self-administration of medications.Physician's orders in effect from 6/1/2026 through 6/14/2026 failed to identify an order for self administration of medications for Resident #64.Observation on 6/14/26 at 10:44 AM noted a medication cup containing red liquid on Resident #64's bedside table. Resident #64 identified the red liquid as cough syrup. Review of the clinical record on 6/14/26 failed to identify Resident #64 was a nursing assessed and identified able to safely self-administer medication.Interview with Licensed Practical Nurse (LPN) #8 on 6/14/26 at 10:49 AM identified she left cough syrup at Resident #64's bedside at approximately 8:30 AM during administration of morning medications. LPN #8 indicated she left the medication because Resident #64 gets mean and swears when she observes him/her taking medications. LPN #8 indicated she was aware of the facility's policy for self-administration of medications. LPN #8 identified Resident #64 had no order for self-administration of medications. LPN #8 further identified she should not have left the cough syrup on Resident #64's bedside table.Interview with the Director of Nursing Services (DNS) on 6/16/26 at 10:16 AM identified LPN #8 should not have left Resident #64's medication at the bedside for self-administration without a physician's order.Interview with the Director of Nursing Services (DNS) on 6/16/2026 at 10:16 AM identified that LPN #8 should not have left Resident #64's medication at the bedside for self-administration without an order.Subsequent to surveyor inquiry, a physician's order for Resident #64 to self-administer medications was entered on 6/14/26.Review of the facility Resident Self Administration of Medication Policy, dated 12/14/2022 and reviewed 10/27/2025, directed, in part, a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The results of the interdisciplinary team assessment are to be recorded on the Resident's Self-administration Assessment in the Resident's medical record. The care plan must reflect self-administration and storage arrangements for each medication.

Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #4 and Resident #8) reviewed for hospitalization, the facility failed to ensure the residents and/or resident representatives were provided with written information regarding the bed hold policy at the time of transfers to the hospital. The findings include:1.Resident #4 had diagnoses that included diabetes, cerebral atherosclerosis, and stroke.The annual MDS dated [DATE] identified Resident #4 had moderately impaired cognition.a.The nurse's note dated 3/21/26 at 1:16 PM identified Resident #4 exhibited altered mental status and signs and symptoms of a stroke. The on-call provider was notified, and Resident #4 was transferred to the hospital. The Census Report identified Resident #4 was transferred to the hospital on 3/21/26.A social worker's note dated 3/23/26 at 9:06 AM identified Resident #4 was transferred to the hospital on 3/21/26 and was placed on Title 19 (Medicaid) bed-hold status.The census report identified Resident #4 returned to the facility on 3/26/26. b. Review of the Change in Condition (SBAR) note dated 4/8/26 at 10:42 AM identified that Resident #4 experienced a change in neurological status. Resident #4's pupils were pinpointed and fixed, and the resident exhibited increased slurred speech and increased tremors. Resident #4 experienced a recent stroke on 3/21/26. The Advanced Practical Nurse (APRN) was present and ordered transfer to the emergency department for evaluation and treatment. Hospital transfer documentation dated 4/8/26 revealed that page 6 contained a checklist identifying documents to be provided at transfer. The checklist included items for the bed hold policy and the reason for transfer; however, both check boxes were left blank. The Census Report documented that Resident #4 was transferred to the hospital on 4/8/26 and returned to the facility on 4/16/26.Review of Resident #4's clinical record failed to provide documentation that a Bed Hold Notice was provided to Resident #4 or the resident representative at the time of the hospital transfers on 3/21/26 and 4/8/26.Interview with Registered Nurse (RN) #3 (day shift supervisor) on 6/16/26 at 7:13 AM indicated for emergency transfers to the hospital, the supervisor prints the discharge report and Change in Condition (SBAR) report from the electronic medical record. RN #3 identified the transfer packet also includes a red envelope containing the bed-hold policy. RN #3 stated supervisors do not complete the bed-hold forms and do not maintain copies of documents sent with residents. RN #3 retrieved four red envelopes from the supervisor's office; no documents were attached to the envelopes. RN #3 identified she was unable to locate a copy of the bed-hold notice that should have been contained in the red envelopes.Interview and clinical record review with the Director of Nursing Services (DNS) on 6/16/26 at 7:29 AM identified the nurse should the SBAR (change in condition) note, the transfer/discharge summary, and the Bed Hold Notice. The DNS identified nurses were responsible for documenting whether the Bed Hold Notice was provided. The DNS indicated nurses are not required to maintain copies of transfer documents in the clinical record. The DNS identified that an SBAR note was not completed for Resident #4's hospital transfer on 3/21/26 , so the section indicating whether the Bed Hold Notice was provided was not completed. The DNS further identified on 4/8/26 the SBAR note was not completed and contained an unchecked box for the Bed Hold Notice. The DNS confirmed there was no documentation indicating Bed Hold Notices were provided to Resident #4 or the resident's representative on 3/21/26 or 4/8/26. Interview with the Administrator on 6/17/26 at 6:59 AM identified she located the bed hold notifications. The Administrator identified the admission coordinator was responsible for completing the Bed Hold Notices but was out on medical leave. The Administrator identified the admission coordinator did not document dates or times she contacted Resident #4's representative and confirmed supervisors did not mail Bed Hold Notices. The Administrator indicated the admission coordinator contacts the resident representatives by telephone. Interview with Person #3 (Resident #4's representative) on 6/17/26 at 9:14 AM identified he/she received telephone calls when Resident #4 was sent to the hospital but did not receive written information. Person #3 identified he/she had never heard the term bed hold and did not receive any Bed Hold Notice or written explanation of the bed hold process.Interview with the admission Coordinator on 6/17/26 at 10:27 AM identified she tracked residents sent to the hospital on a Bed Hold Status Form. She identified that she did not document date or time of communication with Resident #4's representative and did not retain documentation of these communications. The admission Coordinator identified she verbally informed Person #3 the bed would be available but did not inform him/her of the 15 day Medicaid bed hold period.2. Resident # 8 had diagnoses that included stroke and femur fracture with orthopedic aftercare.The Medicare 5-day MDS dated [DATE] identified Resident #8 had intact cognition.a. The SBAR note dated 4/28/26 at 10:54 PM identified Resident #8 had a change in condition. Resident #8 was noted to have right sided facial droop, right sided weakness, altered mental status, and slurred speech. Resident #8 was slow to respond and had sluggish pupils. The APRN was notified and ordered to transfer Resident #8 to the emergency room for evaluation. Review of the transfer documents dated 4/28/26 identified a checkbox for the Bed Hold Notice on page 6, which was left blank. The Census Report identified Resident #8 was transferred to the hospital on 4/28/26 and returned to the facility on 4/29/26. b. The SBAR note dated 5/1/26 at 11:58 AM identified Resident #8's surgical sites to left femur and knee had bloody, purulent drainage, +2 pitting edema, no palpable pedal pulse, and the left foot was cold to touch. The surgeon and APRN were notified, and Person #4 (resident representative) were updated. New orders directed transfer to the emergency room.Review of the transfer documents dated 5/1/26 identified a checkbox for the Bed Hold Notice on page 6, which was left blank. The Census Report identified Resident #8 was transferred to the hospital on 5/1/26 and returned to the facility on 5/1/26. c. A nurse's note dated 5/4/26 at 10:12 AM identified the orthopedic office reported Resident #8 was sent to the hospital due to surgical site infection and right sided facial droop.The Census Report identified Resident #8 was transferred on 5/4/26 and returned on 5/20/26.d. The APRN note dated 5/29/26 at 10:15 AM identified Resident #8's wound was noted with dehiscence to left knee with a moderate amount of serosanguineous drainage and exposed hardware. The APRN note indicated Resident #8's surgeon was notified and the resident was transferred to the emergency room for further evaluation. The SBAR nurse's note dated 5/29/26 at 11:22 AM identified Resident #8 had a change in condition related to wound dehiscence and exposed hardware. Review of the transfer documents dated 5/29/26 identified a checkbox for the Bed Hold Notice on page 6, which was left blankThe Census Report identified Resident #8 was transferred on 5/29/26 and returned on 6/8/26.Interview with the DNS on 6/16/26 at 8:50 AM identified her expectation is that nurses check the box on page 6 of the SBAR form confirming that the bed hold policy was placed in the red envelope and sent with the resident. The DNS indicated that nurses and supervisors do not mail the bed hold notice to the resident's representative. The DNS identified on 4/28/26, 5/1/26, 5/4/26, and 5/29/26, the nurses did not check the box indicating the bed hold policy was provided, nor did they document notifying the Resident #8's representative of the bed hold policy. The DNS further identified documentation did not reflect that the bed hold notice was provided at the time of Resident #8's hospital transfers. Interview with the Administrator on 6/17/26 at 9:00 AM indicated the admission coordinator mails the bed hold notices to the resident's representatives. The Administrator indicated that she does not know if or where the admission coordinator documents the notification to the resident's representative. The Administrator identified the admission coordinator did not document the dates and times she called Resident #4's representative regarding the bed hold forms. Interview with the admission Coordinator on 6/17/26 at 10:27 AM identified that she tracks residents sent to the hospital and monitors bed hold days using a bed hold status form. She stated she uses this form to track the number of days a resident is hospitalized within the 15 day bed hold period. The admission Coordinator indicated if the resident's representative is in the facility she informs them verbally of the bed hold. Although attempted, an interview with Person #4 was not obtained. Review of the facility Documentation of Bed Hold Status Form directed, in part, put the resident name and date he/she went to the hospital with the date for day 1 and day 7 while the resident is at the hospital and the date the resident returned to the facility. The form indicated the notice and bed hold were mailed by the supervisor. (The DNS identified the supervisors do not mail the bed hold notices). The form does not identify who was notified (resident or resident representative) of the bed hold notification, who notified the representative, nor the date and time the resident/representative were notified.Review of facility Bed Hold Policy undated, directed, in part, identified the facility will reserve the bed of a private pay resident who has been transferred to a hospital as long as payment at the usual self-pay per-diem rate is available to reserve the bed. In the case of a Medicaid resident, the facility will reserve the bed for up to 7 days as long as the facility has not received information that the resident is not expected to return to the facility. The facility will also reserve the bed for up to an additional 8 days as long as the facility has not received information that the resident is not expected to return to the facility. If a Medicaid-assisted resident wishes to reserve the bed during a period of hospitalization for any other or longer period of time, the bed will be reserved as long as payment is made by the resident or resident representative at the facility per usual Medicaid per-diem rate. On the include the resident name, date the form is sent to the resident's representative, and by which staff member.

Based on review of clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #20) reviewed for nutrition, the facility failed to review and revise the care plan timely when a resident experienced significant weight loss and verbalized wanting to lose weight. The findings include:Resident #20 had diagnoses that included anemia, chronic obstructive pulmonary disease (COPD) and lung cancer.A physician's order dated 12/29/25 directed to provide a regular diet with regular texture and thin liquids due to risk of malnutrition.Dietitian #1's progress dated 12/29/25 identified Resident #20 experienced a significant weight loss of 7.6 percent over 90 days and was on a sodium restricted diet. Dietitian #1 identified the recommendation was to liberalize Resident #20's diet to a regular diet with regular consistency to promote increased meal intake.Resident #20's weight was recorded as 129.0 pounds on 12/29/25.Dietitian #1's progress note dated 2/6/26 identified Resident #20 continued to have significant weight loss and was on a regular diet with regular consistencies. Dietitian #1 indicated documentation identified Resident #20's meal consumption was 50 to 100 percent of meals with acceptance of most snacks. Dietitian#1 indicated she ordered Magic Cup (an ice cream type nutritional supplement) once daily, with discontinuation if Resident #20 does not accept.Resident #20's weight was recorded as 122.6 pounds on 2/6/26 (6.4-pound weight loss from 12/29/25).Resident #20's weight was recorded as 123.0 pounds on 2/21/26 (0.4-pound gain from 2/6/26).The Nutrition Evaluation dated 3/6/26 completed by Dietitian #1 identified Resident #20 was at nutritional risk due to need for nursing home services and refusal of facility oral nutritional supplement offerings for variable meal intake. Dietitian #1 identified Resident #20 had significant weight loss of 8.7% over 90 days and 14.6% over 180 days and a current Body Mass Index (BMI) of 23.6% indicating a healthy weight for age. Dietitian #1 indicated Resident #20 stated he/she was trying to lose weight and was advised that was not recommended. Dietitian #1 identified the nursing department reported Resident #20 was sleeping more due to the recent weight loss. Dietitian #1 indicated her recommendations included offering diet as ordered, monitoring weigh trends, updating dietary preferences, and providing alternatives when less than 50% of meals were consumed. Resident #20's weight was recorded as 119.8 pounds on 3/7/26 (3.2- pound weight loss in 14 days and 9.2-pound weight loss from 12/29/25).The annual Minimum Data Set (MDS) dated [DATE] identified Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition, was independent with eating, had no swallowing difficulty, had experienced weight loss of 5% or more in 1 month or 10% or more in 6 months, and was not on a physician-prescribed weight loss plan.The Resident Care Plan (RCP) dated 3/9/26 identified Resident #20 was at potential nutritional risk due to need for short-term rehabilitation/skilled nursing services and refusal of oral nutritional supplements. Interventions included providing diet as ordered, monitoring for signs and symptoms of malnutrition and weight loss, and dietitian evaluation for diet change recommendations as needed. The RCP did not include updated goals or interventions to address ongoing significant weight loss or Resident #20's stated desire to lose weight.A telephone interview and clinical record review with the Dietitian #1 on 6/17/26 at 11:20 AM identified she was aware of Resident #20's continued weight loss and history of refusing nutritional supplements. Dietitian #1 identified although Resident #20 experienced continued weight loss he/she also expressed desire to lose weight. Dietitian #1 was unable to identify any updates made to Resident #20's care plan reflecting person-centered goals or interventions related to Resident #20's expressed desire to lose weight and continued weight loss.Interview with Resident #20 on 6/18/26 at 12:15 PM identified Resident #20 wanted to lose weight and stated he/she had gained weight prior to hospitalization in December 2025. Resident #20 indicated he/she had discussed weight loss with the dietitian.Review of the facility Weight Monitoring policy reviewed on 10/27/25 directed, in part, that the facility would ensure that residents maintain acceptable nutrition parameters such as usual weight or desirable body weigh range, unless the resident's clinical condition or resident preferences indicate otherwise. Additionally, a nutritional assessment would be used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. To the extent possible, the Resident Care Plan would reflect the resident's personal goals and preferences and would include resident-specific interventions.Review of the facility Nutritional and Dietary Supplements policy dated 1/31/23 directed, in part, to provide dietary supplements to maintain adequate nutritional status and resident's highest level of well-being. Additionally, supplements could be provided by dietitian recommendation as allowed by physician standing order and the care plan would be updated with the new or modified nutritional interventions.

Based on observations, interviews, review of the clinical record, and facility policy, for two (2) of three (3) residents (Residents #20 and #67) reviewed for smoking, the facility failed to provide adequate supervision during smoking to ensure proper disposal of smoking materials and failed to mitigate a fire risk related to the presence of flammable materials in an uncovered waste container. The findings include:1. Resident # 20 had diagnoses that included chronic obstructive pulmonary disease, nicotine dependence, and malignant neoplasm of the bronchus or lung.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status (BIMS) score of 15 intact cognition. The MDS further identified Resident #20 used tobacco.A smoking safety screening dated 3/18/2026 identified Resident #20 smoked two (2) to five (5) cigarettes per day, required a smoking apron for safety, and required supervision while smoking.The Resident Care Plan (RCP) dated 5/29/2026 identified Resident #20 was at risk for injury related to smoking. Interventions directed supervision during smoking and use of a smoking apron due to left-hand tremors and allowing cigarettes to burn to the filter.2. Resident # 67 's diagnoses included interstitial pulmonary disease, nicotine dependence, and cognitive communication deficit.A smoking safety screening dated 3/18/2026 identified Resident #67 smoked two (2) to five (5) cigarettes per day and required supervision while smoking.The annual MDS assessment dated [DATE] identified Resident #67 had a Brief Interview of Mental Status (BIMS) score of 15 indicative of intact cognition. The MDS further identified Resident #67 used tobacco.The RCP dated 5/8/2026 identified Resident #67 was at risk for injury related to smoking. Interventions directed supervised smoking during designated times, securing cigarettes and smoking materials at the nurses' station, supervisor's office, or designated location.Observation on 6/15/2026 at 9:20 AM on the [NAME] Patio (resident smoking area) identified Resident #20 and Resident #67 smoking while seated in wheelchairs. a. Resident #20 had an open box of facial tissues positioned next to his/her right leg on the wheelchair, not protected by the smoking apron.b. An uncovered metal garbage can, approximately one-half full of trash including paper items and used cigarette packaging, was located approximately 21 inches behind Resident #67's wheelchair. The garbage can lid was on the ground next to Resident #67's wheelchair and secured by a chain.c. A goose-neck ashtray was positioned approximately two (2) feet from both residents and within arm's reach. Resident #20 and Resident #67 were observed flicking cigarette ashes onto the ground rather than into the ashtray. Nurse Aide (NA) #9 was positioned in front of both residents and did not redirect them to use the ashtray during the observation.Interview with NA #9 on 6/15/2026 at 9:23 AM identified he was responsible for supervising Resident #20 and Resident #67 during smoking. NA #9 indicated he was not aware the residents were discarding ashes onto the ground instead of the gooseneck ashtray. NA #9 identified putting cigarette ashes anywhere, but the ashtray posed a fire risk. NA #9 further identified the uncovered garbage can containing paper waste was a fire risk and should have been covered. Following surveyor inquiry, NA #9 placed the lid on the garbage can.Observation on 6/15/2026 at 9:26 AM noted Resident #67 continued to flick cigarette ashes onto the ground. NA #9 subsequently redirected Resident #67 to use the ashtray for cigarette ashes.Interview with the Director of Nursing (DNS) on 6/15/2026 at 11:16 AM identified the facility smoking procedure required residents to use designated ashtrays and prohibited disposal of cigarette ashes on the ground. The DNS further identified metal trash containers in smoking areas were required to remain covered.Subsequent to surveyor inquiry, on 6/15/26 , the Administrator removed the uncovered metal garbage can from the smoking patio, and staff were provided education regarding appropriate use of goose-neck ashtrays and smoking safety procedures.Review of the facility Smoking policy, directed, in part the facility will establish and maintain safe resident smoking practices. Only facility approved ashtrays and other smoking equipment/paraphernalia shall be used. Metal containers with self-closing devices shall be available in smoking areas. Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking.

Based on observations, interviews, review of the clinical records, facility documentation, and facility policy for 2 of 5 residents reviewed for infection control practices (Resident #85 and Resident #96), the facility failed to maintain proper infection control during medication administration (Resident #85) and failed to wear appropriate Personal Protective Equipment (PPE) during medication administration for a resident who had an indwelling medical device. The findings include: 1.Resident #85 was admitted to the facility in October 2024 with diagnoses that included Parkinson's disease, schizophrenia, anxiety, and dementia. The Resident Care Plan (RCP) dated 4/1/26 identified Resident #85 received antipsychotic medication related to schizophrenia, depression, and anxiety. Interventions included administering medications as ordered and consulting with pharmacy services. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 had intact cognition. The MDS further identified Resident #85 received high-risk medications during the previous 7 days, including antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. The physician's order dated 5/28/26 directed to administer Acetaminophen (medication used to treat pain) 1000 milligram (mg) three times daily for pain, Amlodipine Besylate (lowers blood pressure) 7.5 mg daily, Clonidine (lowers blood pressure) 0.2 mg daily, Clonazepam (treats anxiety) 1 mg three times daily, and Divalproex Sodium (mood stabilizer) delayed-release 500 mg twice daily for schizophrenia. Medication administration observation on 6/15/26 at 9:15 AM identified Licensed Practical Nurse (LPN) #5 moved the medication cart in front of Resident #85's doorway and stated she was preparing Resident #85's 9:00 AM medications. LPN #5 without the benefit of performing hand hygiene opened the medication cart drawer, removed two prepackaged medication packets, closed the drawer, and removed a small pair of scissors from her uniform pocket. LPN #5 cut open the first packet and emptied three Amlodipine 2.5 mg tablets and one Clonidine 0.2 mg tablet into a medication cup. LPN #5 then cut open a second packet containing one Divalproex Sodium delayed release 500 mg tablet and the tablet fell onto the top surface of the medication cart. LPN #5 picked up the tablet with her fingertips and fingernails and placed it into the medication cup. LPN #5 locked the medication cart and entered Resident #85's room carrying the medication cup and an empty drinking cup. LPN #5 poured water from a water bottle in the resident's room into the empty cup and administered the medications to Resident #85 that included the tablet that had fallen onto the surface of the medication cart. Resident #85 consumed the medications. LPN #5 exited the room and documented administration of the medications in the electronic medical record. LPN #5 did not wash or sanitize her hands after medication administration. Interview with LPN #5 on 6/15/26 at 9:25 AM identified she could not recall whether she sanitized her hands before preparing Resident #85's medications but stated she usually does. LPN #5 identified when Resident #85's Divalproex tablet fell onto the top of the medication cart and she should not have picked up the tablet with her fingers and placed it into the medication cup. LPN #5 stated she should have discarded the tablet. LPN #5 indicated the reason she did not discard Divalproex tablet was because she did not have another Divalproex tablet available and the medication was not stocked in the emergency medication supply. LPN #5 identified Resident #85 needed the medication and the prepackaged system prevented her from removing a replacement tablet from another packet. LPN #5 indicated she cleaned the top of the medication cart at approximately 7:00 AM; however, she had administered medications to at least six residents before preparing medications for Resident #85 and had not cleaned the medication cart again. Interview with the Director of Nursing Services (DNS) on 6/15/26 at 9:40 AM identified nurses must wash or sanitize their hands before preparing medications for each resident and after leaving a resident's room. The DNS stated LPN #5 should have discarded Resident #85's Divalproex tablet after it fell onto the contaminated medication cart surface. The DNS identified LPN #5 should have poured Resident #85's medication directly from the packages into the medication cup and LPN #5 should not have touched Resident #85's medications with her fingers or fingernails. Review of the facility Medication Administration Policy dated 10/27/25 directed, in part, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Wash hands prior to administration of medications. Remove medications from packaging taking care not to touch medication. Observe resident consumption of medication. After giving medications to resident wash hands per protocol. 2. Resident #96 was admitted to the facility with diagnoses that included sepsis requiring intravenous (IV) antibiotics, bile duct cancer, and bile duct obstruction with a biliary stent and an indwelling biliary drain. admission nurse's note dated 6/10/26 at 9:19 PM identified that Resident #96 was cognitively intact and had an indwelling midline IV device for intravenous (IV) antibiotic administration, as well as an indwelling biliary tube. The physician's order dated 6/10/26 directed to administer Ampicillin (medication used to treat infections) 2 grams IV every 6 hours for bacteremia and directed to change the sterile end cap on the midline IV catheter with each use, observe the site every two hours during use, flush each lumen every 12 hours, and change the IV administration set every 96 hours. The physician's orders failed to direct implementation of Enhanced Barrier Precautions (EBP) related to Resident #96's indwelling medical device. The Resident Care Plan (RCP) dated 6/12/26 identified Resident #96 received IV antibiotics related to bile duct cancer and sepsis associated with bile duct obstruction. Interventions included administration of IV antibiotics through the midline IV catheter as ordered. The RCP failed to identify EBP related to Resident #96's indwelling medical devices, including the midline IV catheter. Observation on 6/16/26 at 12:43 PM of IV antibiotic administration by Licensed Practical Nurse (LPN) #6, with Registered Nurse (RN) #3, Infection Preventionist, present, identified EBP signage posted outside Resident #96's room. LPN #6 performed hand hygiene, donned gloves, and prepared the IV antibiotic. LPN #6 then accessed Resident #96's midline IV catheter without wearing proper personal protective equipment (PPE), only wearing gloves during care and not wearing a gown. RN #3 entered the room, performed hand hygiene, donned gloves, and remained in the room during the procedure without donning a gown. Interview with LPN #6 on 6/16/26 at 12:57 PM identified Resident #96 was on EBP due to a midline IV catheter an indwelling medical device. LPN #6 identified a gown should have been worn when accessing Resident #96's midline IV catheter. LPN #6 indicated she did not wear a gown because she forgot. LPN #6 identified Resident #96 should have had a physician's order and an RCP addressing EBP and identified that although the Infection Preventionist usually enters the order and implements the care plan, any nurse is able to add them. Interview with RN #3 on 6/16/26 at 1:03 PM identified Enhanced Barrier Precautions required the use of a gown and gloves when accessing an indwelling medical device. RN #3 further identified LPN #6 should have worn a gown during the IV antibiotic administration. Subsequent to surveyor inquiry, the Resident Care Plan (RCP) was revised on 6/16/26 to identify Resident #96 was on Enhanced Barrier Precautions related to the midline IV catheter with interventions that included wearing a gown and gloves during high-contact care activities. Review of the facility Enhanced Barrier Precaution Policy undated, directed, in part, an order for Enhanced Barrier Precautions should be obtained for residents with indwelling medical devices, and that Enhanced Barrier Precautions include donning a gown and gloves during high contact activities, including accessing an indwelling medical device.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #19) reviewed for immunizations, the facility failed to ensure the pneumococcal vaccine was administered as requested by the resident. The findings include:Resident #19 was admitted to the facility in April 2025 and had diagnoses that included lung disease, respiratory failure, and heart failure.The Resident Influenza Vaccination form dated 4/3/25, signed by Resident #19, identified the resident consented to receive the pneumococcal conjugate vaccine (PCV20).The Resident Care Plan (RCP) dated 4/3/25 identified Resident #19 had a history of respiratory failure and lung disease. Interventions included use of a bilevel positive airway pressure (Bipap-non-invasive medical device that helps a person breathe) machine, nebulizer treatments (medical device that turns liquid/respiratory drugs into a mist for inhalation), and follow up appointments with pulmonologist. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had moderately impaired cognition. The assessment further identified Resident #19's pneumococcal vaccination status was up to date.Review of Resident #19's electronic medical record under the immunization section failed to identify any history of receiving or refusing the pneumococcal vaccine, and there was no documentation of a pending order or administration of the vaccine.Interview with Registered Nurse (RN) #3 the Infection Preventionist (IP), and RN #4 (Regional Director of Nursing) on 6/16/26 at 10:00 AM identified RN#3 assumed the IP role in March 2026. Both RN #3 and RN #4, indicated they were unaware of the reason why Resident #19 had not received the pneumococcal vaccination despite Resident #19 documented consent to receive the vaccine upon admission. RN #4 indicated Resident #19's family would be contacted to confirm whether they still wished for Resident #19 to receive the pneumococcal vaccine.Interview with Person #1 on 6/16/26 at 2:12 PM identified he/she did not recall being contacted by the facility regarding Resident #19 receiving the pneumococcal vaccine and stated he/she would be in agreement with Resident #19 receiving it.Review of the facility Pneumococcal Vaccine policy dated 11/24/22 directed, in part, each resident would be assessed for the pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. The pneumococcal vaccination was recommended for all adults 65 years and older who have not previously received any pneumococcal vaccine.Review of Center for Disease Control and Prevention recommendations identified pneumococcal vaccination is recommended for adults 65 years and older with comorbidities such as lung disease or heart disease who have never received a pneumococcal vaccine.

Based on observation, clinical record review, facility documentation, facility policy, and interviews, for one of one resident (Resident #8) reviewed for dignity, the facility failed to ensure a resident who was being fed was fed in a dignified manner. The findings include: Resident #8 had diagnoses that included diabetes, stroke, and muscle wasting. The Resident Care Plan (RCP) dated 4/22/26 identified Resident #8 was at potential nutritional risk. Interventions directed to provide and serve the prescribed diet and nutritional supplements as ordered.The physician's order dated 4/24/26 directed a carbohydrate-controlled diet with chopped food and thin liquids.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had intact cognition and required set-up assistance for eating. A physician's order dated 6/10/26 directed to provide feeding assistance by one staff member.Observation on 6/15/26 at 9:00 AM noted Nurse Aide (NA) #5 entered Resident #8's room with his/her breakfast tray. Resident #8 was seated nearly upright in bed with an overbed table positioned in front of him/her. NA #5 placed the tray on the overbed table, removed the napkin from the tray, and placed it on the resident's chest. NA #5 remained standing on the right side of the bed and began feeding Resident #8 cream of rice cereal. A bedside chair was available at the head of the bed on the right side; however, NA #5 did not use it. NA #5 stood over Resident #8 and fed him/her large, overfilled spoonfuls of cereal, with food falling from the spoon. Resident #8 coughed while eating the cereal. NA #5 then offered a sip of juice and resumed feeding another large spoonful of cereal, after which Resident #8 coughed again. NA #5 again provided juice. After Resident #8 consumed approximately one-half of the cereal, NA #5 offered yogurt. NA #5 fed Resident #8 overfilled spoonfuls of yogurt, and Resident #8 coughed again. NA #5 provided another sip of juice and continued feeding Resident #8 while remaining in a standing position. Resident #8 consumed the entire serving of yogurt in approximately eight heaping spoonfuls.NA #5 then opened a carton of chocolate milk, and Resident #8 consumed two sips. NA #5 asked Resident #8 if he/she had enough to eat while Resident #8 was coughing. Resident #8 nodded affirmatively. At 9:11 AM, NA #5 removed the tray and exited the room.Interview with NA #5 on 6/15/26 at 9:12 AM identified she had been trained to sit while feeding residents but could not recall when the training occurred. NA #5 indicated staff should sit at eye level, converse with the resident, provide small bites, and alternate bites with fluids. NA #5 identified she did not sit while feeding Resident #8 despite seeing the available chair because she felt physically hot and busy that morning. NA #5 identified she should have sat down while feeding Resident #8. Interview with the Director of Nursing Services (DNS) on 6/15/26 at 9:00 AM identified her expectation was staff providing feeding assistance should sit next to the resident at eye level, engage the resident in conversation, offer fluids between bites, and provide only one-half to one spoonful of food at a time. The DNS stated NA #5 should not have stood while feeding Resident #8 and should have used the chair available in the room to maintain the resident's dignity.Subsequent to surveyor inquiry, the DNS provided staff education that included sitting next to residents during feeding assistance, providing appropriate-sized portions on utensils, offering liquids between bites, remaining focused on the feeding task, and engaging residents in conversation as appropriate.Review of the Meal Supervision and Assistance policy dated 10/27/25 directed, in part, to ask the resident the order in which he/she prefers to eat the food, feed slowly allowing plenty of time between bites, continue feeding the resident until he/she has had enough food or until the meal is finished. Be sure the residents' faces and hands are washed after he/she has finished the meal. Provide a relaxing and enjoyable environment during mealtimes.

Based on observations, staff interviews, facility documentation, and facility policy during a tour of the Food Services Department, the facility failed to ensure dishwasher temperatures were maintained according to the manufacturer's requirement to adequately sanitize dishware. The findings include: Interview and observation of the dishwashing process with the Director of Food Services and Dietary Aide (DA) #1 on 12/5/24 at 1:37 PM identified a wash cycle temperature of 148 degrees Fahrenheit (F) and a rinse cycle temperature of 150 degrees F. According to a mounted metal NSF Data Plate on the front of the unit, dishwashing temperatures for the hot water sanitizing cycle should have a wash tank minimum temperature of 160 degrees F, and a final sanitizing rinse minimum temperature of 180 degrees F. The observed temperatures failed to meet the manufacturer's requirement to ensure adequate hot water sanitization temperatures. The Director of Food Services identified that sometimes the cycle needed to be run a couple of times to get the temperature up to the minimum manufacturer's requirement, he restarted the cycle several more times on the same tray of dishes (12 plastic bowls) and although during the repeated cycles the rinse cycle rose to 188 degrees F, the wash temperature never reached the required minimum of 160 degrees F. Interview and review of the December 2024 dishwasher temperatures logs with DA #1 identified she recorded a wash temperature of 145 degrees F and a rinse temperature of 160 degrees F as well as all the other recorded wash and rinse temperatures being below the requirement. DA #1 stated that dishwasher temperatures below the required minimums were a common occurrence, and although the dish washing log had the correct temperature parameters listed on the bottom of the page including a directive to stop washing and alert the manager or designee, she stated she had not followed the facility policy. The Director of Food Services indicated that the unit had been scheduled for service the following day and that, going forward, the chemical sanitizing method would be used until the unit was serviced, inspected, and considered operational by the service technician. Subsequent to surveyor inquiry, the Director of Food Services indicated the current dishes as well as the previous 2 loads could not be deemed adequately sanitized based on the wash temperatures not meeting the minimum manufacturer's requirements. The Director of Food Services switched the unit to perform chemical sanitizing, the minimum chemical sanitizing temperatures were noted to be met, and he stated he would start the rewashing process to properly sanitize all 3 loads. Review of the Ware washing policy dated 9/2017 identified, in part, the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware. Further, the policy indicated that all dish machine water temperatures would be maintained in accordance with the manufacturer's recommendations for high temperature or low temperature machines.

Based on observations, facility documentation, interviews, and facility policy , the facility failed to ensure resident food was served at a safe temperature and was appetizing. The findings include: Review of the facility monthly Food Committee Meeting minutes dated 10/30/24 and 11/26/24, identified that residents complained that the soup and coffee was served cold. Interview with Resident Council attendees on 12/4/24 at 11:00 AM indicated food was not served at a safe and appetizing temperature approximately 50% of the time. Observation on 12/5/24 at 12:11 PM identified dietary staff were preparing to plate food. A test tray was requested. The cook indicated the steam tray temperature was 150 degrees Fahrenheit (F) prior to initiating plating. The plates were maintained in a plate warmer until ready for use. After dietary aids put beverages and a desert on the trays, an insulated cover was placed over the plate. All trays were loaded onto a metal serving cart, the test tray was placed as the final tray, and the cart left the kitchen at 12:25 PM. Observation on 12/5/24 at 12:26 PM identified the meal cart was delivered to the Colonial A unit. The first tray was removed by nursing assistant at 12:27 PM and taken to a resident's room. After all other trays had been delivered, the test tray was removed from the cart at 12:39 PM. Both the Food Service Director and Surveyor used calibrated thermometers to check the temperatures of the food as follows: Pork chops with gravy: surveyor temp 118 degrees F/Food Service Temp 118.2 degrees F/Goal 135 degrees F; Mashed Potatoes: surveyor temp 119.4 degrees F/Food Service Temp 120 degrees F/Goal 135 degrees F; Hot beets: surveyor temp 111 degrees F/Food Service Temp 111 degrees F/Goal 135 degrees F; Milk: surveyor temp 46 degrees F/Food Service Temp 46 degrees F/Goal 41 degrees F. The Food Service Director identified that the test tray temperatures were not appropriate according to the set requirement. Review of the facility policy for Food Quality and Palatability identified food and drinks must be served at a safe and appetizing temperature to meet resident's needs.

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for pressure ulcers, the facility failed to ensure weekly skin checks (body audits) were conducted per the physician orders, and failed to ensure that a Registered Nurse (RN) assessment was conducted for a resident who was readmitted to the facility with a pressure ulcer. The findings include: Resident #39's diagnoses included a stage 4 pressure ulcer, failure to thrive, and dementia without behaviors. A. The quarterly Minimum Data Set (MDS) assessment date 1/17/23 identified Resident #39 was severely cognitively impaired and required assistance of 1 staff member for bed mobility. The Resident Care Plan in effect from 3/1/23 through 4/30/24 identified a stage 4 pressure area to the coccyx, continue with treatments as ordered, and weekly skin checks on shower days. Physician's orders dated 3/1/23 through 4/30/23 directed weekly body audits on shower days. A physician's order dated 3/22/24 directed a body audit on admission, daily for 3 days then once per week on Fridays. An interview and clinical record review with the DNS on 12/4/24 at 12:40 PM, failed to identify documentation that body audits had been completed weekly per the physician orders from 4/7/23 to 6/30/23. Additionally, the clinical record failed to reflect documentation that skin assessments had been completed per the physician orders from 3/23/24 to 4/18/24 daily for 3 days, then weekly. Interview with RN #3 on 12/4/24 at 1:00 PM identified that there was an issue with the lack of weekly body audits being completed from 4/7/23 through 4/18/24, and that per the facility practice, weekly body audits were completed by the charge nurse and any new skin issues were documented weekly on the body assessment form. Re-interview with the DNS on 12/5/24 at 9:45 AM identified that the charge nurses along with Resident #39's assigned NA were responsible for ensuring weekly body audits were completed as ordered on the appropriate weekly body audit form and that most residents had body audits scheduled on their shower days. B. Review of the hospital discharge summary dated 3/22/24 identified Resident #39 had a pressure ulcer. A readmission Nursing Assessment completed on 3/22/24 at 10:48 PM by Licensed Practical Nurse (LPN) #5 identified a stage 2 coccyx wound but failed to identify measurements of the wound and failed to describe the wound appearance. Further review of the clinical record, failed to identify that Resident #39's pressure ulcer (coccyx wound) had been assessed by a Registered Nurse (RN). A readmission physician's order dated 3/22/24 directed to cleanse Resident #39's coccyx with normal saline pack wound with Aquacel AG and cover with dry, clean dressing. Review of Registered Nurse (RN) #2's admission nurse's note dated 3/22/24 at 6:40 PM identified that although Resident #39 had been readmitted with a coccyx pressure ulcer there was no RN assessment or measurement of the wound in the nurse's note or on Resident #39's readmission form. Resident #39's Resident Care Plan dated 3/24/24 indicated he/she returned from the hospital with a stage 4 pressure that was unchanged. Interventions directed to assist with positioning every 2 hours, provide pressure relieving/reducing devices to bed and chair, skin checks on shower days, and treatment to the coccyx as ordered. Review of Resident #39's facility wound physician note dated 3/25/24 identified a stage 4 pressure area (not stage 2 per LPN #5). Additionally, the area was measured and noted to be 1.5 cm long (centimeters) by 1 cm wide and 0.5 cm deep with undermining (separation of skin from underlying tissue). Interview and clinical record review with LPN #5 on 12/4/24 at 3:00 PM identified that LPN #5 had staged Resident #39's wound but failed to document any measurements. LPN #5 stated that there was a lot going on when Resident #39 was admitted and could not recall if RN #2 had come to assess the resident's pressure ulcer. LPN #5 identified that the facility practice was for the RN to assess pressure ulcers and document the results on the admission/readmission assessment. Interview and clinical record review with RN #2 on 12/4/24 at 3:20 PM identified that she was not aware LPN #5 had staged Resident #39's pressure ulcer until reviewing the clinical record with the surveyor. RN #2 indicated that the LPN does not normally stage a pressure ulcer. Although RN #2 stated she must have seen the wound as she had written a note indicating the pressure ulcer was present, she was unable to explain why there was no assessment or measurement of the wound in the clinical record. Interview with the DNS on 12/5/24 at 9:45 AM identified that the nurses (RNs and LPNs) would usually assess resident wounds together upon admission or readmission to the facility. The DNS identified that the RN was responsible for assessing and documenting a pressure ulcer which included measurements and characteristics of the wound. Review of the Pressure Injury Prevention and Management Policy dated 12/15/22 directed, in part, that pressure ulcer monitoring would be completed by the RN Unit Manager or designee to review all relevant documentation including pressure injury risks, progression towards healing and compliance at least weekly and document the summary of findings in the medical record. Additionally, licensed nurses would conduct a full body skin assessment on all new admissions and re-admissions, weekly, and after any newly identified pressure injury and that findings would be documented in the medical record.

Based on observations, review of the clinical record, facility policies and interviews for the only sampled resident (Resident #22) reviewed for positioning and mobility, the facility failed to apply a left wrist hand splint as ordered. The findings include: Resident #22's diagnoses included Cerebral Vascular Accident (CVA), contracture of left hand joint, and flaccid hemiplegia affecting left dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had intact cognition and was dependent with bed mobility, transfers and activities of daily living including upper body dressing. The Resident Care Plan dated 11/28/24 identified Resident #22 had a self-care deficit related to a CVA and was at risk for further contractures. Interventions included instructions for a left wrist brace to be worn when out of bed and during transfers. A physician's order dated 6/16/20 and currently in effect directed the left-hand splint to be worn from 7:00 AM to 3:00 PM. Further instructions noted for the 7:00 AM to 3:00 PM shift were to don (apply) the left hand splint with morning (AM) care, and doff (remove) the left-hand splint with last rounds on the 7:00 AM to 3:00 PM shift. Observation on 12/2/24 at 12:38 PM identified Resident #22 was lying in bed, alert, verbal and appropriately answering questions. Additionally, Resident #22 was not wearing a left-hand splint. Observation on 12/3/24 at 11:45 AM noted Resident #22 was lying in bed, without the benefit of a left-hand splint being applied. Observation on 12/4/24 at 1:12 PM identified Resident #22 was seated in his/her wheelchair in the hallway. Additionally, it was noted Resident #22 was wearing a left lower leg brace, but a left-hand splint was not applied. Interview with Nurse Aide (NA) #3 on 12/4/24 at 1:32 PM identified that she was the NA providing care for Resident #22. NA #3 noted that she usually would put the left-hand splint on Resident #22 for a couple of hours in the afternoon when Resident #22 was out of bed. Further interview with NA #3 and observation at that time, identified instructions for splinting that were taped to the wall in Resident #22's room which indicated to apply a left-hand splint at 7:00 AM, with instructions directing how to apply the left-hand splint. NA #3 stated that the information was in the electronic health record (EHR) directing how to care for Resident #22. Review of the task section (with an original date of 9/7/17 and currently in effect) in the EHR noted splint application/removal. apply to left hand 8:00 AM to 12:00 PM and then 2:00 PM to 6:00 PM daily. Remove 12:00 PM to 2:00 PM and 6:00 PM, check skin for redness and report to charge nurse (which was a discrepancy from the physician orders to wear the left-hand splint from 7:00 AM to 3:00 PM). Further instructions noted for the 7:00 AM to 3:00 PM shift directed to don (apply) the left hand splint with morning (AM) care and doff (remove) the left-hand splint with last rounds on the 7:00 AM to 3:00 PM shift. NA #3 identified she had placed the left hand splint on Resident #22 for a couple of hours in the afternoon because that was what she had been instructed. Interview with Physical Therapist (PT) #1 on 12/5/24 at 1:26 PM indicated Resident #22's left hand splint should be donned on the 7:00 AM to 3:00 PM shift, applied during AM care and doffed on last rounds per the physician orders. PT #1 provided the splinting and orthotics schedule located in the therapy office, which indicated to apply a left hand splint to be worn on the 7:00 AM to 3:00 PM shift and off on last rounds on the 7:00 AM to 3:00 PM shift. Interview with the Director of Nurses (DNS) on 12/6/24 at 10:21 AM identified the NA would know how to care for a resident by referring to the instructions in the EHR. Review of the EHR with the DNS indicated a discrepancy between the instructions on the physician orders and the instructions in the task section of the EHR. Additionally, the DNS determined there was a transcription discrepancy when the physician orders were inputted into the EHR task section by a licensed staff who no longer worked at the facility. Re-interview with PT #1 on 12/6/24 at 10:30 AM noted PT #1 if the left-hand splint was not applied for a day or so, it wouldn't affect the contracture, but not wearing for long durations would not prevent further contractures, which was the purpose for the utilization of the hand splint. Review of the Prevention of Decline in Range in Motion policy dated 1/27/23 directed, in part, a nurse with the responsibility for the resident to monitor for consistent implementation of the care plan interventions. The Assistive Devices and Equipment policy updated in 2019, indicated that staff and volunteers were trained and demonstrate competency on the use of assisted devices prior to assisting residents.

Based on staff interviews, review of the clinical record, and review of facility policy for 2 of 5 sampled residents, (Resident #44 and Resident #281), reviewed for nutrition/hydration status, for Resident #44 the facility failed to weigh the resident monthly, failed to reweigh the resident after a 5 pound weight loss, and failed to ensure the dietician re-evaluated the resident after a weight loss and per the physician's order, and for Resident #281 failed to complete and appropriately document weights for a resident who was newly admitted , underweight and malnourished. The findings include: 1. Resident #44's diagnoses included atrial fibrillation, repeated falls, and Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and was independent after set up for eating. The Resident Care Plan (RCP) dated 11/5/24 identified Resident #44 had an actual nutrition risk. Interventions included providing nutritional supplements as ordered and monitoring weights for significant weight loss. The physician orders in effect for September 2024 through December 2024 directed to weigh Resident #44 monthly. Review of Resident #44's weight records identified on 9/27/24 he/she weighed 103.8 pounds (lbs.), the record failed to indicate an October weight, on 11/9/24 Resident #44 weighed 97.2 lbs. (6.6 lbs. a 6.4 % loss) and on 11/27/24 he/she weighed 97.9 lbs. The weight record failed to identify that following weight loss on 11/9/24 or 11/27/24 the resident was re-weighed for accuracy. Advanced Practice Registered Nurse (APRN) #1's progress note dated 11/19/24 indicated a need for the dietician to evaluate Resident #44 for decreased oral intake, weight loss, and protein and calorie malnutrition. Interview with Dietician on 12/6/24 at 12:10 PM identified she was responsible for reviewing all facility resident weights weekly to identify weight changes. The Dietician reported that she was unaware of the facility weight policy for weighing residents who had weight loss as she had never been given a copy. Although the Dietician indicated that she had made recommendations and had physician's orders for interventions for Resident #44's weight loss, she was unable to locate a nutritional assessment that would have re-evaluated calorie needs, fluid needs, intake amounts, and addressed the overall weight loss, but that she had not completed the Nutritional Assessment. The Dietician also indicated she would likely have made a recommendation for weekly weights due to the weight loss for Resident #44 if the evaluation had been completed. Interview with NA #3 on 12/6/24 at 12:25 PM identified the Weight Assessment and Intervention policy and procedure was to be followed for significant weight loss and directed to reweigh residents for accuracy when weight loss occurred. NA #3 reported weights were conducted on shower days during the first week of the month and the policy required notification to the unit nurse when there was a significant weight loss. NA #3 could not recall if notification was made in November. Additionally, NA #3 could not recall why Resident #44 was not weighed at all in October 2024. Interview with DNS and RN #1 on 12/6/24 at 12:35 PM identified they were not aware Resident #44 had a significant weight loss. The DNS indicated the resident should, ideally, be re-weighed after a significant weight loss to verify accuracy of any weight loss within 24-48 hours. The DNS indicated Resident #44 had not been re-weighed in November according to the time frame. 2. Resident #281's diagnoses included dementia, severe sepsis with septic shock, and urinary tract infection. The Admission assessment dated [DATE] identified Resident #281 was non-verbal and cognitively impaired. The Admission Assessment indicated Resident #281 required substantial/maximal assistance with eating, was a 2-person physical assist/dependent for transfers. The Admission Assessment indicated Resident #281's most recent weight to be 120 pounds with a date of 1/4/22. The admission assessment was signed by the Registered Nurse Supervisor on 12/1/24. The Resident Care Plan dated 11/30/24 identified actual nutritional risk secondary to being underweight with total feeding assistance and need for a therapeutic diet. Interventions included to provide diet as ordered, feed/assist with meals and snacks and that the registered dietician was to evaluate and make diet change recommendations as needed. A physician's order dated 11/30/24 directed to weigh Resident #281 on admission then weekly one time a day every Tuesday. A nursing progress note dated Tuesday, 12/3/24 at 8:28 PM indicated the facility was unable to weigh Resident #281 due to a broken scale. A Nutrition Evaluation completed by the dietician dated 12/3/24 identified that Resident #281 was underweight and the most recent weight dated 1/4/22 was 120 pounds. The Nutrition Evaluation indicated that there was no admission weight completed or documented, nursing was made aware, and a weight was requested. Additionally, the Nutrition Evaluation identified Resident #281's weight per the hospital electronic medical records (EMR) was 135 pounds on 11/24/24, the resident had low muscle and fat mass, and had a history of being underweight. Interview with NA #5 on 12/5/24 at 12:45 PM identified that Resident #281 should have been weighed upon admission and weights must be completed for every admission. NA #5 indicated that Resident #281's weight should have been done by the NA assigned to the resident when he/she was admitted to the facility, and she was unsure why a weight was not taken. Interview and record review with LPN #4 on 12/5/24 at 12:53 PM identified that Resident #281's weight should have been obtained by the assigned NA on admission and she was unsure why the weight had not been taken. LPN #4 indicated that she normally would catch that an admission weight was not completed and documented a nurses note, but that she must have missed the omission. Review of the clinical record with LPN #4 failed to identify a weight had been completed and documented for Resident #281 since admission. Interview and record review with DNS on 12/5/24 at 1:00 PM identified Resident #281 was new to the facility and should have been weighed upon admission. The DNS indicated it would have been up to the NA or nurse assigned to obtain a weight for Resident #281. The DNS identified she was unsure why Resident #281's weight had not been obtained and documented on admission, and had not been informed a scale was broken. Review of the clinical record with the DNS failed to identify a weight had been completed and documented since Resident #281's admission. Subsequent to surveyor inquiry, on 12/5/24 at 1:26 PM Resident #281 was observed being weighed in his wheelchair by a NA with a recorded weight of 114.2 pounds. Interview and record review with the Dietician on 12/6/24 at 10:00 AM identified that when she conducted Resident #281's Nutrition Evaluation on 12/3/24, she informed the nursing supervisor that the resident did not have an admission weight completed and documented in his/her clinical record and requested a weight be obtained. The Dietician indicated that Resident #281 would be classified as malnourished and underweight with low muscle and fat mass with an ideal body weight of 141 pounds. The Dietician identified that if she had known Resident #281 weighed 114.2 pounds and not 135 pounds (per the hospital electronic medical record she accessed from 11/24/24), she would have changed her nutrition recommendations to add fortified super cereal to Resident #281's daily diet. The Dietician indicated that although she needed to complete a new nutritional assessment for Resident #281 due to the weight discrepancy, she would put the resident on her high-risk list for closer monitoring. Review of the Dietician's document titled Dietician On-Site Visit dated 12/3/24 identified Resident #281 had not had an admission weight completed or documented and that the weight entered on his Admission Assessment was dated 2022. The Dietician indicated that at the conclusion of her visit to the facility on [DATE], she made copies of her Dietician On-Site document and gave copies to the nursing supervisor and the DNS. The Dietician further identified that she was not aware of the scale being broken and that upon Resident #281's admission to the facility, she would have expected nursing to complete and appropriately document the resident's weight in the clinical record where it could have been accessed by her. Review of the facility policy, Weight Assessment and Intervention, undated, directed that any weight change of 5 lbs. or more since the last weight would trigger that the weight be retaken. If the weight was verified and was determined to be a weight loss, nursing would consult with the dietician, MD, and family/responsible party. Additionally, nursing staff will measure a resident's weight on the day of admission, the day after and weekly for 4 weeks, and weights would be recorded in each resident's medical record. 50249 Surveyor: [NAME], [NAME] A. 51867

Based on observations, interviews, review of the clinical record, and facility policy for 2 of 5 residents (Resident #41 and Resident #59) reviewed for infection control, the facility failed to ensure appropriate Personal Protective Equipment (PPE) use during high contact care for residents who required Enhanced Barrier Precautions (EBP). The findings include: 1. Resident #41's diagnoses included peripheral vascular disease, diabetes, and chronic kidney disease. A physician's order dated 5/31/24 directed EBP to be maintained every shift for chronic wounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #41 was cognitively intact and dependent for toileting, bathing, personal hygiene, transfers, and dressing. The Resident Care Plan in effect from 12/1/24 through 12/4/24 identified that Resident #41 was on EBP for leg lymphedema. Interventions directed to wear gloves and a gown when changing contaminated linens and place soiled linens in bags marked biohazard. Review of the Kardex dated 12/4/24 identified Resident #41 was on EBP for chronic wounds and directed staff to wear a gown and gloves when performing high contact activities. Observation of Resident #41 and NA #2 on 12/4/24 at 6:50 AM identified visible signage outside the resident's door that directed staff must wear gloves and a gown when performing high contact activities. A cart containing disposable isolation gowns and other PPE was noted outside of Resident #41's room and NA #2 was observed to be providing high contact care. An interview with NA #2 on 12/4/24 at 6:50 AM identified that Resident #41 was on EBP and the blue dot next to the resident's name outside the door indicated that the resident was on EBP. NA #2 stated that staff should wear gloves and a gown when care and treatments were provided for a resident with chronic wounds. NA #2 identified that she should have been wearing PPE, but she was rushing. Additionally, NA #2 indicated she was unaware of the facility policy. An interview with the Director of Nursing (DNS) on 12/4/24 at 8:06 AM identified that she had observed NA #2 not wearing PPE on 12/4/24 at 6:50 AM. The DNS indicated that all staff had been educated on wearing appropriate PPE and educated that the blue dot next to the resident's name directed the use of EBP. The DNS was unable to identify why NA #2 was not wearing proper PPE during the provision of high contact care for Resident #41, she should have been, and further stated that she would provide the facility policy. 2. Resident #59's diagnoses included a stage 3 pressure ulcer, severe obesity, and type 2 diabetes. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was cognitively intact, required maximal assistance with personal hygiene, and was dependent with chair to bed and bed to chair transfers. The Resident Care Plan (RCP) dated 9/30/24 identified a risk for infection requiring EBP use related to a chronic pressure ulcer on the left buttocks. Interventions included EBP and the resident required the use of gown and gloves during dressing, transferring, and wound care. An observation on 12/2/24 at 10:36 AM identified signage posted on Resident #59's door which was visible prior to entry, indicating EBP with directions that providers and staff must wear gloves and a gown for high contact activities. Nurse Aide (NA) #1 was not observed to be wearing any PPE while providing care to Resident #59. An interview with NA #1 on 12/2/24 at 10:40 AM identified she had been bathing Resident #59, using a basin and washcloth, and changed his/her sheets. NA#1 indicated she was aware that PPE should be worn prior to providing care to a resident in a room that was identified to require the use of EBP. NA #1 stated that she had not worn PPE because she had forgotten to do so. Review of the facility's Enhanced Barrier Precautions policy identified that staff members are to wear gloves and a gown during high contact resident care activity (dressing, bathing, transferring, changing linens, etc.) for residents on EBP. 51182

Based on clinical record review, observations, and interviews for the only sampled resident (Resident #5) reviewed for respiratory care, the facility failed to follow a hospital discharge order for specialist consultation. The findings include: Resident #5 's diagnoses included end stage renal disease, urinary tract infection, and heart failure. Review of the hospital discharge summary dated 8/4/24 directed that Resident #5 follow up with a nephrologist in 1 week. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was cognitively intact, and dependent with bed mobility, transfers, personal hygiene, bathing, and dressing. Review of the Advance Practice Registered Nurse (APRN) #1 Progress Note dated 10/28/24 identified that Resident #5 had chronic kidney disease and the plan was for the Resident #5 to follow-up with a nephrologist as recommended. Additionally, Resident #5 had experienced a hypotensive (low blood pressure) episode and was supposed to follow-up with a nephrologist after her/his hospital stay in August. Further review of the clinical record failed to identify Resident #5 was seen by a nephrologist until 11/18/24. Following the nephrology consultation, orders directed Resident #5 to avoid nephrotoxins and renal dose medications and that Resident #5 should be seen again in follow-up in 3 months. An interview with Resident #5 on 12/4/24 at 12:10 PM identified that if he/she had known about the hospital discharge instruction to follow up with a nephrologist in 1 week after discharge from the hospital in August, he/she would have requested the consultation to have been scheduled timely. An interview with APRN #1 on 12/4/24 at 1:11 PM identified that Resident #5 was to follow up with a nephrologist after her/his discharge from the hospital on 8/4/24. APRN #1 identified that she did not ask Resident #5 if he/she would like to follow up with the nephrologist and she was not sure if anyone else had spoken to the resident regarding an appointment with the nephrologist. APRN#1 further identified that the hospital discharge orders were recommendations and that the recommendations were reviewed and considered, but that she had felt it was unnecessary for Resident #5 to follow up with the nephrologist and the facility does what's appropriate for the residents.

Based on observations, review of the clinical record, facility policy and the interview for the only sampled resident (Resident #22) reviewed for activities of daily living, the facility failed to maintain clean and trimmed fingernails. The findings include: Resident #22 diagnoses included cerebral vascular accident (CVA), joint derangement, contracture, and left flaccid hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #22 had intact cognition and was dependent of 1 for upper/lower body dressing, and personal hygiene. The Resident Care Plan dated 11/28/24 identified Resident #22 had a self-care deficit related to a CVA and was at risk for further contractures. Interventions included to provide assistance of 1 for bathing, check skin, trim nails on bath day, and report any new abnormal skin areas to the charge nurse. A physician's order dated 12/4/24 directed a body audit every week on shower day. Observations on 12/2/24 at 12:38 PM, 12/3/24 at 1:00 PM, and 12/4/24 at 9:20 AM, identified Resident #22 fingernails were soiled with a brownish debris below the nailbeds and nails were abnormally lengthy. Observation on 12/4/24 at 1:10 PM identified Resident #22's fingernails were noted to be soiled with a brownish debris below the nailbeds and lengthy. Additionally, Resident #22 identified his/her nails were lengthy and he/she did not like them to be so long. Resident #22 identified that he/she had not requested his/her nails to be cleaned/trimmed because it was not up to me. Interview with Nurse Aide (NA) #3 on 12/5/24 at 1:54 PM identified that Resident #22 had a bath on 12/3/24 (Tuesday) and should have had nail care done at that time. NA #3 identified that although she did not provide Resident #22 a bath on 12/3/24, she did provide morning care to the resident on 12/4/24 and 12/5/24. NA #3 observed that Resident #22's nailed were long/soiled, should have been cleaned and trimmed, but she did not complete nail care due to being too busy. Interview with the DNS on 12/5/24 at 2:45 PM identified the NA was responsible to cut and clean resident's nails, and the nurse was responsible to oversee the task was completed. Review of the Care of Fingernail and toenails policy directed, in part, directed colleagues to review the resident's care plan to assess for any special needs of the resident. According to the policy, nail care would include cleaning and regular trimming.

Based on staff interviews and review of the clinical record for the only sampled resident, (Resident #44), reviewed for Activities of Daily Living (ADL's), the facility failed to prevent a decline in transfer and ambulation (walking) abilities. The findings include: Resident #44's diagnoses included atrial fibrillation, repeated falls, and Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 had severe cognitive impairment, required substantial/maximum assistance for chair to bed and bed to chair transfers, partial/moderate assistance for sit to stand ability, and had not been ambulating. The Resident Care Plan (RCP) dated 7/10/24 identified Resident #44 had a deficit in ADL self-care performance. Interventions included ambulate with an assist of 1 with a rolling walker (RW) with a wheelchair (WC) to follow twice a day for 200 feet. A physician's order dated 8/14/24 directed staff to ambulate Resident #44 twice a day to prevent a decline in function. Review of the 9/1/24 to 9/30/24 Nurse Aide (NA) flowsheet documentation identified Resident #44 rarely walked in the hallway. Further review identified Resident #44 ambulated in his/her room [ROOM NUMBER] out of 60 opportunities for the month of September (36 missed opportunities). Review of the 10/1/24 to 10/31/24 NA flowsheet documentation identified that Resident #44 did not ambulate in the hallway and that he/she walked in his/her room for a total of 21 out of 62 opportunities for the month of October (41 missed opportunities). Review of the 11/1/24 to 11/30/24 NA flowsheet documentation identified that Resident #44 did not ambulate in the hallway and that he/she walked in his/her room for a total of 4 out of 60 opportunities for the month of November (56 missed opportunities). An interview with NA #3 on 12/4/24 at 10:45 AM identified that Resident #44 had a decline in his/her ability to walk and transfer, and now required increased assistance from staff to wlk and transfer. NA #3 indicated that she had not notified anyone of Resident #44's decline. An Interview with Licensed Practical Nurse (LPN) #2 on 12/4/24 at 1:35 PM identified she did not think Resident #44 was able to ambulate currently and was definitely not ambulating 200 feet according to the RCP. An interview with Rehabilitation Director, Physical Therapist (PT) #1 on 12/4/24 at 12:18 PM identified that Resident #44 had not been evaluated by PT recently and that he/she was due for a routine quarterly evaluation around January of 2025. PT #1 had not been notified that Resident #44 had a decline in his/her ability to walk and transfer. Further PT #1 indicated had he been notified sooner; he would have scheduled Resident #44 for an evaluation to determine Resident #44's status. Re-interview with LPN #2 on 12/5/24 at 2:35 PM identified that subsequent to surveyor inquiry, she had been informed by NA #3 of Resident #44's substantial decline in ambulation and transfers. LPN #2 indicated that while she had known the resident had not been ambulating; after speaking with NA #3 and the surveyor, she had placed a request for PT to evaluate Resident #44 due to his/her decline. An interview with PT #1, the Director of Nursing Services (DNS), and Registered Nurse (RN) #1 on 12/6/24 at 1:00 PM identified that Resident #44 would be evaluated by PT in the near future due to the resident's decline in ability to ambulate and if there was a decline Resident #44 would be scheduled for rehabilitation services to try and regain lost function.

Based on interviews, review of clinical record, and facility policy for the only sampled resident, (Resident #27), reviewed for personal property, the facility failed to report the loss of a resident's personal belonging to the State Agency within the 24-hour time requirement. The findings include: Resident #27's diagnoses included Huntington's disease, major depressive disorder, and bilateral cataracts. The annual Minimum Data Set assessment dated [DATE] identified Resident #27 had long and short term memory loss and was dependent with personal hygiene, dressing, and required maximal assistance for chair to bed and bed to chair transfers. The Resident Care Plan (RCP) dated 12/10/23 identified Resident #27 was at risk for impaired visual function related to cataracts. Interventions included the wearing of glasses, and monitoring for signs and symptoms of acute eye problems including changes in ability to perform activities of daily living and blurred vision. A Complaint and Concern Log form dated 12/18/23 identified a family member reported the loss of Resident #27's bracelet. Interviews attached to the form failed to identify the time of the report by the family member. Although the facility conducted a search of the room and shower room, they were not able to locate the bracelet. Social services, nursing, and the Administrator were made aware of the lost bracelet and interview investigation forms were obtained from 9 staff members, 2 of whom provided care for Resident #27 during the time in which the bracelet went missing. An interview with Person #2 on 12/5/24 at 11:38 AM identified Resident #27's bracelet was a thick chain link 14 Karat (K) gold bracelet, measuring 6 1/4 inches in length and engraved with security information and numbers to call if the resident got lost. Person #2 noted the bracelet had a secure clasp and was valued at over $200. He/she further indicated that after reporting the loss of the bracelet to the Supervisor he/she was informed the police could be called if he/she believed it was necessary. An interview with the facility Administrator and DNS on 12/5/24 at 12:06 PM identified that the Administrator was aware of the lost bracelet. If the bracelet was stolen, she would have reported the incident to the police and to the state agency within 2 hours, however the Administrator failed to identify she had any evidence the bracelet had not been stolen. Further, the Administrator indicated that due to the engraving no one would have stolen the bracelet from Resident #27 and the engraving devalued 14K bracelet. Review of the facility's Resident Personal Belongings/Missing Items Policy identified that the facility protects the rights of a resident to possess personal belongings, Although the facility had a missing item policy, the policy failed to identify what action the facility would take upon the identification of a missing item. Review of the facility's Abuse policy identified that in cases of Misappropriation of resident property with no injury a report is to be filed within 24 hours to both the State Agency and law enforcement, and a written follow-up report would be sent to the State Agency within 72 hours of the incident and include a copy of the Accident/Incident report.

Based on interviews and record reviews for the only sampled resident, (Resident #329), reviewed for advance directives, the facility failed to ensure the advance directives consent was signed and available. The findings include: Resident #329's diagnoses included traumatic subdural hemorrhage, history of traumatic brain injury, and epilepsy. The hospital Interfacility Transfer Summary (W-10) dated [DATE] identified Resident #329 had a status of DNR/DNI (do not resuscitate/do not intubate). The physician's order dated [DATE] directed for Resident #329 to be a full code, indicating that cardiopulmonary resuscitation (CPR) was to be performed. The admission Minimum Data Set assessment dated [DATE] identified Resident #329 had a Brief Interview of Mental Status (BIMS) of 9 indicating moderate cognitive impaired and she/he required partial/moderate assistance for eating and substantial/maximal assistance needed for toileting and dressing. The Resident Care Plan dated [DATE] identified Resident #329 was to be provided with CPR (fully coded). Interventions included to provide end of life care per the resident's wishes, discuss code status with resident/family/responsible party, and have the advance directive consent signed. Interview and clinical record review with the Director of Nurses (DNS) on [DATE] at 11:00 AM failed to identify an available signed advance directive. Although the packet was noted to be in the chart, the advance directive form remained blank. The DNS indicated that facility practice was to obtain a code status within 24 hours of admission. A follow up interview with the DNS on [DATE] at 10:08 AM identified the facility policy for advance directives required the supervisor or charge nurse to review the code status paperwork with the resident or responsible party upon admission and then obtain a physician's order to reflect the resident's wishes. She believed the paperwork was not signed because Resident #329's responsible party was not available. An interview and record review with APRN #1 on [DATE] at 9:40 AM identified resident code status' should be obtained within 24 hours of admission and that she had reviewed the code status with Resident #329 on [DATE]. APRN #1 stated that aside from her/his aphasia (speaking/understanding deficit) Resident #329 was able to make her/his needs known and answered yes when presented with the full code option for resuscitation code status. Review of the hospital W-10 with APRN #1 indicated that although Resident #329 was discharged with a status of DNR, APRN #1 denied talking to Resident #329's responsible party to clarify the advance directive wishes because the phone number on file did not work adding in the world we live in she/he defaults to being a full code just like someone on the street would. An interview on [DATE] at 10:40 AM with Registered Nurse (RN) #1 identified that the facility policy required the RN supervisor to review and obtain signatures on the advance directives paperwork, if a residents BIMS (brief interview of mental status determining cognitive status) was over 13 (intact) then the resident reviewed and signed the advance directives paperwork. If the BIMS was below 13, the advance directive paperwork was signed by the responsible party. RN #1 indicated that Resident #329's paperwork had not been completed because the responsible party had a lot going on, had been going back and forth with the code status decision, but the facility was able to speak to the responsible party on [DATE] verbally confirming Resident #329 DNR/DNI status wishes. Subsequent to surveyor inquiry, the advance directives paperwork was signed by the responsible party, RN supervisor, and APRN, to reflect a code status of DNR/DNI. A phone interview with Person #1 on [DATE] at 12:28 PM identified the facility had not contacted her/him upon the resident's admission to verify Resident #329's resuscitation code status. Person #1 indicated that she/he was the conservator of person for Resident #329 to make healthcare decisions. Although resuscitation paperwork had been sent to Person #1 on [DATE] no one had followed up with him/her regarding the resident's code status, and on [DATE] when she/he visited the facility with the paperwork, there was no one from administration available to speak with regarding the resident preferred code status. Person #1 identified that she/he spoke with RN#1 on [DATE] and approved Resident #329's DNR/DNI code status. Review of the Advance Directives Policy dated ,d+[DATE] directed in part that it is the resident's right to formulate an advance directive, and the facility would identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to advance directives during the care planning process.

Based on clinical record reviews, a review of facility documentation and interviews for one sampled residents (Resident#30) reviewed for accidents, the facility failed to provide the necessary assistive device to prevent an potential accident and /or for one of four sampled resident reviewed for smoking (Resident # 8), the facility failed to follow the resident plan of care regarding a smoking device to prevent a potential accident. The findings include: 1. Resident #30's [DIAGNOSES REDACTED]. The physician's order dated 6/30/16 directed to transfer the resident with limited assistance of one using a rolling walker and to provide limited assistance with toileting and/or upper body and lower body dressing. The care plan dated 6/30/16 identified a recent fall with facial concussion due to a self-care deficit with interventions that included to provide limited assistance of one for bed mobility, transfers and ambulation with a rolling walker. The admission MDS dated [DATE] identified the resident with intact cognitive skills, history of falls and noted an unsteady balance and that the resident was only able to stabilize with staff assistance. The care plan dated 7/12/16 identified falls secondary to vertigo with interventions that included to anticipate and meet resident's needs, Antivert (medication for dizziness), physical therapy and directed staff to apply the appropriate footwear. The nurse's notes dated 9/3/16 at 2:58 P.M. identified the resident vomited once, verbalized feeling dizzy and indicated the resident received Antivert medication in the morning as ordered. A review of the Medication Administration Record (MAR) identified Antivert 25 MG was administered as ordered at 10:00 A.M. and 6:00 P.M. to Resident #30. Further review of nurse's note dated 9/3/16 at 8:53 P.M. identified the nurse was called into the resident's room and the resident was observed lying on the bathroom floor on his/her left side against the door and complained of severe pain to the left hip and tenderness on the left occipital area. The resident was assessed by staff and noted with a significant ecchymotic area to the knuckles on the left hand and a hematoma on the right arm. Tenderness was noted to touch. The APRN was notified of the incident and directed staff to send the resident to the hospital. Review of the hospital discharge summary dated 9/5/16 identified the resident sustained [REDACTED]. Recommendations included to apply a sling for comfort to the right elbow, no surgical intervention needed and directed to follow-up with orthopedics within one week. Interview and demonstration with NA#14 on 11/7/16 at 3:05 P.M. identified that when assisting Resident #30 on 9/3/16 to stand up from the toilet and transfer to the sink to wash his/her hands, NA #14 did not use the rolling walker to transfer the resident from the toilet to the sink. NA#14 reached out for the rolling walker that was located outside of the bathroom and the resident fell to the floor. NA#14 indicated the resident reported feeling dizzy at the time of the fall. Observation and demonstration of the incident that occurred on 9/3/16 identified that when NA#14 reached out for the rolling walker, NA#14 turned and extend her/his torso and right arm to reach for the walker which resulted in loss of physical and visual contact with the resident. NA#14 indicated she/he never left the side of the resident and was not aware the resident required contact guard assistance of one. NA#14 indicated she/he was not aware limited assistance of one meant you needed to have your hands in contact with the resident. Clinical record review and interview with Physical Therapy Assistant #1 and the Rehabilitation Manager on 11/7/16 at 11:00 A.M. indicated the resident required limited assistance of one which meant contact guard with the resident was indicated due to the resident's [DIAGNOSES REDACTED].#1 and the Rehabilitation Manager indicated maintaining contact guard with the resident would provide a trigger for the staff to react if the resident started to sway or change position. Maintaining contact guard would also alert the staff when to take a stronger hold on the gait belt, help to prevent/break a fall, control descent and/or to minimize the effect of a fall. Review of the facility policy with the Chief Clinical Officer on 11/12/16 at 1:15 P.M. indicated that proper levels of assistance during ADL can lead to decreased falls and other injuries while increasing independence among residents. The Chief Clinical Officer indicated a staff in-service will be provided to ensure communication and understanding of language used by therapy to communicate care to nursing. 2. Resident #8's [DIAGNOSES REDACTED]. RCP dated 9/23/16 identified the resident at risk for injury due to smoking. An intervention directed the application of a smoking apron while smoking. A smoking assessment dated [DATE] identified Resident #8 required supervision with smoking and required adaptive equipment that included a smoking apron. A quarterly MDS assessment dated [DATE] identified Resident #8 had severe cognitive impairment (BIMS 7) and required extensive to total assistance with ADL. During observation of the scheduled 1:15 PM smoking on Wedgewood patio of Resident #8 on 11/10/2016 1:21:31 PM in the presence of the ADNS identified four residents and two (2) staff noted around a table on the patio. NA#5 was noted seated next to Resident #8 directly observing the resident while she/he was smoking. Resident #8 was observed sitting in a wheelchair positioned in front of the table with a circular ash tray positioned directly in front of him/her. The resident was noted independently smoking a cigarette with a long ash without the benefit of an apron. Continued observation noted a small amount of ash located on the resident's left upper chest area. Interview with NA#5 with ADNS present on 11/10/2016 at 1:25 PM identified Resident #8 had refused to utilize the apron and indicated the resident had a history of [REDACTED]. Subsequent to surveyor inquiry the ADNS provided the apron and Resident #8 was noted willing to accept the application of the apron. An interview with Resident #8 at that time of the incident indicated he/she did not have a problem with the smoking apron. Interview with the DNS and ADNS on 11/10/2016 1:39 P.M. indicated they were not aware Resident #8 refused to wear the apron. The DNS further indicated staff is educated to follow the resident plan of care and/or notify a licensed staff when a resident refuse to wear a smoking apron. Subsequent to surveyor intervention the facility provided a revised care plan that reflected Resident #8 refusal at time to wear his/her smoking apron but failed to provide direction, interventions and/or approaches to guide staff when the resident refused to wear his/her smoking safety apron. Facility smoking policy procedure at the time of the incident directs that the interdisciplinary team will develop plan of care with appropriate interventions that meet the needs of the resident. The policy further identified the resident's care plan will be revised as needed.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had an allergy to a medication, the facility failed to identify the resident's allergy and/or obtain a physician's orders [REDACTED]. The findings include: Resident #1's [DIAGNOSES REDACTED]. The Resident Information form identified Resident #1 was admitted to the facility on [DATE]. The hospital Inter-Agency Patient Referral Report (W-10) dated 12/29/14 identified that Resident #1 was allergic to [MEDICATION NAME] and [MEDICATION NAME] and wound care to the bilateral feet. The nurse's note dated 12/29/14 identified that Resident #1 was admitted to the long term care facility at 5:00 PM. The resident was alert and oriented to person, place and time, blood pressure was 142/84, pulse rate 62 beats per minute, respirations 20, oxygen saturation on room air was 96% and breathe sounds were clear on auscultation. The nurse's note dated 12/30/14 at 1:08 PM identified that during the dressing change a small abrasion was noted to the right outer great toe and a dot size amount of [MEDICATION NAME] was applied to the area followed by a dry protective dressing. The note indicated that within four minutes Resident #1 complained of feeling funny and stated he/she was allergic to [MEDICATION NAME]. Resident #1 complained of burning in the groin, became flushed with nausea and began coughing. Resident #1's the blood pressure was 94/50, pulse 86, respirations 22 and the oxygen saturation 91%. [MEDICATION NAME] 50 milligrams (mg) orally and Epi-pen 0.3 mg intramuscular (IM) were administered, 911 was called, the physician was notified and Resident #1 was transferred to the hospital for an evaluation at 11:30 AM. The Emergency Medical Services pre-hospital care report dated 12/30/14 identified that upon arrival at 11:45 AM Resident #1 was found in bed, the skin was hot and red and the eyes were dry and the pupils were equal and reacting to light. Resident #1 was complaining of difficulty breathing on room air, the oxygen saturation was 90%, the resident was gurgling, had word dyspnea and was placed on a non-rebreather at 15 liters of oxygen therapy, the lung sounds were diminished in all fields. An Intra-Venous (IV) line was established and 50 mg of [MEDICATION NAME] was given IV. On route to the hospital an [MEDICATION NAME] Nebulizer treatment and [MEDICATION NAME] 125 mg IV were administered and a second IV line established Normal Saline infusing, the resident was hypotensive. The resident was transported to the hospital. The Reportable Event Form dated 12/30/14 at 11:30 AM identified that [MEDICATION NAME] ointment was applied to an abrasion on Resident #1's right great toe and subsequently the resident had an allergic reaction. The nurse's note dated 12/30/14 at 6:21 PM identified that Resident #1 had returned to the facility status [REDACTED]. The Advanced Practice Registered Nurse (APRN) progress note dated 12/31/14 identified that when [MEDICATION NAME] was applied to the foot Resident #1 had an anaphylactic reaction, the airway was maintained, the resident was in and out of consciousness with [MEDICAL CONDITION], had received [MEDICATION NAME] 50 mg by mouth and Epi pen IM, the resident was then transferred to the hospital for observations and returned the same day. The facility's policy and procedure on physician orders [REDACTED]. Interview with the Director of Nursing (DON) on 3/5/15 at 10:30 AM identified that on admission to the facility a resident's allergy status is reviewed from the Inter-Agency Patient Referral Report (W-10). The W-10 is part of the admitting process to address if the resident has an allergy and the expectation is for nurses to check the resident's allergy status prior to administering medications and/or treatments. Interview with RN #1 on 3/5/15 at 10:55 AM identified that she had applied the [MEDICATION NAME] ointment on a small reddened area on the right great toe after informing the resident of the plan, shortly after the application the resident had symptoms of an allergic reaction. RN #1 indicated she did not obtain a physician's orders [REDACTED]. RN #1 identified that she must check for allergies [REDACTED].

Based on observation and interview for one of forty resident's rooms (Resident #44) observed for a safe environment, the facility failed to ensure the environment was free from hazards and/or for one of four sampled residents with a history of falls (R#49), the facility failed to ensure equipment was safe/in good repair, resulting in a fall. The findings include: 1. Resident #49 ' s [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident had no cognitive impairment or behavioral issues, was independent for transfers/ambulation and had no history of falls. The care plan dated 4/19/11 identified the resident was independent with transfers. Physician orders [REDACTED]. A facility report and investigation dated 6/10/11 identified that the resident was reaching for the armrest on the riser toilet seat that wasn't appropriately placed on the toilet. The riser toilet seat fell off the toilet and the resident and seat both fell to the floor. The facility documentation identified that the equipment malfunction occurred with the riser toilet seat that was unstable and the recommendation was to repair to the equipment. Further documentation identified that R#49 was complaining of hip pain and transferred to the hospital. Review of the clinical record identified the resident sustained [REDACTED]. Interview with R#49 on 8/30/11 at 11 AM identified that when he/she went into the bathroom to use the toilet, the attached toilet seat wasn't secure. R#49 noted that the toilet seat came off the toilet and both he/she and the seat fell to the floor. Interview with the V.P of Clinical Services on 8/30/11 at 12 noon identified that, although the facility had done preventative maintenance checks of the raised seats, no specific documentation could be provided. Interview with the Administrator on 8/30/11 at 12 noon identified that subsequent to the incident, the adaptive toilet seats were removed and replaced with a different type. Interview with the Director of Maintenance on 8/31/11 at 12 noon identified that the raised toilet seats were not regularly checked as part of preventative maintenance. Further interview identified that he/she was responsible for installing the adaptive raised toilet seats but did not have a regular system of checking that the equipment remained securely attached to the toilet and remained in safe working condition. Interview with the Administrator on 8/31/11 at 2 PM identified that the facility was unable to provide documentation that regular preventive maintenance was being done on the adaptive equipment used on the toilets to ensure that the devices remained secure and safe. 2. Observation of Resident #44's room on 8/30/11 at 10:00 AM indicated the radiator baseboard located at the head of the resident's bed was bent and pulled away from the main unit with a portion of the metal curled upward. The metal was bent in a manner which could cause injury. The nurse aide providing care for the resident's roommate was informed of the hazard and indicated it would be reported to the maintenance department. Observation with the Director of Nurses (DNS) on 9/1/11 at 9:30 AM indicated the repair to the baseboard had not been completed. Interview with the Maintenance Director on 9/1/11 at 1:00 PM indicated he was not aware of the damaged radiator. Review of the maintenance log book for the Wedgewood Unit with the Administrator on 9/1/11 at 1:15 PM indicated there was not an entry for repair of the radiator.