Every finding on record at Autumn Lake Healthcare at Cromwell

Based on observation, interview, record review, and facility policy review, the facility failed to ensure timely assessment and management of pain for 1 of 1 resident (Resident #1) reviewed for pain, when staff did not communicate the resident's report of severe pain to the licensed nurse and failed to ensure timely access to and administration of prescribed PRN pain medication.This resulted in Resident #1 experiencing unrelieved severe pain (rated 8/10 and described as unbearable) for approximately 1 hour and 45 minutes, accompanied by observable signs of distress, including facial grimacing, restlessness, and inability to reposition comfortably, as well as verbalized psychosocial distress.The failure occurred when (1) the nurse aide did not report the resident's complaints of pain to the nurse, (2) the assigned nurse was not available on the unit and medication cart keys were not transferred to another licensed nurse, and (3) no alternate system was in place to ensure timely pain intervention, resulting in a delay in administration of physician-ordered analgesic medication. The findings include:Resident #1's diagnoses included radiculopathy lumbar region, cervicalgia, and dorsalgia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status score of 13 indicating normal cognitive function, was always incontinent of urine and dependent for toilet transfers. Additionally, Resident #1 required as needed pain medication.The Resident Care Plan (RCP) dated 3/3/26 identified Resident #1 had acute and chronic pain related to left Achilles tear, myasthenia gravis, chronic back pain, radiculopathy, and lumbar degenerative disc disease. Interventions included assessing pain every shift, coordinate with the physician as needed for optimal pain control, administer analgesics (pain medication) per the physician orders and document effectiveness and any side effects.Physician's orders dated 2/23/26 and in effect through 3/30/26 directed to administer tramadol hydrochloride (HCL) (medication used to treat pain) 50 milligram (mg) 1 tablet by mouth every 12 hours as needed for chronic pain.Review of Resident #1's Medication Administration Record (MAR) identified that 1 tablet of tramadol HCL 50 mg was administered on 3/30/26 at 10:45 AM (approximately 1 hour and 45 minutes after requesting the medication). Additionally, the MAR identified that Resident #1 had a pain level of 7 prior to medication administration.Observation of Resident #1 on 3/30/26 at 10:10 AM noted Resident #1 in bed with facial grimacing, eyes closed, moving about in the bed attempting to find a comfortable position. Resident #1 stated he/she had severe sharp, stabbing pain in the right hip and right leg and had been waiting for pain medication since 9:00 AM (approximately 1 hour and 10 minutes) after reporting pain to Nurse Aide (NA) #2. Resident #1 rated the pain as 8 on a scale of 0 out of 10 (0 indicating no pain and 10 indicating severe pain). Resident #1 stated it was unbearable and unlike any pain he/she ever felt before and the worst pain he/she has ever had. Observation on 3/30/26 at 10:43 AM noted LPN #3 exiting an area behind the nurse's station and returning to the medication cart, then proceeding to Resident #1's room (approximately 1 hour and 45 minutes after the resident first reported pain).Interview with Licensed Practical Nurse (LPN) #2 on 3/30/26 at 10:16 AM identified she was not assigned to Resident #1 and unaware the resident was in pain. LPN #2 indicated she was unaware that LPN #3 was off the unit and did not have access to the keys for the medication cart to access Resident #1's medication.Interview with LPN #3 on 3/30/26 at 11:02 AM identified (the nurse assigned for Resident #1) and was not made aware by staff that the resident was in pain. LPN #3 indicated she became aware of Resident #1's pain after finding a handwritten note on her medication cart upon return to the unit. LPN #3 indicated after seeing the note, she went to Resident #1's room to assess the resident and administer the ordered pain medication.Interview with Nurse Aide (NA) #2 on 3/30/26 at 11:07 AM identified during morning care around breakfast time (approximately 8:30-8:45 AM), Resident #1 stated he/she did not want to be changed due to pain and requested pain medication. NA #2 indicated she did not inform LPN #3 because she thought she already knew. NA #2 identified when she returned to the room later, Resident #1 reported he/she was still in pain and had not yet received pain medication. NA #2 stated she again did not notify LPN #3, because she observed LPN #3 with the medication cart and assumed she was going to the resident's room next.Interview with the Director of Nursing (DON) on 3/30/26 at 11:22 AM identified staff were responsible for communicating any resident reports of pain to the nurse so the nurse can assess and administer pain medication if needed. The DON indicated each medication cart had a designated key, as well as a separate key for controlled substance storage. The DON identified when a nurse leaves the unit or goes on break, the nurse should transfer the medication cart keys to another nurse to ensure timely medication access. The DON identified Resident #1 should not have waited 1 hour and 45 minutes to receive pain medication after reporting pain)Reinterview with Resident #1 on 3/30/26 at 11:30 AM identified the pain had decreased to 3 out of 10. Resident #1 stated he/she was upset and that it was completely unacceptable to have to wait that long for pain medication with unbearable pain and the resident further stated, I hope other residents never have to experience that. Resident #1 experienced psychosocial distress, as evidenced by verbal expressions of frustration and distress, which constitute harm under the regulatory definition.Review of Pain Assessment and Management Policy undated directed, in part, for staff to identify if the resident had pain and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Additionally, the policy identified that pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and based on his or her clinical condition and established treatment goals.

Based on observations, review of the clinical record, facility policy and interviews for 3 of 3 sampled residents (Resident #30, Resident #34, and Resident #69) residing on the secure unit, the facility failed to ensure a systematic way of determining placement, continued placement, involvement by the physician, resident representative, interdisciplinary team, or the impact residing on a secure unit had on the residents. The findings include:1. Resident #30 's diagnoses included Alzheimer's dementia early onset, anxiety disorder, and epilepsy.A wander risk assessment dated [DATE] identified a high risk for wandering.The admission Minimum Data Set assessment dated [DATE] identified Resident #30 was severely cognitively impaired with short- and long-term memory problems, fluctuations in attention and required total staff assistance with eating, hygiene, transfer, bed mobility, dressing and was non ambulatory.The Resident Care Plan dated 1/27/26 identified Resident #30 was an elopement risk/wanderer as evidenced by impaired safety awareness, wander risk assessment and history of elopement attempts at home prior to hospitalization. Interventions included to complete wander risk assessment per policy, consider wander guard as needed, distract resident from wandering, document and report any wandering or exit seeking behaviors every shift, room located on the secure unit.A review of the physician's orders in effect from 3/1/26 through 3/31/26 failed to direct Resident #30's placement on the secured unit.A review of the Advanced Practice Registered Nurse (APRN) notes dated 3/12/26, 3/17/26, 3/20/26, 3/23/26, and 3/30/26 failed to direct Resident #30's placement on the secured unit.2. Resident #34's diagnosis included vascular dementia, schizoaffective disorder and personality disorder.The annual Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status score of 14 indicating no cognitive impairment, no wandering behaviors and was independent with dressing, bed mobility, transfers, and ambulation.The Resident Care Plan dated 3/31/26 identified Resident #34 as an elopement risk/wanderer as evidenced by history of exit seeking behaviors. Interventions included complete a wander risk assessment distract the resident from wandering, document and report any wandering or exit seeking behaviors every shift, room located on the secure unit, wander guard (anti elopement device) as ordered, check placement every shift, check function on 11:00 PM to 7:00 AM shift A physician's order in effect from 2/14/26 through 4/1/26 directed to check the wander guard function every day on 11:00 PM to 7:00 AM shift.A physician's order in effect from 2/14/26 through 4/1/26 directed to check wander guard placement to right wrist every shift.An Advanced Practice Registered Nurse (APRN) note dated 3/2/26 identified exit seeking behaviors but failed to identify criteria for remaining on a secure unit.A wandering elopement assessment dated [DATE] identified high risk for wandering. A review of nurse's notes dated 3/1/26, 3/2/26, 3/7/26, 3/8/26, 3/9/26, 3/10/26, and 3/11/26 identified Resident #34 with exit seeking behaviors.A social service Resident Care Plan meeting note dated 3/31/26 failed to identify Resident #34 met criteria to remain on, had resident representative involvement in placement on, that the least restrictive area was discussed, or that the interdisciplinary team reviewed the impact residing on the secure unit had on the resident.3. Resident #69's diagnosis included Wernicke's encephalopathy, alcohol abuse, and protein calorie malnutrition.The quarterly Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status score of 13 indicating no cognitive impairment, no wandering behavior and was independent with dressing, bed mobility, transfers and ambulation.A wandering elopement assessment dated [DATE] identified Resident #34 at risk to wander.The Resident Care Plan dated 3/13/26 identified Resident #69 was an elopement risk/ wanderer as evidenced by a risk assessment score. Interventions included complete wander risk assessments per policy, monitor, document and report any wandering or exit seeking behaviors every shift, and that Resident #34's room was located on the secured unit.An APRN note dated 3/30/26 failed to identify criteria to remain on the secured unit.A review of the physician's orders dated 3/1/26 through 3/31/26 failed to direct placement on a secured unit.A review of nurse's notes dated 3/3/26 through 4/1/26 failed to identify criteria to remain on a secure unit.Interview and observation with Resident #69 on 3/29/26 at 11:17 AM identified he/she rode the exercise bike in the Rehabilitation Therapy Gym on the 3rd floor to assist with improving his/her shuffling gait but needed to be escorted off the unit due to it being locked. Resident #69 indicated that when he/she requested to be escorted, staff indicated that they did not have the time to accompany him/her. According Resident #69's activity calendar (used to track his exercise bike riding time) the last time the resident rode the exercise bike was on 3/17/26 (12 days prior) when he/she was able to ride 3.5 miles. Resident #69 denied having the exit code off the unit.Interview with Person #3 on 4/1/26 at 11:32 AM identified he/she and Resident #69 did not want the resident to be located on the secured unit. Person #3 indicated that at the next care meeting, he/she was going to discuss having Resident #69 placed on a less secure unit. Person #3 indicated that Resident #69 wanted to ride the bike in the gym and it helped with his/her shuffling gait. Additionally, Person #3 indicated that Resident #69 did not want or try to leave the facility and would never try to leave without permission.Interview with Social Worker (SW#1) and the Director of Nursing (DNS) on 4/1/26 at 1:00 PM identified that Resident #69 was appropriately placed on the secure unit, however, the DNS indicated that she needed to check the secured unit policy to identify the criteria for and/or the need for reevaluations for placement on the secure unit. SW#1 and the DNS further indicated that Person #3 had never discussed moving Resident #69 to a less restrictive unit, however, there currently was no bed available to move the resident. The SW indicated that Resident #69 had Wernicke's encephalopathy, was negative, had difficulty interacting with others, and was not a very pleasant person. Further the interdisciplinary team would discuss which resident would be appropriate to move from the secure unit when a bed became available. Although the SW#1 indicated she had seen the resident on the exercise bike daily, (which Resident #69 denied). The surveyor failed to observe Resident #69, over the last 3 days, at any time, to be off the unit. Additionally, The DNS and SW #1 indicated that they could check for a less restrictive environment for Resident #69 at a sister facility and could reevaluate the resident placement. The DNS and SW #1 were unable to indicate if they routinely had used a criteria or reevaluated Resident #69's need to remain on a secure unit. A reinterview with Resident #69 on 4/1/26 at 2:00 PM identified that he/she was p****d and upset that staff did not take him to ride the exercise bicycle and that he/she had been unable to ride at all this week. An interview with the Director of Rehabilitation on 4/1/26 at 2:51 PM indicated that the gym was always open to every resident in the facility but Resident #69 was on a secure unit. This had been discussed in the Resident Care Plan meetings and the staff on the unit were responsible for making sure Resident #69 got to the gym to ride the exercise bike.An interview and record review with LPN #8 on 4/1/26 at 2:42 PM failed to identify that Resident #69 or his/her conservator consented to be placed on a secure unit.An interview and review of the clinical record with the DNS and Registered Nurse (RN) #3 (Regional Clinical Services) on 4/1/26 at 3:01 PM failed to identify they were able to provide any information used for Resident #30, #34, or #69 to reside on a secured unit including:Criteria used for placementCriteria to remain placed on the unitResident representative involvement in the decision to be on a secure unitPhysician involvement/evaluation to remain on or be placed on the unitInterdisciplinary team reviews of documentation to ensure the resident was placed in the least restrictive environment orEvaluation of the impact on the resident from residing on a secure unit.A review of the Abuse policy directed, in part, involuntary seclusion is defined as separation of a resident from other residents or from his/her room or confinement to his/her room with or without roommates against the resident's will or the will of the resident's legal representative.A review of elopements and wandering residents' policy dated 11/27/25 directed, in part, the facility was equipped with door locks/alarms to help avoid elopements. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementation interventions to reduce hazards and risks, monitoring for effectiveness and modifying interventions when necessary.Although requested, a facility policy for a secure/dementia unit was not provided.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #180) reviewed during the initial pool screening, the facility failed to provide a privacy bag for a resident with an indwelling urinary catheter. The findings include:Resident # 180's diagnoses included a neurological cause of urinary retention, chronic kidney disease, weakness, and a comprehension communication deficit. The nursing admission assessment dated [DATE] identified Resident #180 was cognitively intact and required set up or clean up assistance for eating and oral hygiene and partial to moderate assistance for toileting, walking and transferring.The baseline Resident Care Plan in effect 3/27/26 to 3/30/26 identified Resident #180 had an indwelling urinary catheter related to urinary retention. Interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance door to the room.A physician's order dated 3/27/26 directed to ensure privacy cover was on the urinary collection bag each shift.A nurse's note dated 3/27/26 at 6:40 PM identified Resident #180 was admitted with a draining indwelling urinary catheter.Observation on 3/29/26 at 9:54 AM identified the resident lying in bed with an uncovered urinary catheter bag filled with 700 milliliters of yellow urine visible from the hall. Observation on 3/29/26 at 12:12 PM identified the resident lying in bed with an uncovered urinary catheter bag filled with 300 milliliters of yellow urine visible from the hall. Observation and Interview with Assistant Director of Nursing (ADNS) on 3/29/26 at 2:02 PM identified Resident #180 lying in bed on their right side facing the wall with the uncovered urinary catheter visible from the hallway filled with yellow urine. The ADNS identified on admission a catheter cover should have been provided for the urinary catheter bag to ensure privacy and dignity. The ADNS was unable to identify why Resident #180 had not been provided with a privacy cover.Subsequent to surveyor inquiry a blue privacy bag was placed on Resident #180's urinary catheter bag to conceal urinary output.Review of the Foley catheter policy directed, in part, to change the catheter bag as needed because of discoloration of the bag, odor, leakage, etc. The policy failed to indicate the use of privacy covers to maintain dignity.

Based on observations, interviews, record review and policy review for 1 of 3 sampled residents (Resident #82) for pressure ulcers, the facility failed to follow an intervention to prevent the deterioration of an exisiting pressure ulcer. The findings include:Resident #82's diagnoses included chronic respiratory failure, hypoxia, and diabetes mellitus 2.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #82 had a Brief Interview of Mental Status of 11 indicating moderate cognitive impairment and was dependent on staff for bed mobility, sitting to lying, lying to sitting and to stand. Additionally, the MDS identified Resident #82 was at risk for developing pressure ulcers/injuries and did not exhibit rejection of care necessary to achieve goals for health and wellbeing.The Resident Care Plan dated 2/26/26 identified Resident #82 had a potential for impaired skin/pressure ulcer injury development related to oxygen tubing use. Interventions included administering treatments as ordered and checking skin and oxygen tubing placement every shift.A nurse's note dated 3/18/26 at 2:30 PM identified Resident #82 was observed with a stage 2 pressure ulcer between the right ear and where the ear met the head measuring 0.3 centimeters (cm) x 1.0 cm x 0.1 cm, no signs or symptoms of infection, and denied pain to the area. Additionally, the physician was updated, new treatment orders were obtained, and foam padding was placed on the oxygen tubing as an intervention.A physician's order dated 3/18/26 directed to apply foam padding to bilateral earpieces of oxygen tubing, check placement and replace as needed for displacement every shift.Review of the nurse's notes the Treatment Administration Record dated 3/18/26 through 3/31/26 failed to identify that Resident #82 refused the foam padding or that the resident was removing the foam padding from the oxygen tubing. Observation on 3/29/26 at 11:17 AM identified Resident # 82 wearing a nasal cannula which was lying directly on the wound without the benefit of a foam padding. Further observation failed to identify that a foam padding was in the residents bed or on the floor.Interview and observation with Resident #82 on 3/31/26 at 9:05 AM identified a nasal cannula lying directly on the wound without the benefit of foam padding. Resident #82 stated that the nurses had been applying cream to the open area on the right ear and that there was supposed to be padding on the oxygen tubing, but those darn ear things keep falling off. Further observation failed to identify that a foam padding was in the residents bed or on the floor.Interview, observation and clinical record review with the Assistant Director of Nursing/Wound Nurse (ADNS) on 3/31/26 at 9:28 AM indicated that Resident #82's wound to the right ear was identified on 3/18/26 as a facility acquired Stage 2 pressure ulcer caused by oxygen tubing. Additionally, the ADNS identified interventions included application of SSD cream (a topical antibiotic used to prevent infection) and placement of foam padding to the oxygen tubing. On observation, Resident #82 was being administered oxygen by an oxygen concentrator via a nasal cannula, but without the benefit of foam padding applied to the oxygen tubing and the tubing was directly on the wound. Resident #82 had an additional nasal cannula connected to a portable oxygen concentrator (not in use) suspended on the back of his/her wheelchair. Upon observation the nasal cannula connected to the portable oxygen concentrator failed to have foam padding applied. The ADNS asked Resident #82 if he/she had removed the padding, to which the resident responded, No, they fall off and I find them everywhere. The ADNS indicated that the unit nurse was responsible for checking and applying the foam protectors and that Resident #82 should have been wearing foam protectors as an intervention to prevent deterioration of the pressure ulcer.Subsequent to surveyor inquiry the ADNS instructed the nurse on the unit to apply foam padding protectors to Resident #82's oxygen tubing.Review of the Pressure Ulcer Prevention Policy dated 12/15/22 directed in part that residents determined as a risk for pressure ulcers will have interventions documented in plan of care based on specific factors identified in the risk assessment.

Based on observations, interviews, record and policy review for 1 of 4 sampled residents (Resident #40) reviewed for dignity, the facility failed to obtain a consent and provide a resident with podiatry services. The findings include:Resident #40's diagnoses included disc degeneration, chronic kidney disease and heart failure.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had a Brief Interview of Mental Status of 13 indicating intact cognition and was independent for eating, dressing and toileting.The Resident Care Plan dated 1/29/26 identified Resident #40 had a self-care performance deficit related to a deconditioned status. Interventions included for staff to adjust to the amount of physical function as residents' functional status/participation changed with behavior and to check nail length with bathing.Review of the physician's orders signed 3/11/26 failed to identify an order for podiatry services (although orders for other ancillary services were in place).Interview and observation on 3/30/26 at 9:37 AM identified Resident #40 in bed with the residents feet exposed. The toenails were thick, overgrown approximately 1/4 inch, and the right great toenail appeared jagged and uneven. Resident #40 stated that his/her toenails have not been trimmed since he/she was admitted in October 2025, even though he/she has been asking staff to do so.Interview with Licensed Practical Nurse (LPN) # 5 on 3/31/26 at 9:20 AM identified it was the facility policy for anyone needing podiatry services to be placed on the list which was overseen by the scheduler.Interview and review of facility documentation with the Scheduler on 3/31/26 at 9:25 AM identified she was responsible for maintaining the podiatry list. She stated the podiatrist visits monthly to provide services, including toenail trimming, for any residents in need. Review of Resident #40's record failed to identify that he/she had been seen by the podiatrist since being admitted in October 2025.Interview and record review with the Director of Nurses (DON) on 3/31/26 at 10:01 AM indicated that it was facility policy to obtain signed consents upon admission unless the resident was admitted for short term rehabilitation. Review of Resident #40's clinical record with the DON showed that although he/she was initially admitted as a short term resident on 10/13/25, he/she transitioned to long term care on 10/31/25, at which point a podiatry consent should have been obtained. The DON was unable to identify why Resident #40 did not have a signed consent for podiatry services; however, she confirmed that one should have been in place since 10/31/25, as all podiatry services are provided by an outside vendor.Subsequent to surveyor inquiry, the DON contacted the conservator, obtained a signed consent for podiatry services dated 3/31/26, and Resident #40 was placed on the podiatry list to be seen at the next visit.Review of the Podiatry Services Policy revised 10/28/25 directed in part that it was facility policy to ensure residents receive proper treatment and care to maintain mobility and good foot health.

Based on observation, interviews, and facility policy review for 1 of 3 medication rooms reviewed for medication storage, the facility failed to store Schedule II-V controlled medications in a permanently affixed compartment within the medication refrigerator. The findings include:Interview and observation of the second floor medication room with Licensed Practical Nurse (LPN) #4 on 3/31/26 at 6:41 AM identified the following:For the North Side unit, located in the refrigerator on the second shelf, it was identified that although the controlled substance storage box was noted to be locked, it was not permanently affixed to the refrigerator. Inside the North Side controlled medication compartment was 1 unopened bottle Lorazepam two (2) milligram (mg) per milliliter (ml), 30 milliliter (ml) vial with an expiration date of 3/2027.For the South Side unit, located in the refrigerator on the second shelf, it was identified that although the controlled substance storage box was noted to be locked, it was not permanently affixed to the refrigerator. Inside the South Side controlled medication compartment were 4 unopened bottles of Lorazepam 2 milligram (mg) per milliliter (ml), 30 milliliter (ml) vials with an expiration date of 3/2027.LPN #4 indicated that she was unaware controlled substance storage in the medication refrigerator needed to be permanently affixed and that if she had known, she would have notified her supervisor. LPN #4 identified that she had been employed at the facility for approximately 6 months and that the controlled medication compartments had not been permanently affixed to the medication refrigerator since she began working at the facility.Interview and observation with the Assistant Director of Nursing (ADNS) on 3/31/26 at 7:11 AM identified that both the North and South side unit controlled substance storage boxes in the medication room refrigerator were noted to be locked but not permanently affixed to the medication refrigerator. The ADNS indicated that controlled substances medication boxes were required to be permanently affixed to the refrigerator. Subsequent to surveyor inquiry, the ADNS indicated she would be contacting the Maintenance Department to permanently affix both boxes.Interview and observation with the Director of Nursing (DNS) on 3/31/26 at 7:45 AM identified that the keys to both of the controlled substance storage boxes had broken approximately 6 months ago and were replaced with new boxes. She indicated she assumed the boxes had been permanently affixed to the refrigerator when replaced and was unaware they had not been. The DNS stated that it was her responsibility and the facility policy to ensure narcotic boxes were permanently affixed, and she would have the Maintenance Department correct the issue as soon as possible.Subsequent to surveyor inquiry, the North Side and South Side controlled medication boxes in the second floor medication room refrigerator were permanently affixed.Review of the storage of undated medications policy directed, in part, that Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments.

Based on observation, interviews, and review of facility policy, the facility failed to ensure resident identifiable information and resident medical records were stored in a secure location. The findings include:Observation on 3/30/26 at 1:42 PM in the unoccupied and unlocked medical record room located in the basement of the facility identified there were 217 banker boxes with medical records ranging from 2013 to 2026. The boxes contained resident medical records with personally identifiable information including name, date of birth , medical record number, social security numbers, and diagnoses.Observation and interview with the Director of Nurses (DON) on 3/30/26 at 2:35 PM identified 217 banker boxes in the unoccupied and unlocked medical record room located in the basement of the facility. The boxes contained resident medical records with personally identifiable information including name, date of birth , medical record number, social security numbers, and diagnoses from 2013 to 2026.The DNS indicated that she was not familiar with the facility policy on resident medical records and personally identifiable information. The DNS identified that medical records should be stored in a secured (locked) location and that it was the responsibility of the staff member who entered the medical record room to ensure that it was locked when they exited. The interview failed to identify why the medical record room was not secured.Review of the maintenance of clinical records policy dated 5/7/24 directed in part that clinical records of the facility will be safeguarded against loss, destruction, or unauthorized use. Additionally, the policy directed that records will be filed by resident name and year and kept in a locked and monitored area of the Medical Records Department.

Based on observations, review of the clinical record, facility documentation and interviews for 1 of 3 sampled residents (resident #30) reviewed for falls, the facility failed to ensure appropriate hospice provider communication had occurred for seating and following a fall. The findings include:The admission Minimum Data Set assessment dated [DATE] identified Resident #30 was severely cognitively impaired with short- and long-term memory problems, fluctuations in inattention and required total staff assistance with transfers, bed mobility, dressing and was non ambulatory. Resident #30 had a history of falls prior to admission.The Resident Care plan dated 3/22/26 identified Resident #30 had a terminal prognosis related to hospice services beginning 3/22/26. Interventions included hospice Registered Nurse (RN), work cooperatively with the hospice team to ensure the resident's, physical and social needs were met, and work with nursing staff to provide maximum comfort for Resident #30.A nurse's note dated 3/22/26 at 2:28 PM identified that Resident #30 was accepted into a hospice program.A nurse's note dated 3/28/26 at 11:41 AM identified Resident #30 was observed on the floor in a semi-prone (face-down) position in front of the wheelchair. Staff reported the Resident #30 leaned forward, lost his/her balance, and fell out of the wheelchair. Resident #30 was noted to have a small open area on the bridge of his/her nose and right inner nostril. Resident #30 did not exhibit signs of acute pain or discomfort during the assessment. The nurse's note failed to include documentation that hospice was notified of Resident #30's fall with injury.Facility Accident and Incident report dated 3/28/26 identified Resident #30 was observed on the floor in a left semi-prone position in front of his/her wheelchair. Resident #30's injuries included a small skin tear on the bridge of the nose measuring 0.2 centimeter (cm) in length, 0.2 cm in width, 0.1 cm in depth and a small open area inside the right nostril. Resident #30 was alert but confused and required assistance from 1 staff member for transfers and wheelchair mobility both prior to and following the incident. An investigation statement written by LPN #6 dated 3/28/26 identified she was alerted the resident had fallen out of the chair. A written statement by Nurse Aid (NA) #5 indicated Resident #30 was transferred into the wheelchair and began to lean to the left side. NA #5 repositioned Resident #30 who then began leaning again and the resident was repositioned a second time. NA #5 called for the nurse for help and as soon as the nurse arrived, Resident #30 started to fall to the floor and NA #5 attempted but was unable to prevent the fall. The Accident and Incident report failed to include documentation that hospice was notified of the fall with injury.An interview with LPN #6 on 3/31/26 at 1:21 PM indicated she was at the nurse's desk when NA #5 informed her Resident #30 was on the floor. LPN #6 identified prior to the fall Resident #30 had been placed in a black transport wheelchair. LPN #6 indicated the hospice nurse had informed her that Resident #30 should have been seated in a Broda chair; however, she stated she was unaware of this requirement. LPN #6 identified the Broda chair was not present in Resident #30's room at the time of the fall and was unsure when it had been ordered, indicating it may have arrived on Friday, 3/27/26.An interview and review of facility documentation with RN #2 (hospice RN) on 3/31/26 at 2:23 PM identified the recommendation for the Broda chair was made on 3/22/26 (8 days prior to the fall) due to Resident #30's trunk instability and lack of control. The Broda vendor had notified RN #2's hospice when the Broda chair had been delivered to the facility on 3/23/26 (7 days prior to the fall), it was delivered to the resident's room and indicated that he/she had notified facility staff of the delivery. She indicated that the facility process when changing the plan of care directed the hospice nurse to make the recommendation on a recommendation form, notify the family member and the facility staff, then place the form in the binder, which she indicated had been done. On review of the hospice binder the recommendation dated 3/22/26 was present and RN #2 indicated that the facility nurse should have conveyed the information to the appropriate staff for implementation. Additionally, RN #2 indicated that a family member had notified her of Resident #30's fall, and that the facility never made notification to the hospice vendor. After an assessment post fall, on 3/29/26 between 1:00 PM and 2:00 PM RN #2 discovered that Resident #30 had been placed in a transport wheelchair instead of the Broda chair that should have been used because a transport chair was not appropriate to stabilize Resident #30's trunk.An interview and clinical record review with RN #4 on 4/2/26 at 10:35 AM indicated that he completed Resident #30's post fall Accident Incident report. RN #4 stated when he assessed Resident #30, he/she was on the floor in front of a small black wheelchair not a Broda chair and the Broda chair was absent from the room. The resident's assigned staff, NA #5, was from a staffing agency and failed to ask any staff member which chair Resident #30 should have been placed in and she had incorrectly utilized a transport wheelchair. On review of the clinical record, RN #4 failed to identify that there an order placed for the Broda chair or that the information had been placed on Resident #30's NA care card/Kardex (used to direct NA resident care) but since hospice had made the recommendation, it should have been noted in both areas. The facility protocol included the hospice provider writing the recommendation on a hospice form, notifying the nursing staff, then placing the recommendation in the hospice binder. Nursing staff would then place the recommendation in the APRN book for approval and nursing would write an order, transcribe it onto the NA care card and the Resident Care Plan. RN #4 was unable to explain why the hospice recommendation sheet was not reviewed and placed in the APRN book, but the recommendation should have been addressed and further, if it had been placed in the APRN book, why the APRN had not been addressed the recommendation.A review of the Hospice Services facility policy dated 1/26/23 directed, in part, the written agreement will set out at least the following: The services hospice will provide, the hospice's responsibilities for determining the appropriate hospice plan of care, and the services the facility will continue to provide based on each resident's plan of care. A communication process including how communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. Additionally, a provision that the facility will immediately notify the hospice about the following: A significant change in the resident's physical, mental, social or emotional status, clinical complications that suggest a need to alter the plan of care. An agreement that it is the facility's responsibility to furnish 24-hour room and board care, meet the residents' personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriate based on the individual's needs. A delineation of the hospice's responsibilities including but not limited to, providing medical direction and management of the resident, nursing, providing medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions.

Based on interviews, review of the clinical record, and review of facility policy for 3 of 3 residents (Resident #63, Resident #161, Resident #168) reviewed for smoking, the facility failed to accurately code the Minimum Data Set (MDS) assessment for tobacco use. The findings include:1. Resident #63's diagnoses included chronic obstructive pulmonary disease, paranoid schizophrenia, and type 2 diabetes.An annual MDS assessment dated [DATE] identified Resident #63 had a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment, was independent with eating, oral hygiene, and ambulation and did not currently use tobacco. The MDS failed to identify Resident #63 smoked cigarettes.A Resident Care Plan dated 2/13/26 and in effect through 4/1/26 identified Resident #63 was a supervised smoker. Interventions included provide supervised smoking per the schedule posted at the nurses station and smoking assessments quarterly.Smoking assessments dated 2/12/25 and 5/12/25 identified Resident #63 smoked 5 to 10 cigarettes a day. Smoking safety screenings dated 8/12/25, 12/8/25, and 3/8/26 identified Resident #63 smoked 2 to 5 cigarettes a day.2. Resident #161's diagnoses included chronic obstructive pulmonary disease, dementia, and nicotine dependance.An annual MDS assessment dated [DATE] identified Resident #161 had a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment, was independent with eating, oral hygiene, and ambulation and did not currently use tobacco. The MDS failed to identify Resident #161 smoked cigarettes.A Resident Care Plan dated 2/13/26 and in effect through 4/1/26 identified Resident #161 was at risk for injury due to smoking. Interventions included supervision when smoking, smoking during designated times, and smoking assessments quarterly.Smoking assessments dated 12/21/24, 9/21/25, 12/21/25, and 3/21/26 identified Resident #161 smoked 2 to 5 cigarettes a day. Smoking assessments dated 3/21/25 and 6/21/25 identified Resident #161 smoked 5 to 10 cigarettes a day.3. Resident #168's diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and nicotine dependence.An annual MDS assessment dated [DATE] identified Resident #168 had a Brief Interview of Mental Status score of 13 indicating no cognitive impairment, was independent with eating, oral hygiene, and ambulation and did not currently use tobacco. The MDS failed to identify Resident #168 smoked cigarettes.A Resident Care Plan dated 2/13/26 and in effect through 4/1/26 identified Resident #168 was at risk for injury due to smoking. Interventions included supervision when smoking, smoking during designated times, and smoking assessments quarterly.Smoking assessments dated 6/20/25, 9/20/25, 12/20/25, and 3/20/26 identified Resident #168 smoked 1 to 2 cigarettes a day.Interview on 4/1/26 at 10:24 AM with Licensed Practical Nurse (LPN) #7 (MDS Coordinator) identified she was responsible for the coding of comprehensive MDSs. LPN #7 identified Resident #63's comprehensive MDS, Resident #161's comprehensive MDS, and Resident #168's comprehensive were incorrectly coded as not using tobacco. LPN #7 indicated that since all 3 residents were active smokers at the time of their assessments, the MDS coding was incorrect and should have included tobacco use.Interview with the Director of Nursing (DON) on 4/1/26 at 1:10 PM identified MDS staff were responsible for the coding of MDSs' and that residents who smoke should be correctly coded as smoking on their MDS.Review of the Resident Assessment Instrument (RAI) instruction manual (used to direct MDS processes) dated October 2025 directed in part, that if a resident used tobacco products in some form within the look back period then the coding of section J1300 should indicate yes for tobacco use.Review of the facility's Minimum Data Set policy identified in part, the MDS coordinator will complete assigned sections and triggered care area assessments. MD notes and orders, the current plan of care, and the treatment record will be used to support MDS completion.

Based on the tour of the Dietary Department, staff interviews, facility documentation, and facility policy, the facility failed to ensure open food items were dated to include dates opened/expired/use by and failed to ensure food was served under sanitary conditions. The findings include: Tour of the kitchen with the Dietary Manager on [DATE] at 10:56 AM identified the following: a. The threshold of the walk in refrigerator where the door meets the doorframe had a heavy accumulation of dust and debris. Interview with the Dietary Manager identified that floors were swept after every meal service. b. An opened package containing 5 hotdogs was wrapped in plastic wrap but failed to identify an open date or expiration date. c. A 48 ounce container of Ricotta Cheese with a received date of [DATE] (with approximately ,d+[DATE] of the contents removed) was observed with a black and orange-like appearing substance along the inner rim and encroaching into the Ricotta Cheese. d. A 25 gallon container/tub of Spanish Onions was observed to be visibly dirty with a brown-like substance on the inside and outside of the container/tub and the and container/tub was uncovered. The Dietary Manager stated the tubs were wiped weekly but the tubs were last wiped down a week and a half ago. e. The walk in freezer was found to have a 10.8 pound box of pancakes with 25 of 144 pancakes remaining. The package was not sealed and open to the air. Additionally the package was not dated or tied and no expiration date for the pancakes was listed on the box or the package. f. 1 box of omeletts with 8 of 34 omeletts remaining was found open to air. The package was not dated or tied and lacked an expiration date. g. Seven 13.5 pound boxes of French Toast failed to identify an expiration date. h. A 10 pound box of pork crumble was observed to be open with approximately a half bag of contents remaining. The bag was not dated with an open date or expiration date. Interview with the Dietary Manager identified that all staff were responsible for ensuring foods in the refrigerator were checked for closure and expiration date, with the cooks checking the refrigerator daily in the morning. i. The ice machine located outside of the freezer was observed to have a heavy accumulation of a white substance inside the machine above the ice and a dark substance on the machine above the ice. A heavy accumulation of dust was observed on the ice machine side vents. The Dietary Manager stated the ice machine was last cleaned by her on [DATE]. The Dry Storage room was observed to contain the following: j. A 25 pound bag of dried cranberries, noted to be almost full, was not tied and open to air. k. Heavy dirt and debris was observed behind the can shelving near the air conditioner. [NAME] shavings and dirty insulation with black specks/debris were observed on the window sill, on the floor in front of the air conditioner, and behind the racks of cans on the far wall of the Dry Storage room. Interview with the Dietary Manager identified that she was not aware of the insulation and dirt. The air conditioners were installed two days ago and per the Dietary Manager, Maintenance was responsible for cleaning up after the air conditioner installation. l. The third floor Nourishment Room ceiling tile above the refrigerator was found to be visibly stained and was approximately 12 inches by 12 inches in size. Review of the Facility's Environment Policy HCSG Policy 028, dated revised ,d+[DATE], identified that all food preparation areas and food service areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure the kitchen is maintained in a clean and sanitary manner. The Dining Services Director will ensure that employees are knowledgeable in the proper procedures for cleaning and sanitizing of food service equipment and surfaces. Food contact surfaces will be cleaned and sanitized. The Dining Services Director will ensure that a routine cleaning schedule is in place for cooking equipment, food storage areas, and surfaces. Review of the Facility's Food Storage: Dry Goods Policy HCSG Policy 018, dated revised on ,d+[DATE], identified that dry goods will be appropriately stored in accordance with the FDA food code. Packaged and canned food items will be kept clean, dry, and sealed. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.

Based on interview and review of facility documentation, the facility failed to ensure that Payroll Based Journal (PBJ) data (staffing information) for the third quarter (April, May, and June 2023) was submitted as required by the Centers for Medicare and Medicaid Services (CMS). The findings Include: Interview and review of facility documentation with the Administrator on 7/25/24 at 10:30 AM identified that he was aware that PBJ data for the third quarter of 2023 had not been submitted. The Administrator further indicated that the facility's corporate office was responsible for submitting PBJ data to CMS, however had failed to submit the information as required. Additionally, the Administrator identified that because of the failed data submission, the facility contracted a private based company to submit PBJ data on its behalf effective 1/1/24.

Based on observations, interviews, and review of facility documentation, for 4 of the rooms/resident areas on the Elm Unit, 7 of the rooms/resident areas on the Maple Unit, 9 of the rooms/resident areas on the Oak Unit, and 2 of the rooms/resident areas on the Hickory Unit, the facility failed to ensure the residents' rooms and furnishing were maintained in a clean, safe, homelike and sanitary manner and in good repair. The findings included: 1. On 07/19/24 and 07/24/24, observations throughout the day of the Bathroom between rooms [ROOM NUMBERS] on the Elm Unit identified the following: a. The surface of the wall underneath the sink had the drywall and tile removed. The plumbing and wall studs were exposed with tile debris falling from the wall. An interview and tour with the Director of Maintenance (DOM) on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long the drywall had been missing. At one point there was a leak that required the drywall and tile to be removed. 2. On 07/19/24 and 07/24/24, observations throughout the day of the Bathroom between rooms [ROOM NUMBERS] on the Elm Unit identified the following: a. The ceiling tile appeared discolored and had a buildup of a black substance. An interview and tour with the DOM on 07/24/24 from approxmately 9:00 AM to 10:00 AM identified he was unsure of how long the ceiling tile had been like that but identified concerns with water dripping down from the 2nd floor. 3. On 07/19/24 and 07/24/24, observations throughout the day of the Bathroom in room [ROOM NUMBER] on the Elm Unit identified the following: a. The surface of the wall had paint which appeared to be peeling. b. Underneath the sink there was a hole in the drywall and tile. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long the hole was there. 4. On 07/19/24 and 07/24/24, observations throughout the day of the 2nd floor Shower room on the Maple Unit identified the following: a. The faceplate of the radiator had fallen off and was on the ground. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long the cover had been off, but it would be identified on an environmental round. The DOM fixed this while the tour was conducted. 5. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER]A in the Maple Unit identified the following: a. The window blinds had broken and/or missing slats. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long it had been broken, but it is common for residents to take the slats out so the residents can see out the window. 6. On 07/19/24 and on 07/24/24, observations throughout the day of room [ROOM NUMBER]B in the Maple Unit identified the following: a. The Bathroom door handle was permanently locked. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was not aware of the problem with the handle, but that it would have been identified on an environmental round. 7. On 07/19/24 and on 07/24/24, observations throughout the day of the Bathroom in room [ROOM NUMBER] in the Maple Unit identified the following: a. The ceiling tile appeared discolored and had a stain. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure how long the stain was there. 8. On 07/19/24 and on 07/24/24, observations throughout the day of the Bathroom in room [ROOM NUMBER] in the Maple Unit identified the following: a. The ceiling tile appeared discolored and had a stain. An interview and tour with the DOM on 07/24/24 from approximately 9:00AM to 10:00 AM identified he was unsure of how long the stain was there. 9. On 07/19/24 and on 07/24/24, observations throughout the day of the Bathroom between rooms [ROOM NUMBERS] in the Oak Unit identified the following: a. The toilet bowl had a reddish-brown stain. An interview and tour with the DOM on 07/24/24 from approximately 9:00AM to 10:00 AM identified he was unsure of how long the stain was there. 10. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] in the Oak Unit identified the following: a. The wall at the doorway under the light switch had exposed sheet rock. An interview and tour with the DOM on 07/24/24 from approximately 9:00AM to 10:00 AM identified he was unsure of how long the sheetrock had been exposed. 11. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER]B in the Oak Unit identified the following: a. The call bell light outlet had a cover plate and a 3x5 gap with exposed wires. An interview and tour with DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long the cover plate had been missing. 12. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] A/B on the Oak Unit identified the following: a. The bathroom vent had a large accumulation of dust and debris. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified the vent was last cleaned in May of 2024. 13. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] in the Oak Unit identified the following: a. The ceiling tile appeared discolored and was stained. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long the stain was there. 14. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] in the Oak Unit identified the following: a. The ceiling tile appeared discolored and was stained. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long the stain was there. 15. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] in the Oak Unit identified the following: a. The wall had a small hole in the sheetrock behind the window blinds. b. The radiator had a large hole in the grate. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified it had been there for a little while and the hole in the radiator was probably missed on the last environmental round. 16. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] A/B on the Oak Unit identified the following: a. The privacy curtain was falling off the ceiling An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long it had been like that; however, he hooked the curtain to the hooks. 17. On 07/19/24 and 07/24/24, observations throughout the day of the Bathroom in room [ROOM NUMBER] in the Hickory Unit identified the following: a. There were 4 approximately 1/4 inch holes stuffed with pieces of what appeared to be paper towels. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long it has been like that. 18. On 07/19/24 and 07/24/24, observations throughout the day of room [ROOM NUMBER] in the Hickory Unit identified the following: a. There was a hole in the wall above Resident 164's bed which appeared to be missing a faceplate cover. An interview and tour with the DOM on 07/24/24 from approximately 9:00 AM to 10:00 AM identified he was unsure of how long it has been like that. In addition, an interview and tour with the DOM on 07/24/24 from approximately 9:00 AM until 10:00 AM indicated he does conduct environmental rounds to identify any possible issues quarterly. He also indicated each unit has a maintenance log which is routinely reviewed and helps address any issue or concern with environmental areas. The DOM did identify that all environmental concerns identified were unacceptable.

Based on staff interviews, review of the clinical records, facility documentation, and facility policy for 5 of 6 sampled residents (Residents #20, Resident #80, Resident #140, Resident #153, and Resident #668) reviewed for a resident-to-resident altercations, the facility failed to ensure an allegation of mistreatment was reported to the appropriate agencies. The findings include: A.1. Resident #20s diagnoses included dementia, hallucinations, and obesity. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired, required substantial/maximum assist for personal hygiene, was independent/set up for eating, toileting, and transfers. The Resident Care Plan (RCP) dated 2/8/24 identified that Resident #20 had the potential to demonstrate physical behaviors related to dementia. Interventions included that when Resident #20 becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and redirect Resident #153 away from Resident #20. 2. Resident #153's diagnoses included dementia, anxiety, and visual hallucinations. The Admission MDS assessment dated [DATE] identified Resident #153 was severely cognitively impaired, required substantial max assist for personal hygiene, and was dependent for eating, toileting, and bathing. The Resident Care Plan dated 2/8/24 identified that Resident #153 had the potential to demonstrate physical behaviors related to dementia. Interventions included redirecting Resident #153 from Resident #20, and behavior monitoring every shift. A Reportable Event form dated 2/8/24 identified, at approximately 12:30 PM, a staff member yelled for help and LPN #9 went to intervene. Resident #153 went into Resident #20's room, held onto Resident #20's walker and told him/her to let it go. Resident #153 did not let go of the walker and Resident #20 then slapped Resident #153 on the cheek. The staff member separated both residents and neither was injured at the time. The care plans were updated, the Advanced Practice Registered Nurse (APRN), Police, and responsible parties were notified. Both residents were placed on 1 to 1 until cleared by psychiatric services. Adult Protective Services was not identified as being notified. A second Reportable Event form dated 6/12/24 identified, at approximately 11:20 AM identified that Resident #153 was outside Resident #20's room, saw a rollator walker and seated his/herself on the rollator walker seat. Resident #20 looked out his/her door, saw Resident #153 sitting on his/her rollator, and walked over to him/her and hit Resident #153 in the face. Resident #20 was yelling he/she was in my chair and in my stuff. The nurse on the unit heard the commotion and ran to the area to separate the residents. Neither resident appeared injured. The Advanced Practice Registered Nurse (APRN), Police, and responsible parties were notified. Resident #153 was placed on 1 to 1 until cleared by psychiatric services. Resident #20 was sent to a behavioral unit at another facility. The Reportable Event failed to identify that Adult Protective Services were notified. Interview with the Director Nursing Service (DNS) 7/23/24 at 1:18 PM identified that she did not notify Adult Protective Services regarding the incident on 2/8/24 and 6/12/24 because she did not know she was required to do so for a resident-to-resident altercation. B. 1. Resident #80 diagnoses included dementia, diabetes, and muscle weakness. The Quarterly MDS assessment dated [DATE] identified Resident #80 had long and short term memory problems and required partial to moderate assistance from staff with upper body dressing and was independent with ambulation and transfers. The Resident Care Plan in effect on 7/1/24 identified Resident #80 with risk for impaired cognitive function related to dementia. Interventions included administering medications as ordered, monitoring and documenting any changes in cognitive function and engaging in simple structured activities. 2. Resident #140's diagnoses included dementia, hypertension, depression, and anxiety. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #140 was severely cognitively impaired, and was independent with bed mobility, transfers, and ambulation. The Resident Care Plan in effect on 7/1/2024 identified Resident #140 with risk for impaired cognitive function related to dementia. Interventions included engaging the resident in simple structured activities that avoid overly demanding tasks, monitoring and documenting any changes in cognitive function, and using task segmentation to support short memory deficits. Review of the DNS nurse's note dated 7/8/24 at 4:04 PM identified that Resident #140 was observed with a new behavior of touching Resident #80 on top of her chest over her clothing. Review of the Reportable Event dated 7/8/24 identified that Resident #140 placed an open hand on the chest of Resident #80 over his/her clothing. The Reportable Event had a state classification of an E indicating that the event was not Reportable to the State Agency. Review of the Psychiatric and Consultation note dated 7/8/24 identified that Resident #140 was observed by staff touching the chest area of a resident of the opposite gender outside of his/her clothes. When Resident #140 was being reviewed by the psychiatric physician, Resident #140 became agitated over the conversation and stated that Resident #80 put his/her hands over there. Interview with the DNS on 7/23/24 at 11:23 AM identified that LPN #1 contacted her and reported an allegation of mistreatment between Resident #80 and Resident #140. The DNS indicated that she immediately went to the unit and started an investigation of the incident. The DNS identified that she did not report the incident to the state survey agency after she determined that Resident #140 briefly touched Resident #80 on the chest area over his/her clothing. Interview and review of the investigative statement with LPN #1 on 7/24/24 at 10:15 AM identified that on 7/8/24 during her shift, NA #5 reported to her that she was walking in the hallway when she observed Resident #140 sitting in the doorway of his/her room with Resident #80 standing over him/her. Resident #140's hands were noted to be on the outside of Resident #80's clothing, and he/she was holding Resident #80's breasts. LPN #1 further identified that NA #5 had already separated the Residents prior to reporting the issue to her. Additionally, LPN #1 identified that she informed the DNS of the allegation. Interview and review of the investigative statement with NA #5 on 7/24/24 at 10:25 AM identified that she was walking in the hallway when she observed Resident #140 sitting on a chair in the doorway of his/her room with Resident #80 standing over him/her with Resident #140's hands on the outside of Resident #80's clothing and he/she was holding Resident #80's breasts. NA #5 stated that she told Resident #140 to stop, separated Resident #140 from Resident #80 and reported the issue to LPN #1. Interview with the Administrator, DNS, and Clinical Regional Director (RN #3), on 7/24/24 at 11:30 AM identified they did not notify the state agency of the allegation of mistreatment between Resident #80 and Resident #140 because both Residents' Brief Interview for Mental Status (a cognitive test) were low, (cognitive impairment). They further identified that after the facility's internal investigation, it was determined that there was no malintent because Resident #140 did not know what he/she was doing due to severe cognitive impairment. The Administrator identified that he would have reported the allegation of mistreatment to the State Agency had he known that this type of situation still needed to be reported. C. 1. Resident #20's diagnoses included dementia, hypertension, and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was moderately cognitively impaired, independent with bed mobility and transfers, and required supervision with ambulation. The Resident Care Plan (RCP) in effect on 5/1/23 identified Resident #20 had the potential to demonstrate physical behaviors related to dementia. Interventions included intervening before agitation escalates, guiding away from source of distress, engaging calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. 2. Resident #668's diagnoses included dementia, anxiety, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #668 was moderately cognitively impaired and independent with bed mobility, transfers and ambulation. The Resident Care Plan in effect on 5/1/23 identified Resident #668 had behavior issues related to physical altercation with peers and staff. Interventions included to provide a psychiatric consultation as needed and redirection from other residents' personal space. A Reportable Event form dated 5/4/23 at 10:00 AM, identified an unwitnessed event had occurred. A staff member was walking in the hallway when she saw Resident #20 sitting on the ground near the doorway of his/her room while Resident #668 was noted to be holding Resident #20's phone in his hand leaving Resident #20's room. Staff responded and separated Resident #20 and Resident #668. Resident #20 stated that Resident #668 entered his/her room and attempted to take his/her cellphone. Resident #20 tried to take his/her cell phone back but in the process both Residents struck each other, and Resident #20 was pushed to the ground. Review of the resident interviews identified that Resident #668 stated he/she hit Resident #20 while Resident #20 stated that he/she hit Resident #668. Resident #20 and Resident #668 were placed on 1 to 1 observation until they were cleared by the psychiatric physician. Nursing Assessments were completed, and Resident #20 was noted to have an open area on his/her right elbow and left hand. Resident #668 was noted to have a skin tear on the left knee. Advanced Nurse Practitioner (APRN), resident's responsible party, and the police were notified of the altercation. Psychiatric and Social Services were provided. Adult Protective Services was not identified as being notified. Interview with the Director of Nursing Services (DNS) on 7/13/24 at 1:18PM identified that she did not notify the Adult Protective Services about the resident-to-resident altercation. She identified that she was unaware of the state guidelines regarding notifying Adult Protective Services. She further identified that had she been aware of the guidelines, she would have notified Adult Protective Services. Review of the Abuse Reporting and Investigation policy, in part, identified that the facility will not permit residents to be subjected to abuse by anyone including other residents. An investigative report will be conducted to identify the incident, identify staff members responsible for the initial reporting, investigation of alleged violations and reporting results to the proper authorities. Should the investigation reveal that suspected or actual abuse occurred, the administrator/designee must report such findings to the resident representative, Department of Public Health and others that may be required within the mandated time frames. Review of the Abuse: Reporting and Investigation policy, in part, identified that the facility will not permit residents to be subjected to abuse by anyone including other residents. An investigative report will be conducted to identify the incident, identify staff members responsible for the initial reporting, investigation of alleged violations and reporting results to the proper authorities. Should the investigation reveal that suspected or actual abuse occurred, the administrator/designee must report such findings to the resident representative, Department of Public Health and others that may be required within the mandated time frames. 50250

Based on observation, interviews, and a temperature test, the facility failed to ensure that food was palatable, attractive, and at a safe and appetizing temperature. The findings included: Interview with Resident #34 on 7/19/24 at 1:30 PM identified the food was not good and he/she gets cold food. Interview with Resident #107 on 7/22/24 at 10:14 AM identified the food was not good, they don't like the vegetables. Interview with Resident #19 on 7/22/24 at 11:40 AM identified the food was not good and did not know he/she had options for different meals if they did not like what was on the menu Interview with Resident #46 on 7/22/24 at 12:14 PM identified in general the food was not that great. The food was not appealing. Resident #46 stated the kitchen does not separate portions and the vegetables were mushy. On 7/24/24 a test/temperature tray conducted with the Dietary Manager identified the lunch tray consisting of meatloaf with gravy, mashed potato, corn, roll, and cheesecake left the kitchen at 1:04 PM. The test tray arrived on the second floor at 1:08 PM and was delivered to residents starting at 1:10 PM. The last tray was delivered at 1:22 PM. The temperature of the test tray was conducted with the Dietary Manager at that time and identified the following: The meatloaf internal temperature was 120.4 degrees Fahrenheit (F) per the surveyor calibrated thermometer and 120.9 degrees F by the Dietary Manager's thermometer. The potatoes internal temperature was 131.4 degrees Fahrenheit (F) per the surveyor calibrated thermometer and 124.2 degrees F by the Dietary Manager's thermometer. The cheesecake was 77.7 degrees Fahrenheit (F) per the surveyor calibrated thermometer and 77.3 degrees F by the Dietary Manager's thermometer. An interview with the Dietary Manager on 7/24/24 at 1:22 PM indicated that a palatable temperature for the meatloaf should be at least 135 degrees F and a palatable temperature for the cheesecake should be 38 degrees F to 40 degrees F. The Dietary Manager stated a contributing factor for the high temperatures of the cheesecake was the trays of cheesecake came directly out of the refrigerator and were stored on an open metal cart throughout the entire time staff was plating all the meals (approximately 160 meals). A contributing factor for the low meatloaf temperatures was a non-functioning pellet plating system. Subsequent to surveyor inquiry an electrician was contacted for repair of the pellet plating system.

Based on observations, review of the clinical record, facility policy, and interviews for the only resident (Resident #103), reviewed for incontinence, the facility failed to provide timely incontinent care to a dependent resident. The findings include: Resident #103's diagnoses included hemiplegia and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) and chronic pain syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #103 was mildly cognitively impaired, was totally dependent on staff for bed mobility and toileting hygiene and did not transfer out of bed. Resident #103 was always incontinent of bowel and bladder. The Resident Care Plan dated 5/15/24 identified Resident #103 had bowel and bladder incontinence and is at risk for complications with yeast in the urine. Interventions included washing, rinsing, and drying the perineum and changing clothing after incontinence episodes every 2 hours and as needed. Continuous observations of Resident #103 on 7/24/24 from 9:00 AM to 11:39 AM identified that at 11:39 AM, NA#1 and NA #2 entered Resident #103's room to perform incontinent care. After obtaining permission from the resident to observe care, Resident #103, was identified to have had a small liquid bowel movement. Dried fecal material was noted to be adhering to the outside ring of fecal material on his/her buttocks which required NA #2 to apply friction to remove the fecal matter. Interview with NA #1 and NA #2 on 7/24/24 at 11:45 AM identified that incontinent care is given every 2 hours and as needed. NA #2 identified she had last given Resident #103 care at 7:45 AM. Although NA #2 indicated she went in at 11:00 AM and checked Resident #103 for incontinence, constant observation by the surveyor failed to identify NA#2 had entered Resident #103's room. Interview with LPN #3 on 7/24/24 at 1:26 PM identified that incontinent care is given every 2 hours and when the residents use their call bell. The NA's get the residents up and change them if the residents are soiled and then transfer the residents back to their chairs. LPN #3 stated that NA #2 indicated care was provided to Resident #103 at 8:45 AM. LPN #3 additionally stated that NA#2 should have provided Resident #103 with an incontinent check/care at 10:45 AM (within approximately 2 hours) and further stated she would have expected Resident #103 to be checked/care given sooner than the surveyor observed. In a second interview with NA#2 at 1:37 PM she confirmed she was responsible for Resident #103's incontinent care and that she had last provided Resident #103 incontinent care at 7:45 AM (approximately 4 hours prior to the observation of care). Interview with Resident #103 on 7/24/24 at 1:58 PM identified that he/she could not recall being checked earlier than when the surveyor observed his/her care. Interview with Director of Nursing Services (DNS) on 7/25/24 at 8:55 AM identified that incontinent care is given 4 times a shift and when a resident needs to be changed. The DNS indicated that incontinent care is not given exactly every 2 hours but is given more frequently than every 4 hours. Review of the Perineal care policy dated 12/14/2022 directed, in part, to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Although requested, a facility policy for incontinence care was not provided.

Based on review of the clinical record, facility policy, and interviews for 2 of 2 residents, (Resident #94 and Resident #152), reviewed for kidney failure who receive specialized services and who were on a fluid restriction, the facility failed to have a systematic approach in place to assess daily fluid intake amounts on consecutive days. The findings include: 1. Resident #94 's diagnoses included chronic kidney disease Stage 4 (severe) and Diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #94 was moderately cognitively impaired and independent with eating, bed mobility, transfers, and toileting. The Resident Care Plan dated 6/17/24 identified renal insufficiency related to end stage chronic kidney disease now on a specialized service. Interventions included providing the specialized service as ordered by the provider, monitor, document and report any complications every shift, and due to a fluid restriction, to check with the charge nurse before bringing fluids between meals. A physician's order dated 6/18/24 directed a fluid restriction of 1200 milliliters (ml) per day: 480 ml to be given by nursing and 720 ml to be given by dietary. The Medication Administration Record (MAR) identified a fluid restriction of 1200 ml per day beginning on 6/19/24 with amounts noted for each shift but the MAR failed to indicate a total fluid intake for each 24-hour period. The Documentation Survey Report indicates fluids given by staff on each shift as follows: 7/14/24 120 ml on evening shift, 7/15/24 360 ml on evening shift, 7/16/24 360 ml on evening shift, 7/17/24, 420 ml on the evening shift and 120 ml on the overnight shift, 7/18/24 360 ml on evening shift, 7/19/24 480 ml on evening shift, and on 7/20/24 360 ml on evening shift. Review of the intake and output worksheets identified there was an intake and output book at the nurse's station but lacked an entry for 7/14/24, on 7/15/24 a 300 ml intake, on 7/16/24 a 480 ml, on 7/17/24 a 480 ml, on 718/24 a 480 ml, on 7/19/24 360 ml, and on 7/20/24 480 ml. Review of the clinical record failed to indicate that total fluid intake amounts were calculated from 7/14/24 through 7/20/24. Interview with RN #3 on 7/25/24 at 12:50 PM identified that when a resident were to show symptoms of dehydration, an assessment would be conducted, and the practitioner would be notified. RN #3 indicated that the facility failed to have a mechanism in place to total fluid intake every 24 hours. RN #3 identified that the Dietician assessed residents for total fluid needs/goals, but if the resident failed to meet that goal, there were no designated staff who would look at the 24-hour total each day to make the determination if the fluid goal was met or exceeded. Further, per the standard of practice, RN#3 indicated that if a resident did not meet their 24 hour fluid goal for 3 consecutive days, a dehydration assessment should be conducted, and the Dietician and medical practitioner should be notified. 2. Resident #152's diagnoses included end stage renal disease, moderate protein-calorie malnutrition, and congestive heart failure. The admission Minimum Data Set assessment dated [DATE] identified Resident #152 was moderately cognitively impaired, was independent with eating, dependent on staff for personal hygiene, and dependent for chair/bed-to-chair transfers. The Resident Care Plan dated 6/4/24 identified Resident #152 was at risk for dehydration or potential for fluid deficit related to his/her fluid restriction, end stage renal disease, and congestive heart failure. Interventions included monitoring and document intake and output amounts. A physician's order dated 7/3/24 directed to maintain a fluid restriction of 1200 milliliters (ml) in 24 hours every shift with 480 ml from nursing (days: 180 ml, evenings: 180 ml, nights: 120 ml) and 720 ml from dietary. Observation of Resident #152 on 7/19/24 at 11:41 AM identified him/her with dry mucous membranes. Intake and output record flowsheets dated 7/7/24 through 7/20/24, from Resident #152 ' s paper chart, identified Resident #152 was on a 1200 ml fluid restriction in 24-hours and had intake and output documentation that did not exceed 480 ml per day with no 24-hour total documented. On 7/7/24 120 ml on night shift and 360 ml on evening shift; on 7/8/24 120 ml on night shift; 7/9/24 60 ml on night shift and 360 ml on evening shift; 7/10/24 60 ml on night shift and 360 ml on evening shift; 7/11/24 60 ml on night shift and 360 ml on evening shift; 7/12/24 60 ml on night shift and 360 ml on evening shift; 7/13/24 60 ml on night shift and 360 ml on evening shift; 7/14/24 no entries; 7/15/24 360 ml on evening shift; 7/16/24 60 ml on night shift and 360 ml on evening shift; 7/17/24 60 ml on night shift and 350 ml on evening shift; 7/18/24 60 ml on night shift and 360 ml on evening shift; 7/19/24 360 ml on evening shift; 7/20/24 60 ml on night shift and 360 ml on evening shift. Intake amounts documented in the MAR from 7/7/24-7/20//24 were as follows: 7/7/24 100 ml on night shift, 420 ml on day shift, and 360 ml on evening shift; 7/8/24 60 ml on night shift, 360 ml on day shift, and 360 ml on evening shift; 7/9/24 60 ml on night shift, 180 ml on day shift, and 180 ml on evening shift; 7/10/24 60 ml on night shift, 480 ml on day shift, and 360 ml on evening shift; 7/11/24 60 ml on night shift, 360 ml on day shift, and 360 ml on evening shift; 7/12/24 60 ml on night shift, 180 ml on day shift, and 360 ml on evening shift; 7/13/24 60 ml on night shift, 120 ml on day shift, and 360 ml on evening shift; 7/14/24 60 ml on night shift, 360 ml on day shift, and 300 ml on evening shift; 7/15/25 60 ml on night shift, 360 ml on day shift, and 360 ml on evening shift; 7/16/24 60 ml on night shift, 180 ml on day shift, and 360 ml on evening shift; 7/17/24 60 ml on night shift, 360 ml on day shift, and 360 ml on evening shift; 7/18/24 60 ml on night shift, 80 ml on day shift, and 360 ml on evening shift; 7/19/24 60 ml on night shift, 280 ml on day shift, and 360 ml on evening shift; and 7/20/24 60 ml on night shift, 240 ml on day shift, and 360 ml on evening shift. Interview with the Director of Nursing Services (DNS) on 7/25/24 at 9:20 AM identified that the intake and output record flowsheets in the paper chart are not part of the official clinical record, are used only as a worksheet, and should not be in the resident ' s chart. All intake and output documents are located in the electronic clinical record where the nurse for each shift documents the total intake for that shift. The DNS further identified that a total intake for 24 hours is not documented, however each nurse can see the entries of the previous two shifts so that they could see if the resident went over their physician prescribed fluid restriction. If the fluid restriction was exceeded, the staff could notify the Advanced Practice Registered Nurse (APRN). The DNS failed to identify what the nurse ' s actions would be taken if the resident intake was below the fluid restriction or how staff would know if the resident was not meeting their fluid goal for 3 days consecutively. Interview with Nurse Aide (NA) #1 on 7/25/24 at 10:09 AM identified that fluid intake amounts are not documented by them in the electronic record, however when she sees an intake and output record flowsheet in the intake and output book, she will write the intake on the sheet for the nurse to review. Interview with LPN #11 on 7/25/24 at 11:20 AM identified that she documents the total intake for her shift in the electronic record, which includes what the NA ' s document on the intake and output sheets added to what she provides during the shift. LPN #11 stated that she does not look at the entries of the previous two shifts and can only be responsible for the intake on her shift, and that her goal for residents on a fluid restriction is 500 ml on the day shift. Interview with the Clinical Regional Nurse (RN #3) on 7/25/24 at 12:50 PM identified that the facility does not a have a process to tally 24-hour totals for residents who are on intake and output. RN #3 further identified that the facility would report to the provider when a resident was symptomatic for a lack of hydration and that an assessment would be conducted, but there was no system to identify when a resident did not meet their 24-hour fluid total that had been determined by the Dietician. RN #3 identified that if a resident showed signs and symptoms of dehydration the physician would be notified, but that there was not a process to identify when a resident did not meet their fluid goal for consecutive days according to standards of practice. Additionally, RN #3 indicated that the Dietician and provider should be notified, and an assessment should be completed. Intake and output should be documented and totaled to identify any deviations from estimated fluid goals or fluid restrictions. Review of the clinical record for Resident #152 failed to reflect documentation of the total amount of fluid intake meeting the fluid restriction of 1200 ml without exceeding it. Between 7/5/24 through 7/21/2024, there were 14 days where the documented amounts for each shift did not total over 800 ml for 24 hours and there was no corresponding nursing staff documentation/assessments/notes to indicate Resident #152's hydration status when his/her fluid intake did not meet 800 ml since the initial readmission dehydration risk screener conducted on 7/4/24. Review of the intake measuring and recording, and hydration and prevention of dehydration policy directed, in part, to record the fluid intake after the resident consumed the fluids at the end of your shift total the amounts of all liquids the resident consumed and record the intake and output on the intake and output record. Physician orders to limit fluids will take priority over calculated fluid needs. The Dietitian may refer calculated needs to the physician if restrictions potentially increase the risk of dehydration. 50179 51183

Based on review of the clinical record, facility policy, and interviews for 2 of 8 residents, (Resident #25 and Resident #107), reviewed for unnecessary medications, the facility failed to follow physician orders for obtaining a blood pressure before administration of a medication (Resident #25), and failed to correctly input an order for medication administration and failed to follow a physician's order for medication administration (Resident #107). The findings include: 1. Resident #25's diagnoses included hypertension, atrial fibrillation, and schizoaffective disorder. Physician order dated 1/3/24 directed Atenolol (a medication for high blood pressure) 50 milligrams (mg) by mouth twice a day, hold for systolic blood pressure (SBP) less than 100, and hold for a heart rate (HR) of less than 60 beats per minute. The annual Minimum Data Set assessment dated [DATE] identified Resident #25 had moderately impaired cognition and was independent with eating, oral hygiene, toilet use, showering, and personal hygiene. The Resident Care Plan dated 1/9/24 identified Resident #25 had an alteration of cardiac/respiratory status related to hypertension and chronic obstructive pulmonary disease. Interventions included administering medications as ordered, monitor for side effects, document and report cardiac distress, and obtain vital signs as ordered. Review of the Medication Administration Record and the clinical record with Licensed Practical Nurse (LPN) #4 on 7/23/24 at 12:40 identified that although Resident #25 received Atenolol 50 mg twice daily beginning in February 2024, the resident's blood pressure was taken once in February on 2/5/24, once in March 2024 on 3/6/24, once in April 2024 on 4/5/24, once in May 2024 on 5/5/24, once in June 2024 on 6/5/24, and once in July 2024 on 7/4/24, equating to greater than 340 missed blood pressure readings. Interview and record review with Licensed Practical Nurse (LPN) #4 on 7/23/24 at 12:40 PM identified that although Resident #25's heart rate was checked before the 7/23/24 medication administration, the blood pressure was not being taken per the provider medication order with each Atenolol administration twice daily. Interview with LPN #5 on 7/23/24 at 12:45 PM identified that Resident #25's heart rate was taken before the 7/22/24 medication administration but the blood pressure was not being taken per provider medication order. LPN #5 stated the reason the resident's blood pressure was not taken per the provider's order, was that the electronic system did not prompt for a blood pressure to be taken. Review of the facility's Administering Oral Medications Policy, dated March 2019, identified that any pre-administration assessments should be performed before a medication is administered 2. Resident #107 's diagnoses included anemia, chronic myeloid leukemia in remission, depression, and a history of left femur fracture. The 5 day Minimum Data Set assessment dated [DATE] identified Resident #107 was moderately cognitively impaired, was independent with eating, required substantial/maximal assistance to roll left and right, and substantial/maximal assistance for sit to stand transfers. The Resident Care Plan dated 12/12/23 identified Resident #107 had a nutritional problem related to diabetes, a history of chronic myeloid leukemia, chemotherapy, and a significant weight loss. Interventions included administering medications as ordered. A. A pharmacy consultant recommendation for Resident #107 dated 1/16/24 suggested that the prescriber consider changing Vitamin D to Vitamin D3 50,000 units once a month. An APRN order (APRN #1) dated 1/18/24 directed to discontinue the administration of Cholecalciferol (Vitamin D3) oral tablet 1,000 units, 1 tablet once daily and start the administration of Vitamin D3 oral tablet 50,000 units 1 tablet once a day starting on the 23rd and ending on the 24th every month. A review of the Medication Administration Record (MAR) identified that Resident #107 received Vitamin D3 50,000 units for 2 days in January, February, March, April, May, June and July on the 23rd and 24th of each month. In an interview with Pharmacist #1 on 7/24/24 at 12:44 PM it was identified that his recommendation dated 1/16/24 was for Vitamin D3 once per month. Pharmacist #1 was not aware how the Advanced Practice Registered Nurse (APRN) #1 had written the order dated 1/18/24 resulting in Vitamin D3 50,000 units being administered twice a month. In interview with APRN #1 on 7/24/24 at 12:25 PM she identified when she wrote the order for Vitamin D3 oral tablet 50,000 units on 1/18/24, her intention was to administer Vitamin D3 50,000 units per month per the pharmacy recommendation. APRN #1 was unaware that due to the way she had written the order, she had directed facility staff to administer the Vitamin D3 for 2 days concurrently every month, on the 23rd and 24th, since January 2024 (over 6 months' time). B. The Resident Care Plan dated 12/12/23 identified that Resident #107 had an alteration in gastrointestinal status related to anemia and history of gastrointestinal hemorrhage. Interventions included obtaining and monitoring laboratory work, and giving medications as ordered. 1. An APRN order (APRN #1) dated 2/28/24 directed facility staff to inject 1 application of Procrit 10,000 units per milliliter (units/ml.) intramuscularly (IM) once daily every Tuesday, and to hold the medication if the laboratory result for hemoglobin was over 10. Review of the clinical record, laboratory result dated 6/3/24 identified that Resident #107's hemoglobin was 11.1. Review of the Medication Administration Record (MAR) identified that on 6/4/24 LPN #10 had administered Procrit 10,000 units/ml IM despite the physician order to hold the Procrit if the hemoglobin was over 10 (11.1). 2. An APRN order (APRN#2) dated 6/4/24 directed facility staff to discontinue Resident #107's weekly laboratory work for hemoglobin levels and to start obtaining hemoglobin levels monthly. Further, APRN #2 directed Resident #107's Procrit be held on 6/11/24, 6/18/24, 6/25/24, and 7/2/24. APRN #2's progress note dated 6/4/24 directed facility staff to discontinue the Procrit, however, APRN #2 failed to write a physician's order for discontinuation and instead, ordered the Procrit to be held from 6/4/24 through 7/2/24. Review of the clinical record, laboratory result, dated 7/2/24 identified that the Resident #107's hemoglobin was 10.1. Review of the July MAR identified the Procrit was correctly held on 7/2/24 and 7/9/24, according to the laboratory results obtained on 7/2/24, but that on 7/23/24 LPN #5 had administered Procrit to Resident #107, despite a hemoglobin level of 10.1. In an interview and review of the clinical record with LPN #10 on 7/25/24 at 9:40 AM she identified that Resident #107's Procrit had parameters, per the physician's order, to hold the medication if the laboratory value for hemoglobin was greater than 10. Review of the laboratory data with LPN #10 identified that on 6/3/24 Resident #107's hemoglobin was 11.1 and that she had signed that she had administered the medication on 6/4/24 despite the parameter to not administer. LPN #10 identified that if she had held Resident #107's Procrit she would have written a nursing note, however, no note was identified. Further LPN #10 indicated that if the medication was checked off (as it was on 6/4/24), that indicated the medication was administered. Although LPN #10 had signed off giving the medication on the MAR on 6/4/24, she was unable to recall if she had actually administered the Procrit to Resident #107. In an interview with APRN #1 on 7/25/24 at 10:43AM, she identified that her expectation for the administration of Procrit would be for facility staff to follow the physician order as written. APRN #1 indicated that the medication had parameters not to administer when the hemoglobin was above 10 and that on 6/4/24 and 7/23/24 the medication should not have been administered to Resident #107. Although attempted, an interview with LPN #5 was not obtained for the administration of Procrit on 7/23/24. Although requested, a facility policy for physician orders was not provided. Review of the Administering Medications Policy directed, in part, that medications must be administered in accordance with the physician orders. 51183

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 Residents (Resident #77) reviewed for wound care, the facility failed to maintain proper infection control techniques for Enhanced Barrier Precautions (EBP) during wound care, and during a review of the facility laundry services in the facility's only laundry area, the facility failed to ensure a clean environment for laundry processing. The findings include: 1. Resident #77's diagnoses included subacute osteomyelitis and stage 4 pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #77 was cognitively intact and was dependent on staff with toileting hygiene, showering/bathing self, and chair to bed transfers. Additionally, the MDS identified that Resident #77 had an unstageable pressure ulcer. The Resident Care Plan dated 7/17/24 identified EBP. Interventions included appropriate Personal Protective Equipment (PPE) to be used per the Enhanced Barrier Precautions Protocol. A physician's order dated 7/19/24 directed EBP to be maintained at all times every shift. Observation of Resident #77's room on 7/24/24 at 11:00 AM identified EBP signage was posted on the door frame which directed that staff must wear gloves and a gown for wound care. LPN #6 was observed to enter Resident #77's room and complete wound care to the sacral pressure ulcer without the benefit of wearing a gown throughout the treatment. Interview and clinical record review with LPN #6 on 7/24/24 at 12:56 PM identified that she was not aware that Resident #77 was on EBP. Additionally, LPN #6 identified that she would look at the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) to verify if Resident #77 was on EBP. Upon further review of the MAR and TAR, LPN #6 identified that Resident #77 was on EBP and that she should have been wearing appropriate PPE. Interview with the Infection Preventionist (RN #1) on 7/24/24 at 3:17 PM identified that during wound care, the nurse should be wearing a gown and gloves per EBP. Additionally, RN #1 identified that staff can verify if a resident was on EBP by reviewing the EBP signage posted outside of the resident's room, the physician's order, the care plan, and the care card (used by Nurse Aides). Although EBP was a requirement per the Centers for Medicare and Medicaid Services effective 4/1/24, RN #1 identified that the facility was still working on education for the staff and the order for EBP was not created until 7/18/24 (effective 7/19/24). Review of the EBP policy directed, in part, that PPE for EBP is only necessary when performing high-contact care activities. High-contact care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care on any skin opening requiring a dressing. 2. Observation in the Laundry Room with the Infection Preventionist on 7/23/24 at 12:10 PM identified a moderate coating of white/gray debris on the tops of 4 of 4 washers and 5 of 5 dryers. Additionally, the washer room ceiling fan had a moderate buildup of a dark grey substance on all fan blades. On 2 of the washers exposed outer filters, a moderate buildup of a dark gray substance was present. The overhead pipes and wires in both the washer and dryer areas also had a moderate buildup/coating of a dark gray substance. Interview and observation with the Regional Environmental Services Manager on 7/23/24 at 12:15 PM, indicated he was unable to identify the substances on the washers/dryers, ceiling fan, washer filters, or overhead pipes and wires. He further identified that he visits the facility weekly and has seen similar conditions in the washer and dryer rooms on his prior visits. The Regional Environmental Services Manager indicated that the areas needed to be thoroughly cleaned and that he would have facility staff complete the necessary tasks. Interview and observation with the Environmental Services Director, on 7/23/24 at 12:20 PM, identified a window to the outside above 2 washers that had a thick buildup of a dark gray substance on the inside screen. The Environmental Services Director was unable to identify the substance clinging to the inside screen of the window. In addition, a window to the outside located in the dryer room was open approximately 8 inches, lacked a screen, and was coated with a a notable amount of a white substance. Dryers were venting to the outside and there was a large amount of white substances on the grass below the exhaust vent/pipe. The vent discharge area was directly adjacent to the open window and a considerable amount of warm air was venting back into the dryer room where clean, wet, laundry was stored uncovered in a laundry bin placed between two dryers. The Environmental Services Director indicated clean wash should be stored covered and that the outside window in the dryer room should have been closed to prevent the white substance from re-entering the dryer room. Interview, observation, and review of facility documentation with the Environmental Services Director and Laundry Assistant #1 on 7/23/24 at 12:30 PM identified all surfaces and machines in the washer and dryer rooms are cleaned daily. The Environmental Services Director indicated that it was the responsibility of the laundry staff to complete the laundry cleaning schedules as posted. Review of the Laundry Cleaning Schedule for June 2024 and July 2024 identified that clean and soiled area cleaning was to be completed daily, high dust cleaning was to be completed weekly, and light fixtures and windows were to be cleaned monthly (fan cleaning was not noted). Although the Regional Environmental Services Director indicated the areas needed to be thoroughly cleaned, the Laundry Cleaning Schedule had been signed indicating that all the cleaning tasks had already been completed. Observation of the laundry facility on 7/24/24 at 11:30 AM identified that all areas were free of dust and debris, the dryer window was closed, and clean laundry was not noted to be stored uncovered. Although a laundry policy was requested, the facility policy failed to include clean laundry operations for drying, folding, storage or cleaning of the laundry areas. 50249

Based on Resident Council interviews, staff interview, and a review of the Food Committee minutes, the facility failed to act on the Food Committee concerns. The findings include: On 7/24/24 at 1:15 PM, during the Resident Council meeting, Resident #29 and Resident #65 reported that the Food Committee meets monthly, and attendees give feedback for correction, and nothing ever gets done. An interview and review of the Food Committee minutes with the Dietary Manager and the Regional Dietary Manager on 7/25/24 at 11:15 AM identified that on 4/24/24, Resident #93 wanted small portions and didn't want bread on his/her tray and Resident #42 disliked pork and requested gravy on the side. Review of the Food Committee Minutes Review/Follow Up dated 5/25/24 failed to identify a response from the Dietary Department. Food Committee minutes dated 6/25/24 identified Resident #13 requested more scrambled eggs at breakfast and Resident #97 requested 2 boiled eggs twice a week. Review of the Food Committee Minutes Review/Follow Up dated 7/5/24 failed to identify a response from the Dietary Department. The Regional Dietary Manager performed a review of resident food tickets, within the Food Service computer program, to verify if a note had been placed on their food ticket after a request or complaint had been placed in the January of 2024 through July of 2024 Food Committee minutes. The Regional Dietary Manager was unable to identify that resident requests from the Food Committee meeting minutes resulted in a note being placed on their food ticket. Although requested, the Dietary Manager identified the facility did not have a policy for responding to Food Committee concerns.

Based on staff interviews, clinical record review, and facility policy for 1 of 5 residents (Resident #98), reviewed for Preadmission Screening Assessment Resident Review (PASRR), the facility failed to refer Resident #98 to the appropriate state-designated authority for a Level II PASRR evaluation and determination when a new psychiatric diagnosis was identified. The findings include: A PASRR Level I screen dated 3/4/20 identified that Resident #98 needed no further Level I screen unless you have or are suspected of having a serious mental illness of an intellectual or developmental disability and exhibit a significant change in the resident's treatment needs. Resident #98 diagnosis included dementia, congestive heart failure and a new diagnosis of schizoaffective disorder, which was diagnosed in September of 2020. A Psychological Services Progress Note dated 9/13/20 identified that Resident #98 had a psychotic disorder. A Psychological Services Progress Note dated 5/23/22 identified that Resident #98 had schizoaffective disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #98 was severely cognitively impaired, required substantial/ moderate assist for personal hygiene, was dependent for toileting, and bathing, and was independent with eating. Additionally, Resident #98 was noted with diagnoses including psychotic disorder and schizophrenia. The Resident Care Plan dated 1/23/24 identified Resident #98 had a psychosocial wellbeing problem related to schizoaffective psychotic disorder. Interventions identified when a conflict arises, remove Resident #98 to calm, safe environment and allow to vent/share feelings. Also to assist, supervise, and support Resident #98 to identify problems that cannot be controlled. Interview with Social Worker (SW)#1 on 7/23/24 at 10:09 AM identified that she only started working at the facility in 2023 and she was unsure why a PASRR Level II had not been completed for Resident #98 but that the notification for a Level II should have been submitted to the appropriate agency. SW#1 identified that she was in the process of learning how to run audits, that it must have gotten overlooked. Subsequent to surveyor inquiry, SW #1 indicated that she will resubmit for PASRR Level II. The Facility Policy for Resident Assessment -Coordination with PASRR program identified that the facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disease, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have a mental disease, intellectual disease or a related condition to the appropriate state-designated authority for a Level II PASRR evaluation and determination. The Social Service Director shall be responsible for keeping track of each resident's PASRR screening status, referring to the appropriate authority.

Based on clinical record reviews, review of facility documentation and interviews for two of twelve sampled residents (Resident #63 and #8) who were reviewed for errors in the medication regimen, the facility failed to obtain bloodwork per the physician's orders [REDACTED]. The findings include: 1. Resident #63's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #63 had no memory or cognitive deficits and received an anticoagulant medication daily. The resident care plan dated 3/12/15 identified anticoagulant therapy. Interventions directed to administer medication as ordered, obtain labs as ordered and report results to the physician and to monitor, document and report to the physician anticoagulant complications. An Advanced Practice Registered Nurse's (APRN) order dated 3/11/15 directed [MEDICATION NAME] 7 milligrams (mg) daily and recheck the [MEDICATION NAME] Time (PT) and International Ratio (INR) in one week. Review of the laboratory reports identified that on 3/11/15 the PT was 29.8 (normal range 9.4-12.2) and the INR was 2.8 (normal range 2.0-3.5 depending on the dose of the anticoagulant medication). An APRN order dated 3/12/15 directed to obtain PT/INR levels on 3/13/15. The laboratory report dated 3/13/15 identified that the PT was 19.7 and the INR was 1.8. An APRN order dated 3/13/15 directed to recheck the INR in one week. Review of the March 2015 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the laboratory reports failed to reflect documentation of the PT/INR results for 3/18/15 and/or for 3/20/15. Review of the MAR from 3/18/15 through 3/28/15 failed to reflect documentation that the [MEDICATION NAME] had been reordered, therefore the [MEDICATION NAME] was not administered for eleven days. An APRN order dated 3/28/15 directed to administer an immediate dose of [MEDICATION NAME] 7mg now and on 3/29/15, to obtain a PT/INR on 3/30/15 and update the APRN and vital signs every shift for forty-eight hours. The nurse's note dated 3/28/15 at 11:53 PM identified that the charge nurse noted on 3/28/15 that the [MEDICATION NAME] 7mg had been omitted for eleven doses and the PT/INR had not been drawn on 3/18/15. The Reportable Event Form dated 3/28/15 identified a medication error and omission of [MEDICATION NAME]. The report identified that on 3/28/15 the charge nurse, who knew the resident was on [MEDICATION NAME], found the error after checking the physician's orders [REDACTED]. The laboratory report dated 3/30/15 identified the PT was 11.4 and the INR was 1.1 (normal range of 0.8 to 1.2 denotes no anticoagulant therapy). The APRN order dated 3/30/15 directed to discontinue the [MEDICATION NAME] 7mg, start [MEDICATION NAME] 8mg daily and obtain a PT/INR on 4/2/15. The laboratory report dated 4/2/15 identified the PT was 14.3 and the INR 1.3. The APRN order dated 4/2/15 directed to discontinue the [MEDICATION NAME] 8mg, start [MEDICATION NAME] 9mg and obtain a PT/INR on 4/6/15. Interview with the attending physician on 5/27/15 at 12:25 PM identified that for Resident #63 the PT result from 19 to 11 was a significant drop. Interview with the Director of Nursing (DON) on 5/27/15 at 2:10 PM identified that a laboratory requisition had not been completed and placed in the laboratory book, therefore the PT/INR was not drawn on 3/18/15 and the [MEDICATION NAME] reordered. 2. Resident #8's [DIAGNOSES REDACTED].#8 was admitted on [DATE]. The hospital discharge summary dated 4/19/14 identified the following daily medications: [REDACTED]. The nurse's note date 4/19/15 at 6:38 PM identified that the 7AM-7PM Registered Nurse (RN) Supervisor, RN #6, had conducted the admission assessment and updated the attending physician, follow up with discharge medications from hospital. The admission nurse's note dated 4/19/15 at 7:41 PM identified that Resident #8 was admitted to the facility at 4:30 PM via stretcher, was alert, had episodes of forgetfulness, confusion and difficulty remembering new information and recall of necessary information. Review of the admission physician's orders [REDACTED]. Review of the April Medication Administration Record [REDACTED]. The physician's progress noted dated 4/20/15 identified that Resident #8 was seen by the Advanced Practice Registered Nurse (APRN) related to having loose watery stools all day. The note indicated that the APRN had reviewed and signed the Inter-Agency Referral Report (W-10) and the attending physician was to admit the resident. Review of the hospital W-10 identified that the APRN had signed the medication list on 4/20/15. Review of the admission history and physical, the physician's orders [REDACTED].#8 was seen by the attending physician on 4/21/15. The nurse's note dated 4/22/15 at 7:28 AM identified that at 6:10 AM Resident #8 was heard making gurgling noises and banging the bed railings. The charge nurse, Licensed Practical Nurse (LPN) #9 indicated that she went into Resident #8's room and witnessed the resident having a grande mal [MEDICAL CONDITION] that lasted ten minutes. The assessment identified Resident #8's oxygen saturation level was 85% (normal greater than 90%), oxygen at 5 liters per minute was applied and the level went up to 97%. Resident #8 was transferred to the hospital for an evaluation at 7:10 AM. The nurse's note dated 4/22/15 at 2:37 PM identified that the attending physician and family were made aware that Resident #8 had not received medications including all [MEDICAL CONDITION] medications for two days, eight shifts. The Reportable Event Form dated 4/22/15 identified that the admission orders [REDACTED]. Subsequent to the incident the 7AM-7PM Registered Nurse (RN) Supervisor, RN #6, was terminated and an action plan initiated. The hospital discharge summary dated 4/24/15 identified that on 4/22/15 Resident #8 presented after having a witnessed grand mal [MEDICAL CONDITION]. The note identified that the facility was not giving the resident the anticonvulsant medication, as they were not on the medication list provided from the Long Term Care (LTC) facility and the medications had been included on the hospital discharge summary from the recent hospital admission, 4/14/15 through 4/19/15. The summary indicated that during transfer the Emergency Medical Services reported Resident #8 suffered another tonic-clonic [MEDICAL CONDITION] which was relieved with [MEDICATION NAME] 2mg intravenous and in the emergency department was provided loading doses of the anticonvulsant medications, [MEDICATION NAME], and [MEDICATION NAME]. The initial blood work reports identified that the [MEDICATION NAME] level was 2.9 (normal range 4.0-18.0) and the [MEDICATION NAME] level was 1.6 (normal range 12-46). Interview and review of the written statement with RN #6 on 5/27/15 at 1:00 PM identified that Resident #8 arrived and was admitted around 6:00 PM. RN #6 indicated that she had called and left a message with the attending physician of Resident #8's admission and it was the responsibility of the 7PM-7AM Supervisor to verify the medication list because of the hour the resident arrived. RN #6's written statement identified that the physician had called back and approved the medication list. The statement identified that the 7PM-7AM Supervisor asked to speak to the physician to update him on another resident however the physician had already hung up. Interview with the DON on 5/26/15 at 2:30 PM identified that the RN #6 had verified the medications orders with the attending physician and was responsible for inputting the medications into the system, whoever verifies the orders, inputs the orders. Interview with the Advanced Practice Registered Nurse (APRN) #1 on 6/4/15 at 10:23 AM identified that on admission he will review the hospital discharge medications to ensure that the medication doses are correct and review the admitting diagnoses. APRN #1 indicated that he does not review the medication in the computer system to ensure that the medications had been entered.

Based on review of the clinical record, facility investigations, facility policies and procedures, and interviews for 1 of 3 sampled residents reviewed for a change in condition, Resident (R) #1, the facility failed to immediately notify the physician of a significant change in condition following a fall that resulted in a head injury. The findings include: R #1's [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact range of ,[DATE]), rejection of care less than daily, extensive assistance of 2 staff for dressing, personal hygiene, and bathing; limited assistance of 1 staff for toilet use and bathing; set up only for ambulation with walker, and unsteady with ambulation and transfers. A Resident Care Plan (RCP) dated [DATE] identified the problem of Risk for Falls related to medication side effects, history of falls, non-compliance with footwear, poor safety awareness and lateral sway with ambulation. Interventions included, in part, non-skid strips on floor, proper footwear, Rehab to evaluate and treat as needed, R #1 independent with ambulation and transfers with rolling walker as of [DATE], tennis balls placed on walker, re-education and ensure that bed is in proper position [DATE], medical issues identified and fluid restriction initiated [DATE]. Review of a facility investigation, neurological assessment sheet and nursing notes dated [DATE] through [DATE] identified that R #1 was found on the floor outside the his/her bedroom with the walker on top of him/her on [DATE] at 10:45 AM. Registered Nurse (RN) #2, the 7:00 AM through 3:00 PM nursing supervisor in collaboration with Licensed Practical Nurse (LPN) #2, the 7:00 AM through 3:00 PM charge nurse, conducted and documented a comprehensive assessment. A 3 centimeter (cm) by 3 cm hematoma was identified on the left occipital region as well as a 2.5 cm by 2 cm hematoma on the right occipital region. Multiple bruises were identified on the back of R #1's head. Neurological assessment identified an elevated blood pressure of 168 millimeters of mercury (mmHg) systolic/78 mmHg diastolic (normal range ,[DATE]), normal pulse of 66 beats per minute (normal adult range ,[DATE]), normal respiratory rate of 18 breaths per minute (normal range of ,[DATE]), normal pupillary reflex, pupils equal, round, react to light, accomodation (PERRLA), normal hand grasps (normal, equal and firm), normal level of consciousness (alert, with no change in baseline cognition), no [MEDICAL CONDITION] (V), no nausea or vomiting (N/V), no bleeding from the ears (BFE), presence of headache (normal, no headache, HA), and no blurred vision (BV). Physician #2 and Conservator (COP) were notified of the fall and Physician #2 directed to continue neurological assessment per facility policy. Review of the Neurological Assessment Sheet dated [DATE], at 4:30 PM documented by LPN #1, identified a change in status had occurred that included no hand grasps and a change in level of consciousness from alert to unresponsive. A nursing note identified that RN #1, the 3:00 PM through 11:00 PM nursing supervisor was notified and directed LPN #1 to transfer R #1 back to bed. LPN #1 documented that R #1 did not participate in the transfer and continued to be unarousable. R #1 was unable to be aroused for medication administration or supper. RN #1's documented assessment dated [DATE] at 6:04 PM identified that R #1 was lying in bed, sleeping soundly, skin warm and dry, respirations non-labored, temperature 96, respiratory rate 18, blood pressure ,[DATE], oxygen saturation 93%, neuro status intact with pupils reactive to light and accomodation. Additionally, the staff had reported that the resident was awake all night and had received [MEDICATION NAME] earlier in the day. A nursing note dated [DATE] at 8:40 PM documented by RN #3, identified that he/she was called by LPN #3 to assess R #1's increasing lethargy, status [REDACTED]. Physician #1 was notified and directed to apply oxygen via mask to maintain saturation >90% and send to Acute Care Hospital #1 Emergency Department (ED). Review of the facility investigative summary dated [DATE] identified that the facility was notified that the resident sustained [REDACTED]. Interview with RN #1 on [DATE] at 12:10 PM identified that he/she had not received a shift to shift report on [DATE] and was unaware that R #1 had fallen that day and/or had sustained a head trauma. The resident appeared to be sound asleep at the time of the assessment and was not able to cooperate with hand grasps. RN #1 did not consider the change in level of consciousness to be abnormal, as RN #1 had frequently observed the resident sleeping in the facility during the day. Interview with RN #1 on [DATE] at 2:00 PM identified that he/she would have notified the physician that the resident could not be aroused if she had been aware that the resident had sustained a head trauma. Interview with RN #3 on [DATE] at 7:40 AM identified when she came on duty on [DATE] at about 8:10 PM he/she reviewed report with RN #1 and was informed that R #1 had sustained a fall. Interview with LPN #2 on [DATE] at 8:00 AM identified that he/she was present when RN #1 assessed R #1 and that RN #1 was aware of the resident's earlier fall, observed the staff transfer R #1 into bed, and said that R #1 looked like he/she was sleeping. Additionally, RN #1 identified that he/she did not want to notify Physician #2 as he/she might laugh at him/her. Interview with Physician # 2 on [DATE] at 7:30 AM identified that his expectation was that he would have been notified at the time the resident was determined to have a change in condition. Additionally, Physician #2 had been called by the Hospital Emergency Department (ED) physician and Physician # 2 stated that the ED physician was upset and described whhat had occurred to R#1 as the "perfect progression of subdural hematoma." Review of the Acute Care Hospital #2 clinical record identified that R #1's admission [DIAGNOSES REDACTED]. The Power of Attorney requested no surgical intervention based on the resident's wish for do not resuscitate and do not intubate, as well as comfort measures only. R #1 expired on [DATE]. Review of the facility Physician Notification Guidelines identified that it is the nursing staff's responsibility to report any change in a resident's condition to the physician. In situations requiring immediate action (i.e. call 911 and transport of the resident to the emergency room ) with later notification of the physician include: rapid progression of signs and symptoms with rapid deterioration of resident's condition before physician response is obtained.

Based on review of the clinical record, facility investigations, and interviews for 1 of 3 sampled residents reviewed for a change in condition, Resident (R) #1, the facility failed to ensure that a comprehensive neurological assessment was conducted following a significant change in level of consciousness in accordance with professional standards of clinical practice resulting in a delay in potential treatment. The findings include: R #1's [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact range of 13-15), rejection of care less than daily, extensive assistance of 2 staff for dressing, personal hygiene, and bathing; limited assistance of 1 staff for toilet use and bathing; set up only for ambulation with walker, and unsteady with ambulation and transfers. Review of a facility investigation, neurological assessment sheet and nursing notes dated 04/12/13 through 04/15/13 identified that R #1 was found on the floor, outside the bedroom on 04/12/13 at 10:45 AM. The walker was on top of him/her. Registered Nurse (RN) #2, the 7:00 AM through 3:00 PM nursing supervisor in collaboration with Licensed Practical Nurse (LPN) #2, the 7:00 AM through 3:00 PM charge nurse, conducted and documented a comprehensive assessment. A 3 centimeter (cm) by 3 cm hematoma was identified on the left occipital region as well as a 2.5 cm by 2 cm hematoma on the right occipital region. Multiple bruises were identified on the back of R #1's head. Neurological assessment identified an elevated blood pressure of 168 millimeters of mercury (mmHg) systolic/78 mmHg diastolic (normal range 120/80), normal pulse of 66 beats per minute (normal adult range 60-80), normal respiratory rate of 18 (normal range of 16-20), normal pupillary reflex, pupils equal, round, react to light, accomodation (PERRLA), normal hand grasps (normal, equal and firm), normal level of consciousness (alert, with no change in baseline cognition), no [MEDICAL CONDITION] (V), no nausea or vomiting (N/V), no bleeding from the ears (BFE), headache (normal, no headache, HA), and no blurred vision (BV). Physician #2 was notified of the fall and directed to continue neurological assessment per facility policy. Review of the Neurological Assessment Sheet dated 04/12/13, at 4:30 PM documented by LPN #1 identified a change in status had occurred that included no hand grasps and a change in level of consciousness from alert to unresponsive. A nursing note identified that RN #1, the 3:00 PM through 11:00 PM nursing supervisor was notified and directed LPN #1 to transfer R #1 back to bed. LPN #1 documented that R #1 did not participate in the transfer and continued to be unarousable. R #1 was unable to be aroused for medication administration or supper. RN #1's documented assessment dated [DATE] at 6:04 PM identified that R #1 was lying in bed, sleeping soundly, skin warm and dry, respirations non-labored, temperature 96, respiratory rate 18, blood pressure 156/74, oxygen saturation 93%, neuro status intact with pupils reactive to light and accomodation. A nursing note dated 04/12/13 at 8:40 PM documented by RN #3, identified that he/she was called by LPN #3 to assess R #1's increasing lethargy status [REDACTED]. Physician #1 was notified and directed to apply oxygen via mask to maintain saturation >90% and send to Acute Care Hospital #1 Emergency Department (ED). Review of the facility investigation of the accident identified a witness statement signed by RN #1 on 04/12/13. RN #1 documented that R #1 was being evaluated status [REDACTED]. RN #1 identified that he/she had not been present at the time of the fall, however a nurse had reported that the resident was sleeping in the wheelchair, was placed in the bed, soundly asleep and vital signs and neurological checks were within normal limits with no pain and no respiratory distress. An investigative summary documented by the Director of Nursing on/04/17/13 identified that the facility was notified that the resident had sustained a subdural hematoma, was transferred to Acute Care Hospital #2, and was placed on a palliative care unit per the resident's directive. Interview with RN #1 on 04/30/13 at 12:10 PM identified that he/she had not received a shift to shift report on 04/12/13 and was unaware that R #1 had fallen that day and/or had sustained a head trauma. The resident appeared to be sound asleep at the time of the assessment and was not able to cooperate with hand grasps. RN #1 did not consider the change in level of consciousness to be abnormal, as RN #1 had frequently observed the resident sleeping in the facility during the day. Interview with RN #1 on 05/10/13 at 2:00 PM identified that he/she would have notified the physician that the resident could not be aroused if she had been aware that the resident had sustained a head trauma. Interview with RN #3 on 05/13/13 at 7:40 AM identified when she came on duty on 04/12/13 at about 8:10 PM he/she reviewed report with RN #1 and was informed that R #1 had sustained a fall. Interview with LPN #2 on 05/13/13 at 8:00 AM identified that he/she was present when RN #1 assessed R #1 and that RN #1 was aware of the resident's earlier fall, observed the staff transfer R #1 into bed, and said that R #1 looked like he/she was sleeping. Additionally, RN #1 identified that he/she did not want to notify Physician #2 as he/she might laugh at him/her.

Based on clinical record review, review of facility documentation and interviews for one sampled resident (Resident #128) who required a mechanical lift for transfers, the facility failed to ensure that the lift was functioning properly and/or utilized as per the manufacturer's specifications to prevent an injury and/or for one of two sampled residents (Resident #226) who had a behavior of wandering, the facility failed to ensure that interventions were implemented when the resident was exit seeking. The findings include: 1. Resident #128's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #128 had memory deficits, moderate cognitive impairment, required total two person assistance with transfers between surfaces, and functional limitation in range of motion on both sides of the lower extremities. The resident care plan dated 3/20/12 identified a potential for falls. Interventions directed transfer with assist of two via a mechanical lift out of bed to an electric wheelchair daily as tolerated. The nurse's note dated 5/28/12 at 12:23 PM identified that Resident #128 fell during a transfer from the bed to the custom wheelchair, a laceration was observed on the lower buttock and upper thigh crease, and subsequent to physician notification the resident was transferred to the Emergency Department (ED). The 12:49 PM note indicated that Resident #128 returned at 12:30 PM, stitches used to close the laceration on right buttock crease, order to cleanse with normal saline, pat dry, apply bacitracin followed by a peri pad and change dressing with every incontinent brief change to avoid infection. The 5/28/12 nurse's note at 8:48 PM identified that no sutures were visible, there was a moderate amount of frank blood that oozed out each time the area was touched and again subsequent to physician notification Resident #128 was transferred to the ED. The 5/28/12 10:36 PM nurse's note identified that Resident #128 returned with internal and external sutures to be removed in ten days. The ED clinical narrative note dated 6/8/12 identified that the right buttock sutures were removed. An assessment identified a deep laceration approximately two inches long, steady moderate sanguineous bleeding. The discharge [DIAGNOSES REDACTED]. NA #1 indicated that she was positioned on the side of the wheelchair and the licensed nurse was behind the wheelchair holding onto the bar to maneuver the resident into the chair when the lift tipped over sideways onto her, NA #1. NA #1 identified that she did not remove and/or swing the foot rests out of the way and Resident #128 landed on the foot rests. Interview with Licensed Practical Nurse (LPN) #3 on 6/28/12 at 7:15 AM identified that she assisted NA #1 with the transfer on 5/28/12. LPN #3 indicated that the nurse aide sets the resident up and she comes in to assist. LPN #3 identified that that the legs were opened enough under the bed to support the resident's weight, however, when the lift was moved to the wheelchair the legs were not opened wide enough, NA #1 tried to open the legs and that was when the lift tipped over sideways. Interview with the Director of Nurses on 6/27/12 at 1:45 PM identified that the lift was removed from the unit until maintenance could evaluate the lift. Review of the facility's hoyer lift policy directs staff to read the manufacturer's instructions for the lift used in your facility before beginning the procedure. This policy was revised 8/10/01. Interview with the maintenance staff on 6/27/12 at 1:45 PM identified that the facility had several different styles and makes of mechanical lifts, some had been donated, and there were no manufacturer's manuals available for review, therefore the facility was not aware of how often the lifts should be inspected. Interview with the Administrator on 6/28/12 identified that the lift that malfunctioned on 5/28/12 had been removed from the building, the manufacturer had not been informed of the event and that the lifts are check by an outside vendor annually last service was 1/20/12. 2. Resident #226's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident had memory deficits, severe cognitive impairment, had a behavior of wandering one to three days in a week, the wandering placed the resident at significant risk of getting to a potentially dangerous place i.e. getting outside of the facility, was independent with ambulating in room and corridor and required supervision with locomotion on and off the unit. The quarterly MDS dated [DATE] identified that during the seven day look back period, Resident #226 wandered daily. The resident care plan dated 3/22/12 revised through 3/26/12 identified a potential for elopement and a history of removing the wanderguard. Interventions directed wanderguard in place, check placement every shift, check function every day on 11-7 shift, and change wanderguard every 90 days, redirect as needed, and encourage involvement in recreational activities of choice. The care plan failed to reflect interventions that addressed the resident's non-compliance when the wanderguard was removed. The nurse's note dated 6/10/12 identified that at 10:30 AM the wanderguard was noted to be off. The wanderguard was found in the resident's drawer and was replaced. Resident #226 was noted in the dining room at 11:50 AM and at 12:35 PM the staff was unable to locate the resident. All parties were notified and a search was initiated. At 2:45 PM (two hours and fifteen minutes after the resident was identified missing) Resident #226 was returned to the facility by an off duty nurse aide, no injuries were noted. The Reportable Event Form dated 6/10/12 identified that at 12:35 PM the facility staff was unable to locate Resident #226. Review of the facility's investigation identified that at 10:30 AM a nurse from the third floor (Oak Unit) came off the elevator with Resident #226, the resident resided on the second floor. The third floor nurse stated that Resident #226 was observed coming off the elevator. The second floor Licensed Practical Nurse (LPN) #4 indicated that at 10:30 AM she replaced the wanderguard on the resident's right ankle and the last time LPN #4 had seen Resident #226 was at 11:30 AM in the hallway. The investigation identified that the plan upon the resident's return were to implement checks every fifteen minutes including the wanderguard placement. Observations of the second floor, main lobby and entranceway identified an elevator located in the main lobby area; the doors to enter each resident unit are alarmed with a wanderguard alert system and Resident #226's room was located at the end of the hallway down from the nurse's station, one room away from the doorway to access the elevator to the main lobby. Interview with the Director of Nurses (DON) on 6/29/12 at 10:00 AM identified that Resident #226 had exited the facility through the main lobby and the incident had occurred on a weekend when there is no receptionist at the main desk.

Based on clinical record review, facility documentation, observation, and interviews, for one (R#1) of forty-seven residents reviewed for supervision during meals and/or swallowing precautions, the facility failed to ensure that R#1 was provided with the prescribed diet in accordance with the physician's orders [REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] identified that the resident was severely cognitively impaired and required extensive assistance with eating. Review of the care plan dated [DATE] identified that the resident had a history of [REDACTED]. Physician orders [REDACTED]. Review of facility documentation dated [DATE] identified that a visitor was given permission by LPN #1 to give Resident #1 two regular sized (not miniature) marshmallows to eat as the resident sat in a wheelchair in front of the nursing station. CNA #1 was summoned by the visitor when Resident #1 became unresponsive. CNA #1 summoned LPN #2, closest to the resident who identified that Resident #1 was not breathing, and who summoned LPN #1, RN #1 and called EMS. LPN #1 moved the resident to his/her room where cardiopulmonary resuscitation was initiated. Ultimately, Resident #1 was intubated on site and transferred to the Emergency Department and admitted to the hospital with [REDACTED]. The resident expired two days later. During interview on [DATE] at 11:55 AM, LPN #1 stated that on [DATE], s/he had given a visitor permission to give the resident "two" marshmallows based on the fact that the resident had been allowed to eat marshmallows previously. LPN #1 identfied that although s/he had been oriented to refer to the physician's order [REDACTED]. During interview on [DATE], the VP of Clinical Services stated that the expectation would be that the nurse would always refer to the physician's orders [REDACTED]. Subsequent to this incident, LPN #1 was terminated from the facility for failure to follow physician orders, failure to follow swallowing precautions and the plan of care, and failure to follow standards of professional practice.

Based on a review of clinical records, interview, observation and policy review for one of three resident's reviewed for weight loss (Resident #2), the facility failed to ensure that the resident's weight was monitored in accordance with the physician's orders [REDACTED]. The finding included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders, dated from 7/30/11 to 10/31/11, directed the staff to weigh the resident weekly. Review of the significant change Minimum Data Set (MDS) assessment, dated 8/23/11, identified that the resident rarely understood others and/or could not communicate his/her needs to others, had severely impaired cognition, required supervision for eating, experienced a weight loss of 5% or more in the last six months or 10% and/or more in the last six months and weighed 86.0 pounds. Review of a care plan, dated 8/23/11, identified that Resident #2 has a potential for alteration in nutrition related to [DIAGNOSES REDACTED].> or = 75% of most meals and supplements. Interventions included weights per house policy, notify MD with significant weight changes, administer supplements and snacks as ordered, provide diet as ordered, monitor % of meal intake, and sandwich at 2p and 8p. A care plan, dated 8/24/11, identified a self-care deficit related to dementia with interventions that included independent with meals after set-up. A care plan dated 8/24/11 reflected the resident had a significant change in status related to weight loss and a decline in ADL's with interventions that included to document the resident's status and report changes to the family and the physician. A nursing progress note, dated 8/23/11, identified that Resident #2 eats less than 50 % of his/her meals. Review of the Registered Dietician's (RD) progress note dated 8/23/11 identified that the resident had a variable meal intake that has decreased even more over the past few days, with the last weight documented at 85.4 pounds, down 13% over four months from March to July. The resident's daily requirements included 1300 calories, 52 grams of protein and 1,300 milliliters of fluid. The Registered Dietitian recommended a Speech Therapy screen related to the decreased oral intake and to change the house supplement to the Resource 2.0 supplement, eight (8) ounces, three times daily. Review of the clinical record failed to reflect that the Registered Dietician's recommendations were communicated to the physician. A nurse's note dated 9/9/11 at 12:57 identfied that the resident had a 5.7 lb. weight loss (weight of 79.7), that the physician was notified, with an order to obtain a Dietary Consult secondary to the weight loss. The RD note dated 9/12/11 at 14:45 identfied that the resident's weight was 79.7 lbs. with a recommendation to switch to the Resource 2.0. A physician's orders [REDACTED]. The resident's weight on 10/3/11 was 80.5 lbs and decreased to 77.0 on 11/4/11, a 3.5 loss. The clinical record lacked evidence that the weight loss was addressed. Review of the clinical record during the period of 7/4/11 to 11/25/11 failed to reflect documentation that the resident was weighed weekly in accordance with the physician's orders [REDACTED]. Review of the clinical record reflected that although the resident's meal intake from 10/25/11 through 11/24/11 ranged from zero (0) on 60 of the 90 occasions, 26-50% for 24 of 90 occasions, 51-75% for 7 of 90 occasions, and 76-100% for 2 of 90 occasions, the facility failed to ensure weekly weights were monitored, dietary recommendations were implemented timely, and/or the plan of care was revised to address the resident's poor appetite and weight loss. Review of the nursing progress notes, dated 11/24/11 at 2:27 P.M. and 7:17 P.M., identified that Resident #2 refused breakfast, lunch and supper, the Resource supplements and medications. On 11/25/11, the resident was transferred to the hospital at 8:45 am and admitted [MEDICAL CONDITION], urinary tract infection, pneumonia, dehydration, [MEDICAL CONDITION], leukocytosis and lactic acidosis and was admitted to the hospital. Interview with Registered Dietitian #1, on 12/6/11 at 1:00 P.M., identified that in order for Resident #2 to meet his/her caloric needs he/she would have to consume at least 50 % of all meals, in order for the resident to meet his/her protein needs he/she would have to consume 75 % of his/her meals. Interview with the Director of Nursing, on 12/6/11 at 11:30 A.M., identified that the clinical record failed to reflect that weekly weights were monitored.

Based on a review of clinical records, interview, and policy review, for one of three residents reviewed for dehydration risk (Resident #2), the facility failed to monitor the resident's intake and output and/or conduct physical assessments when intake declined. The finding includes: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment, dated 8/23/11, identified that the resident rarely understood others and/or could not communicate his/her needs to others, had severely impaired cognition, required supervision for eating, experienced a weight loss of 5% or more in the last six months or 10% and/or more in the last six months and weighed 86.0 pounds (lbs). Review of a care plan, dated 8/23/11, identified that Resident #2 has a potential for alteration in nutrition related to [DIAGNOSES REDACTED]. Interventions included administer diet, supplements and snacks as ordered, monitor meal intake, and inform the physician of significant weight changes. A second care plan, dated 8/24/11, identified that the resident had a significant change in his/her status related to weight loss with interventions included to document the resident's status and report changes to the family and the physician. Review of the RD's progress note dated 8/23/11 identified that the resident had a variable meal intake, his/her weight had decreased by 13% over the past four months and required 1,300 milliliters of fluid daily to maintain hydration. The Registered Dietitian's recommended that the supplement be changed from the house supplement to a Resource 2.0 formula. A dietary progress note, dated 9/12/11, identified that the resident has been eating poorly, including variable intake of the supplement with a recommendation that the supplement be changed to the 2.0 formula and add ice cream to lunch and supper meals. The resident's weight was 79.7 pounds, a 6.3 lb loss from 8/23/11. Review of the clinical record reflected that the resident's meal intake from 10/25/11 through 11/24/11 ranged from zero (0) on 60 of the 90 occasions, 26-50% for 24 of 90 occasions, 51-75% for 7 of 90 occasions, and 76-100% for 2 of 90 occasions. The facility failed to determine if the resident's fluid intake was adequate in accordance with the plan of care. Review of the clinical record identfied that the resident's weight was 80.5 lbs on 10/3/11 and 77 lbs on 11/4/11, a 3.5 loss. Review of the Registered Nurses' note dated 11/24/11 at 12:27 reflected the resident refused to eat, drink and/or take scheduled medication. The resident's temperature was 100.3 with a respiratory rate of 38 (normal 16-20). The note lacked evidence that the resident was assessed for dehydration. Review of the LPN's nurse's note dated 11/24/11 at 14:27 identified that R #2 had a temperature, erroneously documented as "1100.3, a respiratory rate of 43, refused med's, supplements, and meals. the note identfied that fluids were encourages with 360 cc's consumed and was incontinent of urine once. On 11/24/11 at 15:40, intake and output monitoring was initiated. During the 3-11 shift on 11/24/11, the LPN documented that the resident refused dinner and fluids and was incontinent of urine once. The resident's respiratory rate was documented as 40 breaths per minute. During the 11-7 am shift on 11/24/11 into 11/25/11, the LPN documented that the resident's respiratory rate was 37, the resident consumed 75 cc's of fluid, with no output documented. The facility failed to assess the resident for signs and/or symptoms of dehydration. The LPN's note dated 11/25/11 at 9:00 am identfied that at approximately 8:30 am, the resident was assessed with [REDACTED]. The physician was notified and the resident transferred to the hospital for evaluation. Review of the acute care record identfied that the resident was admitted [MEDICAL CONDITION], urinary tract infection, pneumonia, dehydration, [MEDICAL CONDITION], leukocytosis, and lactic acidosis and was admitted to the hospital. Interview with Registered Dietitian #1, on 12/6/11 at 1:00 P.M., identified that the resident required 1,300 cc's of fluid daily to maintain hydration, however, documentation of the resident's fluid intake and output was not initiated until 11/24/11. Review of the clinical record and interview with the Director of Nursing, on 12/6/11 at 11:30 A.M., identified that the staff encouraged Resident #2 to drink in order to provide adequate fluids. Review of the facility policy and procedure, titled Hydration, identified that residents who have been identfied by dietary and/or nursing for poor fluid and food acceptance would be monitored for a limited period of assessment and determination for the need for continued monitoring.

Based on clinical record review and interview for one (R#3) of three residents with a change in condition, the facility failed to contact the physician when the resident continued to complain of discomfort. The findings include: R# 3's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified short and long-term memory deficits and independent cognition. Review of the Discharge Summary dated [DATE] identified that R#3 was admitted to an acute care facility on [DATE] and discharged back to the long term care facility on [DATE] with a [DIAGNOSES REDACTED].#3 had increased complaints of gastrointestinal distress, hyperactive bowel sounds, and large gas bubbles palpated over the abdomen. The physician was notified and there were no new orders. The nurse's notes dated [DATE] at 5:00AM identified R#3 with continued gas discomfort, the physician was notified and ordered [MEDICATION NAME]. Review of nurses notes dated [DATE] from 7:00AM through 11:00PM identified continued complaints of gas without vital sign assessment or physician notification. On [DATE] at 5AM, documentation reflected that the advanced practice registered nurse (APRN) was called. The nurse's note dated [DATE] at 6:20AM identified that the physician was notified after R#3 complained of abdominal pain with emesis and was transported to the hospital. Vital signs at this time identified a blood pressure of ,[DATE] (was ,[DATE] on [DATE] at 1:45PM ) and pulse of 125 (was 68 on [DATE] at 1:45PM). Review of the hospital discharge record dated [DATE] identified that upon admission to the hospital, the resident's systolic blood pressure was in the 50's and 60's and heart rate was [MEDICAL CONDITION] at 140 to 150 beats per minute. A CAT scan of the abdomen and pelvis was performed noting free air in the abdomen and pelvis consistent with hollow viscus rupture. R#3 expired on [DATE] at approximately 8:30PM after the resident's family changed the code status to comfort measures only. Revew of facility policy directed that the attending physician will be notified of a change in condition by a licensed staff member as warranted and is to include but not limited to significant change in or unstable vital signs and/or abnormal complaints of pain. Interview with MD#1 on [DATE] at 12:00PM identified that although he/she does not recall the situation specifically he/she would have identified that R#3 was at high risk for perforation with a recent history of a small bowel obstruction.

Based on clinical record review and interview for one (R#3) of three residents reviewed with change of condition, the facility failed to monitor vital signs and/or conduct a comprehensive gastrointestinal assessment in accordance with standards of practice. The findings include: R# 3's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified intact short and long-term memory and independent cognition. Review of a Discharge Summary dated [DATE] identified that R#3 was admitted to an acute care facility on [DATE] and discharged back to the long term care facility on [DATE] with [DIAGNOSES REDACTED]. a. Review of the physician order [REDACTED]. Review of the Interdisciplinary Plan of Care dated [DATE] directed for vital signs per physician order [REDACTED].#3 intermittently complained of gastrointestinal discomfort. During this time period a temperature was taken on [DATE], full vital signs (including temperature, pulse, respiratory rate) on [DATE] and [DATE] at 1:45PM. The notes from [DATE] through [DATE] identified R#3 with increased complaints of gas, the physician was notified twice and documentation failed to identify a full assessment that included temperature, blood pressure and pulse until [DATE] at 6:20AM. At that time, the residents blood pressure was ,[DATE] (was ,[DATE] on [DATE] at 1:45PM), temperature was 97.8 was 97.8 on [DATE] at 1:45PM), and pulse was 125 (was 68 on [DATE] at 1:45PM). R#3 was transferred to the hospital at 7:30AM. Review of the hospital discharge record dated [DATE] identified on admission to the hospital, R#3's systolic blood pressure in the 50's and 60's and heart rate was 140 to 150 beats per minute. Review of the death certificate identified that R#3 expired on [DATE] at 6:30PM after the resident's family changed the code status to comfort measures only. Interview with the Director of Nurses on [DATE] at 12:45PM identified that vital signs would be documented according to physician orders [REDACTED]. According to Nurse's Quick Check Skills, Lippincott, 2006, if a previously stable patient suddenly develops a change in neurological or routine vital signs, further assess his condition, and notify the physician immediately. b. The nurse's notes dated [DATE] during the ,[DATE]PM shift, on [DATE] at 5:00AM, on [DATE] during the ,[DATE]PM shift, and on [DATE] during the ,[DATE]PM shift identified that the resident complained of "gas" and failed to identify a comprehensive abdominal assessment to include abdominal palpation to determine abdominal tenderness. According to Lippincott Manual of Nursing Practice, ninth Edition, 2010 when performing a physical examination of the abdomen, include the following: inspection of the abdomen, auscultation of all four abdominal quadrants, percussion for tympany or dullness, light and deep palpation.