Every finding on record at Autumn Lake Healthcare at New Britain

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure the resident was free from medication errors and failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #1's diagnoses included right humerus fracture, radiculopathy and pain left arm and left hip, spinal stenosis and cervicalgia (neck pain). The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven out of fifteen, indicative of severe cognitive impairment and required pain medication. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had pain related to radiculopathy cervical region. Interventions directed administer analgesia (pain medication) per MD orders. A physician order dated [DATE] directed Hydromorphone HCL oral tablet two (2) mg give one (1) tablet by mouth every day, and to administer two (2) mg, give one (1) tablet six (6) hours as needed for pain for 14 days (order expired on [DATE]). Review of August Medication Administration Record (MAR) dated 8/1, 8/2 and [DATE] identified the MAR was signed to indicate Resident #1 received Hydromorphone HCL oral tablet two (2) mg every six (6) hours as needed for pain. Review of the facility controlled medication Proof of Use sheets for Resident #1's Hydromorphone 2 mg as needed for pain, identified Resident #1 was administered a half tablet (total dosage of 1 mg) of Hydromorphone HCL two (2) mg on 8/1 at 3 PM, 8/2 at 8:17 PM and [DATE] at 9 AM. Per the Proof of Use sheets, Resident #1 received half the prescribed dose. Interview and record review with the Director of Nursing (DNS) and Corporate RN #2 on [DATE] at 11:46 AM identified the DNS was not aware of any medication errors. RN #2 and the DNS identified that Resident #1 received the wrong Hydromorphone dose on 8/1, 8/2, and 8/3, and Resident #1 should have received the two (2) mg dose in accordance with physician orders. a. A physician order dated [DATE] directed to administer Hydromorphone HCL oral tablet two (2) mg give one (1) tablet by mouth two (2) times a day for 30 days, and Hydromorphone HCL oral tablet two (2) mg give one (1) tablet by mouth every six (6) hours as needed for pain for 14 days. Review of August MAR dated 8/3 to [DATE] identified the MAR was signed to indicate the Hydromorphone two (2) mg was administered. Review of facility Proof of Use sheet identified Resident #1 was given (1) 1/2 tablet (total dosage of 1 mg) of Hydromorphone HCL 2 mg on the following dates:9 AM dose: [DATE].9 PM dose: 8/4, 8/5, 8/7, 8/8, 8/10, and [DATE].Additional review of the Proof of Use sheet identified no Hydromorphone was signed out to be administered to Resident #1 on the following dates:9 AM dose: 8/6, 8/7, 8/8, 8/9, 8/13 and [DATE].9 PM dose: [DATE]. Interview and record review with the Director of Nursing (DNS) and Corporate RN #2 on [DATE] at 11:46 AM identified the DNS was not aware of any medication errors prior to interview, and no Hydromorphone was used from the facility emergency supply for Resident #1. RN #2 and the DNS identified that Resident #1 received the wrong Hydromorphone dose on 8/4, 8/5, 8/7, 8/8, 8/9, 8/10, 8/13, 8/20 and [DATE], and Resident #1 should have received the two (2) mg dose in accordance with physician orders. Subsequent to surveyor inquiry, a facility incident report dated [DATE] was completed and indicated Resident #1 received the wrong dose several times in August. Review of facility undated Medication Administration Policy directed in part, medications are administered as ordered by the physician and in accordance with professional standards of practice. Sign the MAR after administration, and if a medication is a controlled substance, sign narcotic book. Review of facility undated Controlled Substances Policy directed in part, upon administration, the nurse administering the medication is responsible for recording: the name of resident receiving the medication, name, strength, and dose of medication, time of administration and method of administration, quantity of medication remaining and signature of nurse administering medication.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure a system to ensure accurate reconciliation of controlled drugs timely, and failed to ensure an account of all controlled drugs was maintained and periodically reconciled timely. The findings include: Review of facility documentation identified the most recent facility-wide narcotic audit was completed on 7/22/2026. Although requested, the facility was unable to provide narcotic audits completed during August 2026. Interview and record review with the Director of Nursing (DNS) and Corporate RN #2 and DNS On 8/26/2026 at 11:46 AM identified RN #4 was responsible to complete narcotic count audits twice monthly. The last narcotic audits were completed on 7/22/2026, and narcotic audits were not completed during the month of August. Interview identified when narcotic audits were conducted, the process included review of the white Proof of Use sheet, verification of the count listed on the sheet to the actual count in the narcotic box, verification of the shift-change signatures, and did not include verifying the correct dose was administered. The DNS indicated that when a controlled medication is received from the pharmacy, the white Proof of Use sheet is kept on the unit to be signed when the medication is administered, and a copy/yellow Proof of Use sheet goes to her for tracking of the controlled medication. Interview identified the facility audits did not include a process to confirm all medications received from the pharmacy were accounted for, and the process did not compare the yellow Proof of Use sheets with the white Proof of Use sheets to ensure no controlled medications were missing from the box (i.e. if the medication card and the white Proof of Use sheet were missing). Review of the yellow Proof of Use sheets failed to identify audits were completed and that the count was correct. RN #4 was unavailable for interview during the survey. Interview with the DNS and RN #2 identified the facility did not have a policy directing twice-monthly narcotic audits, but indicated they follow the state Department of Consumer Protection Controlled Substances guidelines for managing controlled substances. CT Department of Consumer Protection Drug Control Division Extended Care Facility Recommendations directed in part, the DNS or designee shall conduct unannounced documented audits of all controlled substance stock on all units at least twice a month. Audits must be formally recorded and kept on file to ensure accountability and track discrepancies.

Based on interviews, observations, clinical record review, facility documentation, and facility policy, the facility failed to maintain a safe environment for residents in two distinct areas, resulting in the findings of Immediate Jeopardy. The facility failed to conduct adequate monitoring of hot water temperatures and to communicate and act upon documented temperatures exceeding 120 F, resulting in water temperatures ranging from 126.3 F to 145.4 F in 44 of 64 resident rooms on the second and third floors. This failure exposed residents to a risk of scalding from excessive water temperatures. Additionally, for one (1) of eight (8) sampled residents (Resident #13) reviewed for accidents, the facility failed to consistently implement a prescribed floor mat fall prevention intervention for a resident with a history of falls and a care-planned floor mat. The findings include: 1. Observation on 4/20/2026 at 11:33 AM identified hot water temperatures exceeded 120 F in 44 out of 64 rooms observed on the second and third floors, water temperatures ranged from 126.3 F to 141.4 F.The Facilities Director (Maintenance Director) was immediately notified to test water temperatures with the surveyor.Observation, interview, and review of facility documentation with the Facilities Director on 4/20/2026 at 12:00 PM using a surveyor calibrated thermometer and a facility calibrated thermometer, hot water temperatures were noted to exceed 120 F in 16 out of 16 rooms tested. Water temperatures ranged from 120.8 F to 145.4 F. He identified that acceptable water temperatures were between 105 F and 120 F and water temperatures were checked daily in random rooms by the assigned Maintenance Technician. If temperatures had been outside the acceptable range, he should have been notified, and he would adjust the mixing valve and re-checked the temperature an hour later to ensure appropriate water temperatures. Review of the facilities daily water temperature logs identified documented water temperatures on 3/9/2026 were 120.4 F in room [ROOM NUMBER], on 3/16/2026 were 121.4 F in room [ROOM NUMBER], on 3/30/2026 were 120.4 F in room [ROOM NUMBER], on 4/6/2026 were 120.5 F in room [ROOM NUMBER], on 4/6/2026 were 122.6 F in room [ROOM NUMBER], on 4/8/2026 were 120.4 F in room [ROOM NUMBER], on 4/14/2026 were 120.3 F in room [ROOM NUMBER], on 4/15/2026 were 121.4 F in room [ROOM NUMBER], located on the 2nd and 3rd floor floors. The Facilities Director indicated that he was unaware of the high-water temperature readings, had never been notified, but should have been made aware by the Maintenance Technician who took the above normal water readings. Additionally, the Facilities Director noted the corrective action would have been to adjust the mixing valve and recheck temperatures to ensure safe water temperatures. The interview failed to identify the reason water temperatures had not been taken on the 2nd and 3rd floors since 4/15/2026 (the past 5 days) and that they should have been.Interview with the Maintenance Technician on 4/20/2026 at 12:55 PM identified that he checked water temperatures in resident rooms at random daily. During a review of the water temperature logs, (as reviewed previously with the Facilities Manager), the Maintenance Technician indicated that although he was aware acceptable water temperatures ranged from 105 F to 120 F and he had recorded temperatures exceeding 120 F), he did not notify the Facilities Manager because he thought the temperatures were okay. The Maintenance Technician indicated the Facilities Manager should have been notified.Interview with the Administrator and Director of Nursing (DON) on 4/20/2026 at 1:00 PM identified that they were not aware of documented high-water temperatures. The Administrator and DON indicated that they should have been made aware by either the Maintenance Technician or the facilities manager so that residents and staff could be notified. The DON identified that there had been no reports of resident burns, that they would be instructing staff to not utilize the hot water until the issue was resolved and for nurses to conduct skin assessments of all residents on the affected units. Review of the Safe Water Temperature policy dated 12/28/2022 directed in part, that hot water temperatures will be maintained with the range of no more than120 F or no less than 100 F in patient care areas. Maintenance staff will test the water temperatures weekly and as needed to ensure they are within appropriate range. Temperatures that are outside the appropriate range will be reported to the Maintenance Director or Administration.The failure of the Maintenance Technician to communicate high hot water temperatures to the Facilities Director, DON, or Administrator and the lack of interventions to prevent and protect residents from scalding or burns due to excessive water temperatures in resident care areas including resident bathrooms resulted in a finding of Immediate Jeopardy. On 4/20/2026 at 3:49 PM the IJ Template was provided via email to the Administrator. On 4/20/2026 at 3:50 PM the facility submitted the removal plan which was accepted by the State Agency. The removal plan included:Immediate adjustment and calibration of the hot water system: temperature of boiler #1 to reduce hot water temperatures for Station 4 and Station 5.Hot water system technicians on site to evaluate hot water system.Safety of water temperatures policy review.Immediate implementation of staff supervision for residents on Station 4 and Station 5 for all bathing and handwashing until system stabilized.Residents on affected units provided alternative bathing methods as needed.The Medical Director was notified of identified hot water temperature readings.The Immediate Jeopardy was removed on 4/20/2026 at 4:00 PM.2. Resident #13 diagnoses included unspecified dementia, epilepsy, and cataracts.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #13 had a Brief Interview of Mental Status of 6 indicating severe cognitive impairment, and was totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and dressing.The Fall Risk Evaluation dated 3/13/2026 at 2:31 PM identified Resident #13 was at moderate risk for falls.The Resident Care Plan dated 3/16/2026 identified Resident #13 had an actual fall. Interventions included applying a floor a mat next to bed (when in bed), reinforcing safety awareness and ensuring the call light was within reach.Resident #13's undated Nurse Aid Resident Care Card (directive for care) directed to apply a floor mat next to the bed (when Resident #13 was in bed) and remove the mat when Resident #13 was out of bed.The Interdisciplinary Team nurse progress note dated 4/9/2026 at 2:14 PM identified Resident #13 did not experience any falls in the past quarter, had a history of falls and the Resident Care Plan was reviewed and updated with individualized interventions to meet his/her needs.Observations on 4/21/2026 at 9:32 AM and at 10:30 AM, identified Resident #13 in bed without the benefit of a floor mat positioned next to the bed, and gray floor mat stored propped against the wall beneath the window.Observation and interview with Nurse Aide (NA) #2 on 4/23/2026 at 7:05 AM identified Resident #13 in bed, with a floor mat positioned on the floor parallel to the bed, an over the bed table was placed on top of the floor mat, also parallel to the bed. Interview with NA #2 identified that Resident #13 had a floor mat in place as a precaution in case the resident rolled out of bed, and that the over the bed table should not be positioned on the mat because the mat was intended to protect Resident #13 from injury if he/she fell. NA #2 was unable to identify who placed the over the bed table on the mat, and subsequent to surveyor inquiry removed the over the bed table from the mat.Interview with the Registered Nurse Unit Manager (RN) #1 on 4/23/2026 at 7:08 AM identified that the over the bed table should not have been placed on top of the floor mat, as doing so defeated the purpose of the mat in preventing Resident #13 from sustaining injuries should he/she roll out of bed. Additionally, RN #1 stated she was unsure of the facility policy on floor mats but further stated that the NAs and any staff who observed Resident #13 were responsible for ensuring that the floor mat was properly placed when the resident was in bed and that no items, such as an over the bed table, should be placed over the mat.Observation on 4/24/2026 at 8:40 AM identified Resident #13 in bed without the benefit of a floor mat positioned next to the bed, the gray floor mat was propped against the wall beneath the window.Review of the Falls and Fall Risk Management Policy reviewed 4/19 directed in part that staff will identify interventions related to the residents' specific risks and causes to try to prevent the residents from falling and to try to minimize complications from falling. Additionally, the staff with input from the attending physician will implement a resident centered fall prevention plan.

Based on clinical record review, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #117) reviewed for Activities of Daily Living (ADL), the facility failed to ensure Resident #117 was ambulated per physician's orders. The findings include: Resident #117 was admitted in March 2026 with diagnoses that included congestive heart failure, respiratory failure and spinal stenosis. Physician's orders dated 3/23/26 directed, in part, physical and occupational therapy as indicated. Physician's orders did not address Resident #117's ambulation or transfer status.The Resident Care Plan (RCP) dated 3/24/26 identified activities of daily living (ADL) deficit and self-care performance related to decreased strength and endurance. Interventions included: assist of 1 ADL seated, assist of 1 ambulation to/from bathroom with rolling walker (RW), assist of 1 for transfers with RW, assist of 1 for bed mobility, assist of 1 with toileting and therapy as indicated.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #117 was cognitively intact and had a Brief Interview for Mental Status score of 15 and required maximum assistance of 1 staff member for activities of daily living including ambulation. Physical therapy notes indicated that Resident #117 was discharged from physical therapy on 4/10/26 due to insurance. Resident #177 was able to ambulate with assistance of 1 staff member in the room and hallway using RW as tolerated.Physician's orders on 4/17/26 directed, in part, ambulation with assistance of 1 staff with RW. Interview with Resident #117 on 4/21/26 at 9:16AM identified she/he recently moved rooms from the short-term unit to a long-term care unit. Resident #117 indicated her/his room change occurred around the 10th of April. Resident # 117 stated that she/he had not been receiving therapy since his/her room change and believed it was due to insurance reasons. Resident #117 indicated she/he was informed by therapy that staff would walk him/her daily when she/he was moved to his/her new room. Resident #117 indicated that staff had not walked him/her since the room changed and they were using the wheelchair even to take him/her to the bathroom. Resident #117 was concerned she/he was not being walked and wanted reassurance that she/he would be walked as needed to gain strength to eventually go home. The Nurse Aide (NA) flowsheets reviewed from 4/17/26 through 4/23/26 lacked documentation Resident #117 had walked in his/her room or in the hallway from 4/17/26 through 4/19/26. NA documentation from 4/17/26 through 4/19/26 indicated not applicable (N/A) for all 3 shifts. In addition, there was documentation that Resident #117 had only walked 4 times in the hallway on 7-3 shift and 5 times in his/her room (4 times on the 7-3 shift and 1 on 3-11 shift) from 4/20/26 through 4/23/26. The NA flowsheets indicated N/A for the rest of the shifts during that timeframe. Interview with Director of Therapy (PT) 1 on 4/23/26 at 10:45AM indicated Resident #117's physical and occupational therapy had been discontinued on 4/10/26 due to insurance purposes and Resident #117 had just restarted physical therapy on 4/20/26 as they had received approval from Resident #117's insurance. PT #1 stated when Resident #117 was discharged from therapy, she/he was able to walk with staff. PT #1 indicated that Resident #117 was placed on the ambulation program on 4/17/26. PT #1 stated there was verbal communication to the nursing supervisor on unit 300 that Resident #117 could be added to the ambulation list and a physician's order could be obtained to walk daily with assistance with RW as tolerated. PT #1 was not aware that nursing staff had not consistently ambulating Resident #117 since his/her discharge from therapy. PT # 1 indicated Resident # 117's new evaluation on 4/20/26 did not indicate Resident #117 had a decline in his/her ADL status including ambulation from 4/10/26 through 4/20/26 when she/he was picked up again by therapy.Interview with NA #1 on 4/23/26 at 2:00PM indicated that she would check the ambulation list on the unit to review who needed to be ambulated on her shift. However, NA #1 could not locate the ambulation list for the unit. NA #1indicated she could also check a resident care card to find out if a resident needed to be ambulated. NA #1 was unable to state if Resident #117 needed to be ambulated.Interview and review of the NA flowsheet documentation and care card with the Assistant Director of Nursing Services (ADNS) on 4/23/26 at 2:10 PM indicated there is usually an updated ambulation list on the unit, but she could not locate the list. She indicated the unit manager had been off for over a week who usually is responsible for posting the sheet on the unit. However, she was able to locate the physician's order and the updated care card for Resident #117 indicating she/he was able to ambulate with staff assistance. The ADNS indicated that NAs should check the resident's care card as it usually indicates if a resident needs to be walked. The ADNS indicated it was a new process to place the ambulation status of a resident on the care card in effort to try to eliminate the use of the ambulation sheet. Though, the ADNS could not state or locate any education related to this new process for NAs. Furthermore, the ADNs indicated that the NAs should have been walking Resident #117 starting 4/17/26 and documenting appropriately on Resident #117's flowsheet.After inquiry, an updated ambulation list of residents was provided to the unit 300 on 4/23/26.A review of Rehabilitative Nursing Policy given onsite, directed, in part, nursing personnel are trained in rehabilitative care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident care plan. The facility's rehabilitative nursing program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Rehabilitative nursing is performed daily for those residents who require such services as prescribed by the attending physician.

Based on clinical record review, facility policy review and interview for 1 of 8 sampled residents (Resident #16) reviewed for accidents, the facility failed to update/ revise the resident's care plan for behaviors. The findings include: Resident #16's diagnoses included dementia, cerebral infraction, and anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 had a Brief Interview of Mental Status of 3 indicating severe cognitive impairment. The assessment also noted totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and personal hygiene.The Resident Care Plan (RCP) dated 12/4/25 identified Resident #16 had potential impairment to skin integrity related to inactivity. Interventions included: using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces and to follow facility protocols for treatment of injury.A nurse progress note dated 1/22/26 at 7:30 AM identified Resident #16 had a change in condition consisting of a reddish/purplish discoloration to the left eyebrow caused when he/she bumped his/her forehead lightly against the mechanical lift bar during transfer. Post event, the resident acquired a reddish/purplish discoloration above his/her left brow, skin was intact, neurological checks within baseline/normal limits and no complaints of pain or discomfort were noted.Interview with RN #1 on 4/22/26 at 2:40 PM identified she believed the discoloration may have occurred because Resident #16 was a total mechanical lift transfer, becomes anxious, and often grabs the bar, which could cause him/her to bump against the machine or by pulling up on the side rail during care, which could have also lead to a bump and discoloration of the skin. RN #1 identified that she was aware Resident #16 became anxious during transfers prior to the incident. However, RN #1 indicated she did not care plan for anxious behavior, even though she was responsible for updating care plans.Review of the Comprehensive Care Plan Policy revised 1/15 given onsite notes the facility will develop an individualized comprehensive care plan for each resident. Additionally, each resident's comprehensive care plan was designed to incorporate identified problem areas and incorporate risk factors associated with identified risk problems. The Care Planning/Interdisciplinary Team is responsible for periodic review and updating of care plans: when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility after a hospital stay and at least quarterly.

Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #16) reviewed for accidents, the facility failed to thoroughly investigate an injury of unknown origin. The findings include:Resident #16's diagnoses included dementia, cerebral infraction, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 had severely impaired cognition, and was totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and personal hygiene.The Resident Care Plan dated 12/4/25 identified Resident #16 had potential impairment to skin integrity related to inactivity. Interventions included using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces and to follow facility protocols for treatment of injury.Review of the January 2026 physician's orders directed to transfer the resident via a hoyer lift (mechanical lift).A Change in Condition/Concurrent Review dated 1/22/26 at 7:30 AM identified a bruise on Resident #16's left eyebrow that measured 1.5 cm x 0.5 cm.A nurse's note, written by the DNS, dated 1/22/26 at 7:30 AM identified Resident #16 bumped his/her forehead lightly on the mechanical lift bar during a transfer. The DNS further documented that post event it was noted that the resident acquired a reddish/purplish discoloration above his/her left eyebrow. (This is in conflict with accident/incident statements and documentation that did not identify the resident bumped his/her head on the mechanical lift bar, did not determine when the bump occurred, a later interview with the DNS who indicated she could not identify who reported the resident bumped his/her forehead on the mechanical lift bar and surveyor interviews that failed to reflect the resident had bumped his/her head). Review of an Accident/Incident Investigation Staff Interview, written by a nurse aid (who found the bruise), dated 1/22/26 at 7:30 AM identified she found the discoloration on Resident #16's left eye when she entered the room to provide morning care. This was reported immediately to the nurse. Review of the Accident/Incident Investigation statements failed to identify a statement indicating Resident #16 bumped his/her head on the mechanical lift bar.Review of facility documentation failed to reflect that the facility had completed a reportable event form/risk management system entry (RMS) regarding the reddish/purplish discoloration (bruise) above his/her left eyebrow with an unknown etiology.Review of the state agency online reportable events portal failed to reflect that bruise on Resident #16's left eyebrow that measured 1.5 cm x 0.5 cm, with an unknown etiology, had been reported.Review of facility documentation identified the usual staffing during the 11:00 PM - 7:00 AM shift on Resident #16's unit included 2 nurse aides and 1 LPN.Review of the investigative statements regarding Resident #16's bruise, which was found at 7:30 AM on 1/22/26 identified statements were not obtained from the one LPN who worked on 1/19/26 during the 11:00 PM - 7:00 AM shift or from the four nurse aides that worked on 1/19, 1/20 or 1/21/26 during the 11:00 PM - 7:00 AM shifts, as part of the lookback according to facility policy.Interview with RN #1 on 4/22/26 at 9:17 AM, (Unit Manager of Resident #16's unit, and who is responsible for starting the RMS, the change in condition assessment to complete and follow up on any reportable event that occurs on that unit, including obtaining statements per interview with DNS) identified if a bruise is found, the nurses would be responsible to start the RMS, and initiate a change in condition form, and the RN obtains the statements and reviews and locks the change in condition assessment and RMS. Further, all of the documentation is kept by the ADNS. Additionally, a 72 hour lookback for staff on the unit is done to obtain interviews.Review of the clinical record with RN #1 identified an RMS was never completed after the bruise on Resident #16's left eyebrow, that measured 1.5 cm x 0.5 cm, was found. RN #1 indicated an RMS should have been completed at the time of the incident, and although she was the unit manager and responsible for compiling statements, which RN #1 indicated she did obtain, the ADNS would have the statements at this point.Interview with the Assistant Director of Nurses (ADNS) on 4/22/26 at 9:44 AM identified that, according to facility policy, Accident/Incident reports are to be completed by the RN Supervisor for all falls, suspected injuries, abrasions, skin tears, and skin discolorations. These reports are then reviewed by the ADNS and DNS and, if necessary, reported to the state agency. Review of Resident #16's clinical record failed to identify a completed RMS. Although RN #1 previously stated that the ADNS would have the information/statements related to Resident #16's bruise that was found on 1/22/26, the ADNS indicated she did not have any documentation or statements regarding that incident. Further, although all reportable incidents are tracked sequentially on a log kept by the ADNS, the ADNS identified the bruise found on Resident #16's forehead had not been logged, which the ADNS indicated means that an accident/incident report / RMS had not been done. Further, the ADNS indicated that RN #1 might have the missing documentation even though the even occurred 3 months ago.Re interview with RN #1 on 4/22/26 at 2:40 PM identified that she found the interview statements related to Resident #16's bruise to the left eyebrow observed on 1/22/26, misfiled in an unmarked folder in her desk drawer. RN #1 stated that although she did not complete the RMS (though she should have) she did review the statements for the 72 hour lookback. Based on this review, she believes the discoloration may have occurred because Resident #16 requires a total mechanical lift transfer, becomes anxious, and often grabs the bar, which could cause him/her to bump against the machine. RN #1 also noted that the resident can pull up on the side rail during care, which could also lead to a bump and discoloration. RN #1 stated she did not consider the discoloration to be an injury of unknown origin because she assumed one of these scenarios had occurred. However, after reviewing the Accident/Incident information she indicated that there were no statements from staff in her possession indicating that the resident actually bumped him/herself on the side rail or lift. RN #1 further stated that she is responsible for reporting injuries of unknown origin to the Director of Nursing immediately upon reviewing the 72 hour lookback. Although she felt confident about what might have happened to Resident #16, she indicated that without documentation to support the assumption, she should have notified the DNS.Interview with the DNS on 4/23/26 at 8:53 AM identified that facility policy required all injuries of unknown origin to be investigated, which was part of the abuse policy, and if no apparent cause is identified, the incident must be reported to the state agency (this is in conflict with state and federal law as injuries of unknown origin are indicators of abuse and are to be reported within 2 hours of identification). The DNS could not identify how she determined that the bruise on Resident #16's forehead was caused by the resident bumping the mechanical lift bar but stated she would not have signed off on the assessment if she had not been sure that occurred. Additionally, the DNS noted that she might have additional interview statements in her office. However, she stated that it is ultimately the responsibility of the unit manager to follow up on all Accident/Incident reports to ensure they are complete.Follow up interview with the DNS on 4/24/26 at 9:46 AM identified that she was unable to locate any additional interviews or documentation regarding the discoloration to the resident's left eyebrow which would indicate that Resident #16 had hit his/her head on the mechanical lift bar during a transfer.Review of the Abuse, Neglect and Exploitation Policy directed that possible indicators of abuse include but are not limited to physical marks such as bruises or patterned appearances and physical injury of a resident of unknown source. Additionally, reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies within specified timeframes: immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serios bodily injury or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Additionally, an immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur. Written procedures for investigation include identifying and interviewing all involved persons including the alleged victim, witnesses and others who might have knowledge of the allegation, focusing the investigation on determining if abuse , neglect, exploitation, and/or mistreatment has occurred, the extent and the cause and providing complete and thorough documentation of the investigation.The Administrator will follow up and report the results of the investigation when final within 5 working days of the incident as required by state agencies.

Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #16) reviewed for accidents, the facility failed to report an injury of unknown origin (bruise above the left eyebrow) to the state agency within established timeframes. The findings include:Resident #16's diagnoses included dementia, cerebral infraction, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 had severely impaired cognition, and was totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and personal hygiene.The Resident Care Plan dated 12/4/25 identified Resident #16 had potential impairment to skin integrity related to inactivity. Interventions included using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces and to follow facility protocols for treatment of injury.Review of the January 2026 physician's orders directed to transfer the resident via a hoyer lift (mechanical lift).A Change in Condition/Concurrent Review dated 1/22/26 at 7:30 AM identified a bruise on Resident #16's left eyebrow that measured 1.5 cm x 0.5 cm.A nurse's note, written by the DNS, dated 1/22/26 at 7:30 AM identified Resident #16 bumped his/her forehead lightly on the mechanical lift bar during a transfer. The DNS further documented that post event it was noted that the resident acquired a reddish/purplish discoloration above his/her left eyebrow. (This is in conflict with accident/incident statements and documentation that did not identify the resident bumped his/her head on the mechanical lift bar, did not determine when the bump occurred, an interview with the DNS who indicated she could not identify who reported the resident bumped his/her forehead on the mechanical lift bar and surveyor interviews that failed to reflect the resident had bumped his/her head). Review of an Accident/Incident Investigation Staff Interview, written by a nurse aid (who found the bruise), dated 1/22/26 at 7:30 AM identified she found the discoloration on Resident #16's left eye when she entered the room to provide morning care. This was reported immediately to the nurse. Review of the Accident/Incident Investigation statements failed to identify a statement indicating Resident #16 bumped his/her head on the mechanical lift bar. Review of facility documentation failed to reflect that the facility had completed a reportable event form/risk management system entry (RMS) regarding the reddish/purplish discoloration (bruise) above his/her left eyebrow with an unknown etiology. Review of the state agency online reportable events portal failed to reflect that bruise on Resident #16's left eyebrow that measured 1.5 cm x 0.5 cm, with an unknown etiology, had been reported. Interview with RN #1 on 4/22/26 at 9:17 AM, (Unit Manager of Resident #16's unit, and who is responsible for starting the RMS, the change in condition assessment to complete and follow up on any reportable event that occurs on that unit, including obtaining statements per interview with DNS) identified if a bruise is found, the nurses would be responsible to start the RMS, and initiate a change in condition form, and the RN obtains the statements and reviews and locks the change in condition assessment and RMS. Further, all of the documentation is kept by the ADNS. Additionally, a 72 hour lookback for staff on the unit is done to obtain interviews. Review of the clinical record with RN #1 identified an RMS was never completed after the bruise on Resident #16's left eyebrow, that measured 1.5 cm x 0.5 cm, was found. RN #1 indicated an RMS should have been completed at the time of the incident, and although she was the unit manager and responsible for compiling statements, which RN #1 indicated she did obtain, the ADNS would have the statements at this point.Interview with the Assistant Director of Nurses (ADNS) on 4/22/26 at 9:44 AM identified that, according to facility policy, Accident/Incident reports are to be completed by the RN Supervisor for all falls, suspected injuries, abrasions, skin tears, and skin discolorations. These reports are then reviewed by the ADNS and DNS and, if necessary, reported to the state agency. Review of Resident #16's clinical record failed to identify a completed RMS. Although RN #1 previously stated that the ADNS would have the information/statements related to Resident #16's bruise that was found on 1/22/26, the ADNS indicated she did not have any documentation or statements regarding that incident. Further, although all reportable incidents are tracked sequentially on a log kept by the ADNS, the ADNS identified the bruise found on Resident #16's forehead had not been logged, which the ADNS indicated means that an accident/incident report / RMS had not been done. Further, the ADNS indicated that RN #1 might have the missing documentation even though the even occurred 3 months ago.Re interview with RN #1 on 4/22/26 at 2:40 PM identified that she found the interview statements related to Resident #16's bruise to the left eyebrow observed on 1/22/26, misfiled in an unmarked folder in her desk drawer. RN #1 stated that although she did not complete the RMS (though she should have) she did review the statements for the 72 hour lookback. Based on this review, she believes the discoloration may have occurred because Resident #16 requires a total mechanical lift transfer, becomes anxious, and often grabs the bar, which could cause him/her to bump against the machine. RN #1 also noted that the resident can pull up on the side rail during care, which could also lead to a bump and discoloration. RN #1 stated she did not consider the discoloration to be an injury of unknown origin because she assumed one of these scenarios had occurred. However, after reviewing the Accident/Incident information she indicated that there were no statements from staff in her possession indicating that the resident actually bumped him/herself on the side rail or lift. RN #1 further stated that she is responsible for reporting injuries of unknown origin to the Director of Nursing immediately upon reviewing the 72 hour lookback. Although she felt confident about what might have happened to Resident #16, she indicated that without documentation to support the assumption, she should have notified the DNS.Interview with the DNS on 4/23/26 at 8:53 AM identified that facility policy required all injuries of unknown origin to be investigated, which was part of the abuse policy, and if no apparent cause is identified, the incident must be reported to the state agency (this is in conflict with state and federal law as injuries of unknown origin are indicators of abuse and are to be reported within 2 hours of identification). The DNS could not identify how she determined that the bruise on Resident #16's forehead was caused by the resident bumping the mechanical lift bar or who reported that to her but stated she would not have signed off on the assessment if she had not been sure that occurred. Additionally, the DNS noted that she might have additional interview statements in her office. However, she stated that it is ultimately the responsibility of the unit manager to follow up on all Accident/Incident reports to ensure they are complete.Follow up interview with the DNS on 4/24/26 at 9:46 AM identified that she was unable to locate any additional interviews or documentation regarding the discoloration to the residents left eyebrow which would indicate that Resident #16 had hit his/her head on the mechanical lift bar during a transfer.Review of the Abuse, Neglect and Exploitation Policy directed that possible indicators of abuse include but are not limited to physical marks such as bruises or patterned appearances and physical injury of a resident of unknown source. Additionally, reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies within specified timeframes: immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serios bodily injury or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up and report the results of the investigation when final within 5 working days of the incident as required by state agencies.

Based on observations, interviews, review of the clinical record, and review of facility policy for 1 of 1 resident (Resident #85) reviewed for blood glucose monitoring, the facility failed to maintain appropriate infection control practices during blood glucose monitoring. The findings include: Resident #85 was admitted to the facility in February 2014 with diagnoses that included type 2 diabetes, dementia, and depressive disorder. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #85 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition and dependent with personal hygiene, dressing, and toileting. Additionally, the MDS identified Resident #85 received insulin 7 days a week.Physician's orders dated 3/12/26, directed to perform blood glucose monitoring twice a day, administer Toujeo Solostar (long-acting insulin used to lower blood sugar) 60 units subcutaneously (under the skin) once a day, and Tradjenta (medication used to control blood sugar) 5 milligrams (mg) once a day for diabetes. The Resident Care Plan (RCP) dated 4/2/26 identified Resident #85 had diabetes with interventions that included diabetes medications as ordered, diet as ordered, monitor compliance with diet, inspect feet daily, podiatry consultation, and labs as ordered. Observation on 4/23/26 at 7:20 AM of Licensed Practical Nurse (LPN) #2 performing Resident #85's blood glucose monitoring identified LPN #2 entered the room wearing gloves applied prior to entry, carrying a blood glucose meter, a multi-vial test strip bottle, lancet, alcohol wipes, gauze, and gloves. Resident #85 was in bed lying on his/her back, LPN #2 placed the blood glucose meter directly on Resident #85's blanket on the bed (without the benefit of placing a barrier on the blanket). LPN #2 removed a test strip from the multi-vial test strip bottle, inserted the test strip into the blood glucose meter, cleansed Resident #85's right index finger, used a lancet to puncture the finger, applied the blood sample to the test strip, and the meter displayed an error message. LPN #2 removed the strip from the meter, then without the benefit of removing her gloves or sanitizing her hands, she obtained another test strip from the multi- vial bottle and attempted a second sample from the same finger without a new puncture; the meter again displayed an error. LPN #2 exited the room with the meter and supplies, discarded the used items, placed the blood glucose meter on the medication cart without the benefit of disinfecting the meter, then removed her gloves and performed hand hygiene. LPN #2 donned a pair of gloves, re-entered Resident #85's room, placed the blood glucose meter on Resident #85's roommate's over-bed table without placing a barrier on the table. LPN #2 obtained a strip from the multi- vial test strip bottle, inserted into the blood glucose meter, obtained Resident #85's blood sample, and obtained a blood sugar reading. LPN #2 then exited the room, placed the blood glucose meter and supplies on the medication cart, removed her gloves, performed hand hygiene, and disinfected the meter.Interview with Nurse Aide (NA)# 3 on 4/23/26 at 7:45AM identified she assigned to Resident #85 and his/her roommate for the 7:00 AM to 3:00 PM shift. NA #3 indicated the over-bed table located in the middle of the room, positioned between the privacy curtain and near the foot of the bed, belonged to the roommate of Resident #85. Interview with RN #1 on 4/23/26 at 7:50AM identified LPN #2 should not have placed the blood glucose meter on Resident #85's blanket or the roommate's over-bed table. RN #1 stated LPN #2 should have placed the blood glucose meter on a clean surface by first disinfecting the area and placing a barrier beneath the device. RN #1 further stated LPN #2 should not have brought the multi-vial test strips bottle into Resident #85's room. RN #1 identified she was not familiar with all the specific details of the blood glucose monitoring policy, but any potential contamination of the meter requires disinfection in accordance with manufacturer guidelines, and the meter should always be placed on a clean surface.Interview with LPN #2 on 4/23/26 at 8:00AM identified she should not have placed the blood glucose meter Resident #85's blanket on the bed nor should she have placed the meter on top of the roommate's over-bed table. LPN #2 indicated only one test strip should have been brought into the room, rather than the entire multi-vial bottle. LPN #2 stated she should have cleaned the blood glucose meter and set aside after the initial blood glucose monitoring attempt, and that a spare meter from the medication cart should have been used when reattempting blood glucose monitoring for Resident #85. LPN #2 indicated she was nervous at the time, which caused her the errors made when performing Resident #85's glucose monitoring. Interview with LPN #4 (Infection Control Nurse) on 4/23/26 at 11:00AM identified blood glucose meters should be placed on a clean surface, such as on a table with a barrier and it is not appropriate to use another resident's over-bed table. LPN #4 identified blood glucose meters should be cleaned after exiting a resident room, before placing it on top or in the medication cart, even if the blood glucose meter will be used again in the same room. Review of facility Blood Glucose Policy dated 10/25/26 directed in part, the facility will ensure blood glucose meters will be cleaned and disinfected after each use according to manufacturer's instructions. Gloves should be removed and hand hygiene prior to exiting room. Gloves should be reapplied if visibly soiled or contaminated.

Based on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents reviewed for admission plan of care, (Resident #1), the facility failed to follow physician's orders regarding a medication. The findings include: Resident #1's diagnoses included glaucoma (an eye condition that damages the optic nerve) and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required supervision assistance with bed mobility, and moderate assistance with transfers and personal hygiene. Review of the hospital Discharge summary dated [DATE] directed to continue taking Latanoprost (treats glaucoma) ophthalmic solution 1 drop to each eye daily at bedtime. A physician's order dated 2/8/23 directed to administer Latanoprost Ophthalmic Solution 0.005% one drop in both eyes at bedtime for glaucoma. A medication administration note dated 2/8/23 at 8:51 PM identified that Latanoprost was not administered, as it was not available and was pending delivery from the pharmacy. A medication administration note dated 2/9/23 at 8:54 PM identified that Latanoprost was not administered, as it was not available, and the pharmacy was contacted by the supervisor. No follow-up note was available as to what the pharmacy had communicated to the facility. A medication administration note dated 2/10/23 at 5:45 PM identified that Latanoprost was not administered, but there was no reason documented. Interview with the Pharmacist on 7/18/24 at 10:15 AM identified that the facility first ordered Latanoprost for Resident #1 on 2/8/23 at 7:12 PM. He indicated the medication was filled on 2/8/23 and delivered to the facility and signed for by RN #2 on 2/9/23 at 3:32 AM. Additionally, he reported that for a resident who has been on this medication, missing doses can lead to eye pain or pressure and headaches, depending on the severity of the glaucoma. Interview with the DNS on 7/18/23 at 10:45 AM identified that in February of 2023, the facility had not yet been scanning incoming delivery orders from the pharmacy, and they did not retain any of the pharmacy delivery slips. She indicated the pharmacy would deliver one large delivery for the entire building, and the supervisor would sign for it and then deliver the medications to each unit. She identified that due to the volume of medications in each delivery and time constraints, the supervisor would only individually check and count the narcotics, but best practice would be to check to be sure each medication on the delivery slip was included in the order and then contact the pharmacy as soon as possible to request a STAT order of the missing medications. She reported that if floor nurses are administering medications and discover a medication is missing for a new admission resident, she would expect the staff to be contacting the pharmacy within 24 hours to inquire when the medication would be arriving, and then writing a note in the Electronic Health Record (EHR) identifying that they had called the pharmacy, information on any delays, and when it should be expected to arrive. Additionally, she identified that the nurse should be notifying the physician for all missed doses on medication to request an alternative until the original medication is delivered if applicable, and then documenting their encounter with the physician in the EHR. She indicated that she was unsure of why there was a gap in administration from when the pharmacy reported that the medication was delivered on 2/9/23, and then when nursing first administered the medication to Resident #1 on 2/11/23. Although requested, a policy on new admission pharmacy orders was not obtained.

Based on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of (3) three residents (Resident #1), reviewed for the discharge process, the facility failed to notify the homecare agency timely of a discharge delaying start of care. The findings include: Resident #1's diagnoses included sepsis (complications of an infection), low back pain, dyspnea (difficulty breathing), and orthostatic hypotension (low blood pressure that occurs when standing up from a sitting a lying position). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1was moderately cognitively impaired and required supervision assistance with bed mobility, and moderate assistance with transfers and personal hygiene. The Resident Care Plan dated 2/16/23 identified that Resident #1had a self-care performance deficit related to decreased strength and endurance with interventions that included utilizing the assistance of 1 staff for dressing, bathing, bed mobility, and transfers, and an assist of 1 staff for toileting and ambulation with a rolling walker. A physician's order dated 2/24/23 directed that Resident #1 was stable for discharge home with services on 2/24/23. A late entry social service note dated 2/27/23 at 4:05 PM identified that Resident #1 was discharged and transported home by a family member on 2/24/23. The resdient chose a homecare agency for Physical Therapy (PT), Occupational Therapy (OT), and Skilled Nursing (SN) services. Review of progress notes from 2/17/23 through 2/23/23 failed to identify any previous documentation related to a plan for Resident #1's discharge by social work staff. Review of facility documentation identified that the Interagency Patient Referral Report was sent to the homecare agency on 2/27/23 at 12:01 PM, 3 days after the resident discharged home on 2/24/23. Interview with RN #1 (Home Health Intake Nurse) on 7/18/23 at 11:27 AM identified that the facility sent the referral to them on 2/23/23 but did not send the discharge paperwork until 2/27/23, so they were not aware that Resident #1 had been discharged on 2/24/23 until that time, delaying the start of care for PT, OT and skilled nursing services. When they were made aware of the facility discharge on [DATE], they immediately called the primary care physician to obtain orders. She indicated that the resident was started on services 3/1/23. Further, she identified that admission clinicians are available for start of service on the weekend. Interview and clinical record review with Social Worker #1 and the DNS on 7/18/24 at 12:03 PM identified that SW #2 was responsible for Resident #1's discharge planning, but she was no longer employed at the facility. They indicated that it's the expectation that the Social Worker would document in the clinical record an initial admission note, a progress note on any encounters that they had with the resident and/or family and then a discharge note. They also identified that it would be the expectation that the Social Worker would send the Interagency Report to the homecare agency the same day the resident was discharged . They reported that discharge planning begins on admission, but that a concrete discharge plan is dependent on the insurance. The facility has weekly Medicare meetings, where they obtain more information on how long a resident's stay will be covered for, and once they have a ballpark date, they will start referrals for aftercare, durable medical equipment needed for discharge, and any follow-up appointments required. They indicated that once they identify who will accept a resident's insurance for homecare services, they will call the agency and speak with the representative, and they will let the facility know exactly what they need to send with the referral, and then once the agency reviews the documents, they will call the facility back to let them know if they can accept the resident. They will then communicate to the homecare agency the planned discharge date when it is determined. They indicated they were unable to identify why the facility did not send the Interagency Form and notify the homecare agency that Resident #1 was discharged home until 3 days after the discharge. They were also unable to identify why there was no documentation on the discharge plan prior to the actual discharge home on 2/24/23. Although attempted, SW #2 was unavailable for an interview. Review of the Discharge Summary and Plan policy dated 2015 directed, in part, that the post-discharge plan will contain, at a minimum, a description of the resident's and family's preference for care, a description of how the resident and family will access such services, a description of how the care should be coordinated if continuing treatment involves multiple caregivers, the identity of specific resident needs after discharge, and a description of how the resident and family -need to prepare for the discharge. A copy of the post-discharge plan and summary will be provided to the resident and receiving facility and a copy will be filed in the resident's medical record. Although requested, a policy on referrals to home care agencies was not obtained.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for care planning, the facility failed to ensure care plan was comprehensive. The findings include: Resident #2 was admitted on [DATE] with diagnoses included laryngectomy (surgical removal of larynx (voice box), and had an intact laryngeal tube intact with oxygen via humidifier. A physician's order dated 1/11/2023 directed bedside tracheal humidification to be placed over laryngeal stoma every bedtime. The Resident Care Plan (RCP) dated 1/11/2023 identified Resident #2 had a laryngectomy tube. Interventions directed humidified oxygen as prescribed. The nurse's note dated 1/11/2023 at 7:51 AM laryngeal tube intact, oxygen via humidifier but resident consistently removes humidifier mask. The RPT (Respiratory Physical Therapist) note dated 1/12/2023 at 7:00 AM identified Resident #2 was educated on the importance of keeping humidification over his/her stoma a bedtime and while lying in bed to keep secretions moist. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented, and received oxygen therapy, suctioning and tracheostomy care. Review of the January [DATE] indicated Resident #2 refused tracheal humidification for 9:00 PM on 1/28 and 1/29/2023. Review of the February MAR from 2/1 to 2/15/2023 for 9:00 PM indicated Resident #2 refused tracheal humidification on 2/2 and 2/7/2023. A RPT notes dated 2/8, 2/9 and 2/13/2023 indicated Resident #2 continued to refuse humidification at bedtime. Review of care plan failed to identify a care plan was developed for refusals of humidification to the laryngeal stoma. Interview, clinical record review, and facility documentation review on 6/11/2024 at 1:24 PM with the DNS and RPT #1 identified Resident #2 was provided education regarding the need for humidification to the stoma, and Resident #2 frequently refused the humidification. On 6/11/2024 at 3:23 PM interview and clinical record with the DNS identified although Resident #2 should have been care planned for refusals of humidification, interview failed to identify a care plan was developed, and why a refusal care plan was not developed. Review of facility Care Plans - Comprehensive Policy directed in part, each resident's comprehensive care plan is designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. The Policy further directed the resident has a right to refuse to participate in medical and nursing treatments when such refusals are made, appropriate documentation will be entered into the resident's clinical record in accordance with established policies.

Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #87) reviewed for nutrition, the facility failed to notify the physician and resident representative regarding a significant weight loss. The findings include: Resident #87's diagnoses included type 2 diabetes mellitus, hypertension, anxiety, vascular dementia, and paranoid schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #87 had severe cognitive impairment, required set up assistance for eating, was non-ambulatory, had a height of 67 inches, a weight of 174 pounds, and did not have weight loss in the past six months. The annual MDS assessment dated [DATE] identified Resident #87 had severe cognitive impairment, required supervision for eating inclusive of verbal cues and touching assistance, was non-ambulatory, had a height of 67 inches, a weight of 174 pounds, did not have weight loss in the past six months, and had a mechanically altered therapeutic diet. Resident #87's care plan dated 11/15/23 identified a potential nutritional risk related to dysphagia, type 2 diabetes, dementia, and schizophrenia. Care plan interventions included: monitor weights as ordered, provide, and serve diet as ordered, monitor and document signs and symptoms of dysphagia, and monitor for significant weight loss: 3 pounds (lbs.) in 1 week, greater than 5 percent in 1 month, greater than 7.5 percent in 3 months, and greater than 10 percent in 6 months. Review of the clinical record identified weight records that noted Resident #87 weighed 174.2 pounds (lbs.) on 7/9/23. Further review of the clinical record identified no recorded weights from August 2023 through December 2023. The quarterly MDS assessment dated [DATE] identified Resident #87 had severe cognitive impairment, required supervision with eating, extensive assistance with all activities of daily living, had a weight of 157 pounds, was not on a physician prescribed weight loss regimen and experienced a weight loss of 5% in the past month or 10% in the past six months, and was on a mechanically altered therapeutic diet. Review of physician's orders from July/2023 through February/2024 identified orders that instructed to obtain monthly weights on the 7-3 shift on the 10th day of the month. The weight and vital summary record identified Resident #87 weighed 152 pounds on 1/12/24, indicative of a 13 percent weight loss within a six-month time period. Further review identified Resident #87 was re-weighed on 1/12/24 at 2:40 PM with a resulting weight of 156.6 pounds (weight loss of 10.1 percent from 7/9/23). Review of Dietician #2's nutritional evaluation dated 1/30/24 identified Resident #87 triggered for significant weight loss of greater than 10 percent from the previous recorded weight, and food intake was 50 percent to 100 percent per meal according to the nursing documentation. The evaluation further noted that additional food items would be provided on the resident's tray for optimal food intake and noted that Resident #87's nutrition may decline related to dementia. Review of the nursing progress notes from 1/12/24 through 1/31/24 failed to identify Resident #87's physician and responsible party(ies) were notified of the significant weight loss. Interview and clinical weight record review with RN #1 (wound nurse but covering unit manager) on 5/8/24 at 10:00 AM identified that the dietician was responsible for assessing residents for weight loss. The charge nurse was responsible for recording the weights in the electronic medical record and the unit manager would ensure that there was a weight recorded in the resident's clinical record. There would also be a physician's order directing the frequency of weights. RN #1 could not locate monthly weights from August 2023 through December 2023. She also identified that nursing notifies the dietician, physician, and resident representative of significant weight loss, and it should be documented in the nursing progress notes. In addition, she could not recall whether or not she was aware of Resident #87's significant weight loss. Interview with the DNS on 5/9/24 at 2:15 PM identified that in regards to the monitoring of weights and weight loss in the facility, it is discussed in morning report and there is also an at-risk meeting twice a week. After reviewing Resident #87's clinical record, the DNS could not find documentation to identify that the physician and resident representative had been notified of the resident's significant weight loss. Interview with Dietician #2 on 5/10/24 at 9:45 AM identified Resident #87 triggered for a significant weight loss when she did the nutritional evaluation on 1/30/24. She also noted that she was aware Resident #87 did not have any documented monthly weights from August 2023 through December 2023 and identified that she sent an email to all unit managers and the DNS regarding the missing weights. She further identified that she added extra food items such as pudding, ice cream, and apple sauce on his/her meal tray related to the significant weight loss. In addition, she identified that she had not notified the physician and resident representative(s) of the weight loss because it was nursing's responsibility. Interview with APRN #1 on 5/10/24 at 11:00 AM identified he expects nursing to notify him of a weight loss. He further noted that once he was made aware he reviews the resident's weight loss, goals of care, and provides a plan of care. He recently started in his position of APRN for the facility and was not aware of Resident #87's significant weight loss. The Weight Assessment and Intervention policy identified that the multi-disciplinary team strived to prevent and intervene for undesirable weight loss to the residents. The resident's weight is recorded in each resident's medical record. The threshold for a significant unplanned weight loss would be greater than 5 percent in 1 month, greater than 7.5 percent in 3 months, and greater than 10 percent in 6 months. If weight loss was verified, nursing would notify the dietician, physician, and family.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident #81 and #160) receiving anticoagulant medication, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring that should accompany the use of an anticoagulant. The findings include: 1. Resident #81's diagnoses included acute embolism and thrombosis (disruption of the blood flow in veins and arteries), fractured left femur, and chronic diastolic congestive heart failure. The quarterly MDS assessment dated [DATE] identified Resident #81 had severe cognitive impairment, required maximal assistance with personal hygiene, toileting, was non-ambulatory, and utilized anticoagulant medication (blood thinner) that the assessment noted to be a high-risk medication. The physician's orders for May/2024 directed to administer Apixaban/Eliquis (a blood thinner used to prevent blood clots) 5 milligram (mg) one tablet by mouth every 12 hours. The origination date of the order was 2/23/21 (meaning the resident has been on this medication continuously since that date) According to Eliquis.com, the use of the medication poses a bleeding risk, in that it increases the risk of bleeding and can cause serious, potentially fatal bleeding. Resident #81's care plan dated 3/12/24 identified an alteration in musculoskeletal status related to left femur fracture with an intervention to administer anticoagulant medication as ordered. Further review of the care plan failed to identify the interventions related to the use of the Apixaban and the possible side effects related to the use of an anticoagulant and the increased risk of bleeding. Interview with the MDS Coordinators (LPN #1 and RN #3) on 5/10/24 at 12:25 PM identified Resident #81's care plan did not address interventions to address the possible side effects of anticoagulant therapy. RN #3 further identified that their corporate office directed them to develop anticoagulant care plans only for residents taking Coumadin and Lovenox medications. In addition, LPN #1 identified it was the responsibility of the MDS Coordinator and the nursing staff to ensure the care plan is comprehensive and updated as necessary. Interview with the DNS on 5/10/24 at 10:00 AM identified that residents who are prescribed anticoagulant medication should have a care plan in place for anticoagulant therapy. The DNS added it was not the sole responsibility of the MDS coordinator but nursing as well in developing and updating care plans as needed. Review of the Comprehensive Person-Centered Care Plan policy identified that the facility is to develop an individualized comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. It further identified that the comprehensive care plan is designed to incorporate risk factors associated with identified problems and recognized standards of practice for problem areas and conditions. Additionally, the policy identified that the care planning/interdisciplinary team is responsible for periodic review and updating of the care plans. 2. Resident #160's diagnoses included chronic embolism and thrombosis (disruption of the blood flow in veins and arteries), end stage renal disease, renal dialysis, and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #160 had moderately impaired cognition, required maximal assistance with personal hygiene, was ambulatory, and utilized anticoagulant medication (blood thinner) that the assessment noted to be a high-risk medication Resident #160's care plan dated 3/19/24 identified a potential skin impairment related to fragile skin with an intervention that included to monitor for alteration in skin integrity related to subcutaneous anticoagulant use. Further review of the care plan failed to identify sides and symptoms to monitor for as a result of the resident being on anticoagulant therapy. A physician's order dated 3/31/24 through 5/30/24 directed Apixaban (a blood thinner used to prevent blood clots) 2.5 milligram (mg) one tablet by mouth every 12 hours related to chronic embolism and thrombosis. According to Eliquis.com, the use of the medication poses a bleeding risk, in that it increases the risk of bleeding and can cause serious, potentially fatal bleeding. Interview with the MDS Coordinator (LPN #1) on 5/9/24 at 3:10 PM identified Resident #160's care did not include a care plan that focused on anticoagulant therapy, but noted the resident should have had one. LPN #1 further identified that when the care plan was reviewed, interventions addressing the side effects to monitor could have been developed and implemented. LPN #1 added that it was the responsibility of both MDS and nursing to update and revise care plans as needed. Interview with the DNS on 5/10/24 at 10:00 AM identified that residents who are prescribed anticoagulant medication should have a care plan in place for anticoagulant therapy. The DNS added it was not the sole responsibility of the MDS coordinator but nursing as well in developing and updating care plans as needed. Interview with the Unit Manager/Supervisor (RN #2) on 5/10/24 at 1:10 PM identified that Resident #160 should have a care plan developed for anticoagulant therapy if the resident is taking any anticoagulant medication. RN #3 failed to identify why Resident #160 did not have a care plan developed for anticoagulant and that it was the responsibility of both nursing and MDS to create and to update care plans. Review of the Comprehensive Person-Centered Care Plan policy identified that the facility is to develop individualized comprehensive care plan for each resident that includes measurable objectives and timetables to [NAME] the resident's medical, nursing, and mental and psychological needs. It further identified that the comprehensive care plan is designed to incorporate risk factors associated with identified problems and recognized standards of practice for problem areas and conditions. The policy further identified that the care planning/interdisciplinary team is responsible for periodic review and updating of the care plans.

Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #87) reviewed for nutrition, the facility failed to ensure the dietician assessed the resident for weight loss timely and failed to obtain the resident's monthly weight in accordance to facility policy. The findings include: Resident #87 's diagnoses included type 2 diabetes mellitus, hypertension, anxiety, vascular dementia, and paranoid schizophrenia. Review of Resident #87's weight records identified a weight of 174.2 pounds on 7/9/23, further review identified no documented weights from August 2023 through December 2023. The Resident Care Plan (RCP) dated 11/15/23 identified Resident #87 had a potential nutritional risk related to dysphagia, type 2 diabetes, dementia, and schizophrenia. Care plan interventions directed to monitor resident weight as ordered, provide, and serve diet as ordered, monitor/document signs and symptoms of dysphagia, and monitor for significant weight loss: 3 pounds (lbs.) in 1 week, greater than 5 percent in 1 month, greater than 7.5 percent in 3 months, and greater than 10 percent in 6 months. Resident #42's weight record identified Resident #87 was weighed on 1/12/24 at 9:06 AM with a weight of 152 pounds. (weight loss of 13 percent from 7/9/23). Further weight record reviewed identified Resident #87 had a re-weigh on 1/12/24 at 2:40 PM with a weight of 156.6 pounds (weight loss of 10.1 percent from 7/9/23). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 had severe cognitive impairment and required limited assistance with eating and extensive assistance with bed mobility, toileting, hygiene, transfer, and non-ambulatory. Further review of the resident assessment identified Resident #87 had an unplanned weight loss and was receiving a therapeutic mechanically altered diet. Dietician #2's nutritional evaluation dated 1/30/24 identified Resident #87 triggered for significant weight loss of greater than 10 percent from the previous recorded weight, food intake was 50 percent to 100 percent at meals according to nursing documentation. The evaluation further noted that added food items would be provided on the tray for optimal food intake and noted Resident #87's nutrition may decline related to dementia and the registered dietician would continue to monitor and evaluate as needed. The physician's order dated 4/1/24 with origination date of 10/29/21 directed to obtain a monthly weight on 7-3 shift 10th day of the month. The physician's order dated 4/1/24 with origination date of 10/25/23 directed to provide carbohydrate-controlled diet, ground texture food consistency and thin liquid. Interview and clinical weight record review with RN #1 (wound nurse but covering unit manager) on 5/8/24 at 10:00 AM identified that the dietician was responsible for assessing resident for weight loss. The charge nurse was responsible for recording the weights in the electronic medical record and the unit manager would ensure that there was a weight recorded in the resident clinical record. There would also be a physician's order on how frequently the resident required a weight. RN #1 could not identify why Resident #87 had no weight recorded from August 2023 through December 2023, but she identified that facility had a vacancy for the unit manager, and she or the DNS was covering for being the unit manager during that time period. Interview with Dietician #1 on 5/9/24 at 11:10 AM identified that she was responsible for assessing residents for a weight loss and identified that the facility process was to run a daily weight report that highlights residents with weight loss in 30 days and/or 180 days. She further noted that weight loss is also discussed in the morning report. She identified that a significant weight loss would be greater than 5 percent in 30 days and greater than 10 percent in 180 days. In addition, the dietician also ran a report that identified missing weights at least once a month. She further identified that missing weights would not appear on the weight loss report. Interview with the DNS on 5/9/24 at 2:15 PM identified that the department heads discuss any potential weight loss in morning report and there is also an at-risk meeting twice a week for any resident with a weight loss. She confirmed that Resident #87 had a physician's order for a monthly weight. She also reviewed Resident #87's weight record and noted there were no monthly weights recorded from August 2023 through December 2023. Additionally, she identified that all weights should be entered in the electronic medical record so the resident weight would be included in the weight loss report otherwise, any missing weight would not be reflected in the weight loss report. She was unsure why Resident #87's weight loss had been missed. Interview with Dietician #2 on 5/10/24 at 9:45 AM identified Resident #87 triggered for a significant weight loss when she did the nutritional evaluation on 1/30/24. She also was aware that Resident #87 had no monthly weight recorded from August 2023 through December 2023. She noted that she sent an electronic mail monthly to all unit managers and the DNS regarding the monthly missing weight for Resident #87. She identified that the nursing department was responsible for ensuring the weight was obtained and recorded in the electronic medical record. She also identified that she added extra food items such as pudding, ice cream, and apple sauce on the tray related to significant weight loss. The Weight Assessment and Intervention policy identified that the multi-disciplinary team would strive to prevent and intervene for undesirable weight loss to the residents. The resident's weight would be recorded in each resident's medical records. The threshold for a significant unplanned weight loss would be greater than 5 percent in 1 month, greater than 7.5 percent in 3 months, and greater than 10 percent in 6 months.

Based on observation, review of facility policy and interviews for one sampled resident (Resident #166) observed self-administering medications, the facility failed to ensure the resident was assessed for self-administration of medications. The findings include: Resident #166's diagnoses included chronic obstructive pulmonary disease, heart failure and chronic pain. The resident medication self-assessment forms dated 10/27/23 & 1/4/24 indicated Resident #166 expressed no desire to self-administer medications. The quarterly MDS assessment dated [DATE] identified Resident #166 was cognitively intact and was dependent for transfers, showering, toileting and required set up for meals. The care plan dated 2/29/24 identified a self-care deficit related to decreased strength and endurance, with interventions that included nursing assistants (NA's) to ensure foods are cut into bit sized pieces during each meal tray set up. Observation on 5/7/24 at 10:04 AM identified Resident #166 in bed by the window, with the privacy curtain drawn halfway between he/she and his/her roommate. The resident's overbed table was in front of the resident and it contained a medicine cup with numerous pills visible in the cup. Interview on 5/7/24 at 10:05 AM with Resident #166 identified that the nurses sometimes leave the medications with him/her to self-administer. Resident #166 further explained he/she would never throw the medications away or not take them and proceeded to self-administer the medications contained within the medicine cup. Observation on 5/7/24 at 10:06 AM identified LPN #2 was across the hall from Resident #166's room in a resident's room with the medication cart placed in front of her. The privacy curtain obstructed the view of Resident #166 from the hallway. Interview on 5/7/24 at 10:08 AM with LPN #2 identified that the facility policy is that medications should not be left at the bedside, nurses are expected to remain at the bedside and wait for the resident to take their medications. LPN #2 identified she was near Resident #166's room on this opposite side of the hallway. She further noted that she could peek in on Resident #166 to make sure he/she took the morning medications. In addition, LPN #2 identified that Resident #166 preferred that the nurses not hover and requested privacy. LPN #2 then leaned over and came from behind the medication cart to observe if Resident #166 had taken the medications. All morning medications that were left at the bedside were verified with LPN #2. Review of the medication administration record (MAR) with LPN #2 identified she had poured the following medications into the medicine cup: 1. Amlodipine 5mg daily for high blood pressure. 2. Aspirin 81mg delayed release tablet once daily. 3. Duloxetine HCL 20mg cap once daily for chronic pain related to adjustment disorder with Depression. 4. Gabapentin 300mg daily for diabetic neuropathy related to diabetes. 5. Isosorbide ER 60mg daily for high blood pressure. 6. Multivitamin one tab daily for vitamin deficiency. 7. Tylenol 325mg tabs totaling two tabs (650mg) twice daily for pain related to osteoarthritis. 8. Apixaban 5mg twice daily to prevent clots. 9. Carvedilol 3.125mg twice daily for high blood pressure. 10. Pantoprazole Sodium 40mg twice daily to decrease stomach acid. Review of the physician's orders for May/2024 did not identify an order that directed Resident #166 could self-administer medications. Interview on 5/8/24 at 10:59 AM with the DNS identified that during medication administration the resident should be within the nurse's view so that the nurse can visualize the resident consuming the medication. The DNS further noted that the nurse cannot leave the resident until the medications are consumed and medications should not be left at the bedside. A second interview with the DNS on 5/9/24 at 8:44 AM identified Resident #166 was unable to self-administer medications and noted that he/she had been sick and debilitated when admitted . She further noted that it might be time to re-evaluate the resident for self-administration of medications and noted self-administration assessments are completed upon admission, readmission and quarterly. Review of the Administering Medications policy established that a resident may self-administer their own medications, only if the attending physician in conjunction with the interdisciplinary care team has determined that they have the decision-making capacity to do so safely.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #126), the facility failed to ensure the physician's order and the resident's signed Advance Directives were congruent. The finding includes: Resident #126 's diagnoses included pulmonary fibrosis, asthma, and chronic cough. The physician's order dated [DATE] directed Resident #126's code status was Full Code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR (cardiopulmonary resuscitation). Review of the clinical record identified an Advanced Directive form dated [DATE] that noted Resident #126 had elected a code status of Do No Resuscitate (DNR), which means that a person has decided not to have CPR attempted on them if their heart or breathing stops. The quarterly MDS assessment dated [DATE] identified Resident #126 had intact cognition and was independent with most activities of daily living apart from requiring supervision and set up assistance. Resident #126's care plan dated [DATE] identified the resident had a code status of DNR with interventions that included honor advanced directives through the next review date. Interview with LPN #2 on [DATE] at 1:27 PM identified that when determining a resident's code status, she first checks the physician's orders in the electronic medical record (EMR) and then checks the resident's physical clinical record for the advanced directives to make sure they match. After checking Resident #126's status, she noted that there was an order in the EMR for full code dated [DATE] and the signed advanced directives form in the physical medical record dated [DATE] noted a status of DNR. LPN #2 further noted that if a code occurred (the resident stopped breathing, and or was without pulses), she would follow the physician's order or advanced directive form with the most recent date. Additionally, LPN #2 identified that the advanced directives form should be reviewed and signed within twenty-four hours of a resident's admission or readmission to the facility. Interview on [DATE] at 1:46 PM with the DNS identified that all of the physical clinical records have a red sleeve denoting where the advanced directives are located. She further noted that when a resident is admitted or readmitted advanced directives are reviewed with the resident, family, or conservator within twenty-four hours. She further noted that it sometimes takes longer to get the advanced directives signed by the family or conservator and in those instances the resident would be designated a full code until the advanced directives were reviewed and signed. Additionally, the DNS identified that they would be conducting a facility wide audit to check for any other discrepancies. Interview with Resident #126 on [DATE] at 3:02 PM identified she/he wished to maintain the status of DNR that was elected on the advanced directives that she/he had signed on [DATE]. Subsequent to surveyor inquiry, a physician's order dated [DATE] directed a code status of DNR. Review of the Advanced Directives policy dated ,d+[DATE]established that upon admission to the facility, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directives.

47402 Based on observations, review of clinical records, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #42) reviewed for positioning and range of motion, the facility failed to ensure a physician's order was in place for the use of splints and for one sampled resident (Resident #213) who had orders for a compounded medication, the facility failed to ensure expired medication was not administered to the resident. The finding include: 1. Resident #42 was readmitted to the facility in January of 2024 with diagnoses that included quadriplegia, stiffness of unspecified joint, aphasia, and gastrostomy. The quarterly MDS assessment dated [DATE] identified Resident #42 had severe cognitive impairment, required maximal assistance with toileting, was dependent on staff for personal hygiene, transfers, was non-ambulatory, and had range of motion limitations of bilateral upper and lower extremities. The care plan dated [DATE] identified Resident #42 had the potential for impairment to skin integrity related to immobility, bilateral elbow splints and bilateral hand splints, with an intervention to apply bilateral hand splints. The care further identified a self-care deficit related to limited range of motion with an intervention for staff to place bilateral hand splints during morning (AM) care and remove them during PM care. A review of Resident #42's physician's order for the period of January/2024 through May/2024 failed to identify an order for bilateral hand splints. Resident #42's nurse aide care card instructed staff to apply bilateral hand splints during AM care and remove during PM care. Observation on [DATE] at 12:00 PM identified Resident #42 seated in a wheelchair wearing a hand splint to his/her left hand, the right hand was unadorned. Observation on [DATE] at 2:35 PM identified Resident #42 seated in a wheelchair, there was no splints applied to either hand. Observation with the Charge Nurse (LPN #5) on [DATE] at 12:58 PM identified Resident #42 seated in a wheelchair wearing a hand splint to his/her left hand and the right hand was unadorned. Interview with LPN #5 on [DATE] at 12:58 PM identified Resident #42 should have physician's orders directing the use of hand splints. After reviewing the orders, LPN #5 identified there were no orders in place regarding the use of hand splints. LPN #5 further identified that splints are applied by the NA's and nurses are responsible for checking the splint application and skin integrity. Interview with NA #1 on [DATE] at 1:03 PM identified she applied the splint to the resident's left hand, but the right-hand splint was not functioning. NA #1 further noted that she notified occupational therapy on [DATE] and was awaiting a replacement. Interview with the Unit Manager/Supervisor (RN #2) on [DATE] at 1:30 PM identified residents who utilize splints should have a physician's order addressing its usage based on the occupational therapist's recommendation. RN #2 further noted she reviewed Resident #42's physician's orders from January through [DATE] and was unable to identify a physician's order for splints. In addition, RN #2 identified that Resident #42 was readmitted to the facility in January and the orders for the splint were not added but noted the resident had an order for the splint previously. Interview with the Assistant Director of Rehab (OT #1) on [DATE] at 1:27 PM identified they were notified on [DATE] that the right-hand splint could not be located. OT #1 further noted that a physician's order confirming the recommendation made by the occupational therapist for splint usage should be in place. Interview with the Charge Nurse (LPN #6) on [DATE] at 11:55 PM identified she observed Resident #42 intermittently wearing bilateral hand splints but did not check to see if a physician's order was written for the splint usage. A second interview with OT #1 on [DATE] at 12:30 PM identified Resident #42 was last seen by the occupational therapy department in September of 2023 and was discharged from therapy in October of 2023. OT #1 further noted that a physician's order is required for splint usage to prevent skin breakdown and irritation. Additionally, OT #1 provided the OT discharge summary dated [DATE] which identified recommendations for remove bilateral elbow splints in with AM care and apply with PM care and to apply bilateral hand splints with AM care and remove with PM care. Interview with the DNS on [DATE] at 10:00 AM identified that a resident should have a physician's order when utilizing a splint. The DNS noted that all orders are discontinued when residents are transferred to the hospital and should be reviewed with the physician and reordered as required upon the resident's return to the facility. Review of the Assistive Devices and Equipment policy identified that the facility will maintain and supervise the use of assistive devices and equipment for residents. 2. Resident #213's diagnoses included protein calorie malnutrition, gastro-esophageal reflux disease (GERD) without esophagitis, and end stage renal disease. The admission MDS assessment dated [DATE] identified Resident #213 had intact cognition and was dependent for eating, oral hygiene, toileting, showering/bathing, and dressing. The Resident Care Plan dated [DATE] identified the resident has a nutritional problem or related to advanced age, therapeutic diet, mechanically altered diet, fluid restriction, food allergy, tube feeding supplementation diet, poor by mouth intake, increased nutritional needs. Interventions directed to monitor weight, skin, labs, and oral intake per protocol or as needed. The physician's orders for May/2024 (the origination date of the order was [DATE]) identified an order for Lansoprazole oral suspension 3mg/ml with instructions to administer 10 ml via G-tube one time a day for GERD. Observation of the medication storage room with LPN #4 on [DATE] at 6:59 AM identified Lansoprazole Suspension for Resident #213 with an expiration date of [DATE] written prominently on the bottle in black pen. This medication was discarded into the return to pharmacy by LPN #4 at this time. Review of Resident #213's MAR for [DATE] identified Lansoprazole Suspension was administered daily as ordered from [DATE] to [DATE]. Review of the Point Click Care audit detail report for the Lansoprazole suspension for the month of May for Resident #213 identified the medication was clicked off administered on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 10 days following the medication expiration date. Interview with LPN #4 on [DATE] at 7:00 AM identified the Lansoprazole oral suspension was expired for Resident #213 and should be sent back to the pharmacy and re-ordered and that it should not be in use. Interview with LPN #3 on [DATE] at 11:56 AM identified she administered Lansoprazole oral suspension to Resident #213 on [DATE]. When asked to locate the medication administered to the resident, LPN #3 checked the medication cart and the medication storage room, and the medication was not found. In addition, LPN #3 identified she must have made an error and had not administered the medication as ordered. She further noted that she was going to contact the pharmacy to get a refill of the Lansoprazole. Subsequent to surveyor inquiry LPN #3 struck out administration of Lansoprazole for Resident #213 at 11:59 AM on [DATE]. Interview with the Pharmacist on [DATE] at 12:11PM identified that efficacy following expiration date depends on what the medication is compounded with, and Lansoprazole was compounded with sterile water and Sodium Bicarbonate. He noted the medication was last filled on [DATE] and was good for 14 days following the fill date. In addition, he noted the Lansoprazole would lose efficacy once expired and the expectation is that the medication is used until the expiration date and should have been discarded after [DATE]. Further, the Pharmacist noted that the turnaround time for ordered medication is within 24 hours. Interview with the DNS on [DATE] at 12:50 PM identified she was aware of the medication not being available on the floor and that medications should not be in use following their expiration date. Review of the Administering Medications policy directed medications must be administered in accordance with the orders, including any required time frame. The individual administering the medications must check the label THREE (3) times to verify the right medication, right dosage, right time, right method (route) of administration before giving the medication. The expiration date must be checked prior to administering. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on review of clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #213) who had physician orders for a compounded medication, the facility failed to ensure the medicaion was administered as ordered. Resident #213's diagnoses included protein calorie malnutrition, gastro-esophageal reflux disease (GERD) without esophagitis, and end stage renal disease. The admission MDS assessment dated [DATE] identified Resident #213 had intact cognition and was dependent for eating, oral hygiene, toileting, showering/bathing, and dressing. The Resident Care Plan dated 3/20/24 identified the resident has a nutritional problem or related to advanced age, therapeutic diet, mechanically altered diet, fluid restriction, food allergy, tube feeding supplementation diet, poor by mouth intake, increased nutritional needs. Interventions directed to monitor weight, skin, labs, and oral intake per protocol or as needed. The physician's orders for May/2024 (the origination date of the order was 3/21/24) identified an order for Lansoprazole oral suspension 3mg/ml with instructions to administer 10 ml via G-tube one time a day for GERD. Observation of the medication storage room on 6/8/24 at 6:59 AM identified Lansoprazole Suspension for Resident #213 with an expiration date of 4/30/24 written prominently on the bottle in black pen. This medication was discarded into the return to pharmacy by LPN #4 at this time. Review of Resident #213's MAR for May 2024 identified Lansoprazole Suspension was administered daily as ordered from 5/1/24 to 5/10/24. Review of the Point Click Care audit detail report for the Lansoprazole suspension for the month of May for Resident #213 identified the medication was clicked off administered on 5/8/24 at 8:07 AM by LPN #11, on 5/9/24 at 8:18 AM by LPN #11, and on 5/10/24 at 8:34 AM and struck out at 5/10/24 at 11:59 AM by LPN #3. Interview with LPN #3 on 5/10/24 at 11:56 AM identified she administered Lansoprazole oral suspension to Resident #213 on 5/10/24. When asked to locate the medication administered to the resident, LPN #3 checked the medication cart and the medication storage room, and the medication was not found. In addition, LPN #3 identified she must have made an error and had not administered the medication as ordered. She further noted that she was going to contact the pharmacy to get a refill of the Lansoprazole. Interview with the DNS on 5/10/24 at 12:50 PM identified she was aware of the medication not being administered but was signed for as administered. The DNS identified that medications not passed should not be signed for in the MAR. Review of the Administering Medications policy directed medications must be administered in accordance with the orders, including any required time frame. The individual administering the medications must check the label THREE (3) times to verify the right medication, right dosage, right time, right method (route) of administration before giving the medication. The expiration date must be checked prior to administering. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, facility policy and interviews for one of three sampled medication rooms the facility failed to store medications appropriately. The findings include: Observation on [DATE] at 6:44am of Station 4 medication room with LPN #4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx#10754244 for Resident #16 was stored that expired ,d+[DATE]. Observation on [DATE] at 6:50am of Station 4 medication room with LPN#4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx#10903962 for Resident #394 stored that expired ,d+[DATE]. Observation on [DATE] at 6:53 am of Station 4 medication room with LPN#4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx# 10754244 for Resident #16 was stored that expired ,d+[DATE]. Observation on [DATE] at 6:55am of Station 4 medication room with LPN#4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx# 10728345 stored that expired ,d+[DATE]. Observation on [DATE] at 6:57am of Station 4 medication room with LPN#4 identified Albuterol Sulfate inhalation 0.083% 2.5mg/3ml Rx#10445440 that expired ,d+[DATE]. Observation on [DATE] at 6:59am of Station 4 medication refrigerator with LPN#4 identified Lansoprazole suspension compounded medication 3mg/ml for Resident #213 that expired on [DATE]. Interview with LPN#4 on [DATE] at 7:00am identified the medications were indeed expired and that it was everyone's job to go through the medications regularly to see if they were expired, and that they should be sent back to pharmacy and placed in a red pharmacy return bin if they are expired. Review of the MAR for [DATE] on [DATE] identified Lansoprazole had been signed off administered to Resident #213 on [DATE]st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, and 10th of 2024. Interview with Pharmacist #1 on [DATE] at 12:11pm identified that efficacy following expiration date depends on what the medication is compounded with, this medication (Lansoprazole) was compounded with sterile water and sodium bicarbonate. It was last filled on [DATE] and is good for 14 days following the fill date. The medication would lose efficacy once expired. No further refills had been filled. There was none noted in the system to go out today [DATE]. No electronic refill request could be located once identified it was expired. The expectation is that the medication is only used until the expiration date, and that it should have been re-ordered for the resident and discarded after [DATE]. Once the medication is re-ordered the facility should have received it within 24 hours. Review of the medication storage policy directed the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, review of facility documentation, review of facility policy, and interviews, for 2 of 3 residents (Resident #42 and Resident #230) reviewed for infection surveillance, the facility failed to identify and maintain records of residents with known MDRO colonization and failed to appropriately cohort residents with a known MDRO colonization. The findings include: Resident #42's was admitted to the facility with diagnoses that included hemiplegia, MRSA, C-diff, aphasia, and gastrostomy. The quarterly MDS assessment dated [DATE] identified Resident #42 cognitive skills for daily decision making was severely impaired, required maximal assistance with toileting hygiene, bathing and dependent on care personal hygiene, transfers, and non-ambulatory. The care plan dated 4/15/24 identified Resident #42 had a history of MRSA and C-diff colonization with interventions that included: monitor for sign and symptom of C-diff and monitor or report to MD as needed for sign or symptom of MRSA infection every shift. A physician's order dated 4/25/24 directed for Enhance Barrier Precautions to be maintained at all times every shift for gastrostomy tube. Resident #230's was admitted to the facility with diagnoses that included type 2 diabetes mellitus, urinary tract infection, and acute posthemorrhagic anemia. The admission MDS assessment dated [DATE] identified Resident #230 had moderately impaired cognition, required maximal assistance with toileting hygiene, transfers, personal hygiene, dressing, and moderate assistance with mobility. A review of the care plan dated 3/26/24 for Resident #230 failed to identify any history of a MDRO colonization. Review of the Hospital Discharge Summary dated 3/5/24 identified Resident #230 had ESBL E.coli and was treated with the final day of therapy completed on the day of discharge. Review of the History and Physical progress note dated 3/6/24 written by MD #1 identified that Resident #260 hospital course for a diagnosis of ESBL E.coli-right pyelonephritis for which resident completed 4 days of meropenem (antibiotic). Observation on 5/6/24 at 12:00 PM identified that both Resident #42 and Resident #230 were presently sharing a room. Review of the facility's current Enhanced Barrier and MDRO log with the DNS and the Infection Preventionist Nurse (LPN #8) on 5/8/24 at 8:34 AM failed to identify that Resident #42 had a history/colonization of MRSA and C-diff, and that Resident #230 had a history/colonization of ESBL. Interview with the DNS and LPN #8 on 5/8/24 at 8:34 AM identified that Resident #42 did not use the bathroom, hence why Resident #230 was placed in the same room. The DNS then identified that Resident #230 had ESBL and both residents probably should not have been placed in the same room. The DNS further indicated that the bed board did not reflect the MDRO's history of Resident #42 and #230 and will update accordingly. They added that the admission cooperate nurse completed the bed board indicating the MDRO's, and the IP would be responsible for the MDRO's log. LPN #8 indicated that she started working as the IP nurse in September of 2023 and that she was responsible for updating the MDRO log. LPN #8 further added that it was the practice of the facility to update the MDRO log daily after reviewing: admission records, laboratory testing results, and after daily morning facility report. The DNS and LPN #8 added that they review hospital discharge summary, laboratory testing result and receives a thorough nurse-to-nurse report from hospitals and other acute care settings to obtain the resident's MDRO status. The DNS identified residents with the same infections should be cohort in the same room or with a resident that would be a low risk of acquiring the infection per the facility's policy. Review of the Multidrug-Resistant Organisms policy identified that the appropriate precautions will be taken when caring for residents with known or suspected to have a MDRO. The policy further identified that when single rooms are not available, cohort residents with the same MDRO in the same room, and if not possible cohort with a resident who was at low risk for acquisition of MDRO's and are likely to have a short length of stay.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #1) reviewed for modified consistency diets, the facility failed to supervise the resident in the dining room to ensure that the resident did not have access to food that was not on the resident's modified consistency diet resulting in a finding of Immediate Jeopardy. The Immediate Jeopardy was identified as corrected on [DATE]. The finding includes: Resident #1's diagnoses included dementia and dysphagia. The quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required supervision with ambulation and total dependence of one staff member for eating. The Resident Care Plan dated [DATE] identified the resident was at risk for choking related to history of choking with meals. Interventions included oral hygiene before and after meals, staff to feed, slow pace, ½ teaspoon bite and sip, alternate solids and liquids, honey thick liquids by ½ teaspoon. Resident is to always sit upright at 90 degrees and remain upright at 90 degrees for 45 minutes after meal. The physician's orders dated [DATE] directed regular pureed diet, honey thick consistency, and resident may be independent with rolling walker in dementia unit. A nurse's note dated [DATE] at 5:56 PM identified upon entering the patient's room the resident was observed with shallow breaths with positive peripheral pulse. At 5:11 PM the resident ceased respirations and no pulse was palpable. Cardiopulmonary Resuscitation (CPR) was initiated at 5:11 PM. Emergency Medical Service (EMS) arrived at 5:20 PM and took over care of the resident. Resident left the facility breathing with a pulse. The facility CPR documentation dated [DATE] identified that the code (emergency response/treatment) was started at 5:05 PM. At 5:05 PM, 911 was called and the resident's oxygen saturation (SpO2) was 95%. At 5:10 PM the resident's SpO2 was 60% and CPR was initiated. AED applied at approximately 5:15 PM and did not advise a shock. EMS arrived between 5:15 PM and 5:20 PM. EMS transported the patient to the hospital at 5:45 PM. Review of the ambulance run sheet dated [DATE] identified EMS received a call at 5:03 PM for a resident who was pale with shallow respirations. The resident was not supposed to have food but got food. CPR now in progress. EMS staff arrived at the patient's bedside at 5:19 PM and attempted to insert and endotracheal tube by direct laryngoscopy but they were unable to visualize the vocal cords. A video laryngoscope was used and a partial view of the vocal cords was observed along with a food bolus. A [NAME] was inserted between the vocal cords and an endotracheal tube was passed over the [NAME], through the vocal cords. Correct endotracheal tube placement was confirmed. The patient received 2 rounds of [MEDICATION(S)], circulation resumed and the patient was transported to the hospital. Review of the hospital record and discharge summary dated [DATE] identified the resident was unresponsive on admission secondary to cardiopulmonary arrest in the setting of aspiration event from eating non-pureed food and choking. At the time of admission the patient was also identified with no brainstem activity. It noted that EMS reported suctioning food products from the endotracheal tube. The resident was admitted to the ICU (Intensive Care Unit) on [DATE] and expired on [DATE]. Interview with RN #1 on [DATE] at 1:35 PM identified that she responded to a STAT (emergency summons) in Resident #1's room on [DATE] at approximately 5:00 PM. The nurse (LPN #1) reported to her that she suspected the resident may have eaten something and choked because the resident had a history of eating off other resident's trays and the resident was found unresponsive in the dining room with a tray of food. RN #1 identified when she arrived she found the resident with slow, shallow respirations, on a non-rebreather mask and the resident's oxygen saturation was 95% with a positive pulse. The resident's oxygen saturation dropped to 60% and the patient was noted without a pulse. CPR was initiated and when EMS arrived they assumed the care of the resident and she left the room to complete the discharge paperwork. Interview with NA #2 on [DATE] at 3:45 PM identified on [DATE] at approximately 5:00 PM she went into the dining room prior to the dinner trays being delivered to prepare the coffee cart. NA #1 found Resident #1 alone in the dining room pale, unresponsive, and limp in a chair at a table with a tray of regular food (not pureed) next to the resident. NA #1 identified it was another resident's lunch tray and the tray appeared to have been eaten from, although she could not determine by whom. NA #1 identified she called out for help and LPN #1 responded immediately and attempted the [MEDICATION(S)] but was unsuccessful. NA #3 responded and called a STAT. NA #2 and NA #3 assisted LPN #1 to transfer the resident to the resident's room and into bed. NA #1 identified the resident was still breathing when they transferred the resident into bed but the resident stopped breathing soon after, and the nurses initiated CPR. Interview with LPN #1 on [DATE] at 2:35 PM identified at approximately 4:00 PM she went in to the dining room to get juice and noted the dining room was empty, no meal trays on the table, and a small cart open on one side with dirty lunch trays in the room. LPN #1 identified at approximately 5:00 PM she was called to the dining room by NA #3 and found Resident #1 pale, leaning over in the chair, and unresponsive. LPN #1 saw the lunch tray with whole turkey next to the patient and immediately did the [MEDICATION(S)] because the patient had a history of choking and eating off of other resident's trays. LPN #1 identified the resident was still breathing but unresponsive so they transferred the resident to the resident's room to put her in bed. LPN #1 identified the resident was put on the non-rebreather mask and had a good oxygen saturation. The resident's lungs were suctioned but nothing came out. 911 was called and then the resident stopped breathing and had no pulse. The AED was applied and advised no shock. LPN #1 identified she put the backboard under the resident and CPR was initiated. When EMS arrived they intubated the resident after several attempts, and suctioned a brown substance out of the patient's endotracheal tube. LPN #1 identified she did not observe Resident #1 vomit. Interview with the DNS on [DATE] at 2:00 PM identified she was not aware that the resident may have choked until she received a call from the medical examiner's office on [DATE] requesting the resident's medical record. The DNS identified residents are not allowed in the dining room without supervision. The DNS identified that on [DATE] the staff was provided education to remove all dining carts and trays from the dining room and secure it in a locked room until they can be brought to the kitchen. Audits were initiated on [DATE] to ensure meal trays are not accessible to residents. Interview with the Medical Director on [DATE] at 3:50 PM identified that it is possible that the resident consumed food and choked. The facility did not have a policy for securing food. The facility began educating the staff on [DATE] to remove the tray carts from dining room after each meal, and staff to monitor residents who have an altered diet and have a history of taking food from the food truck. The facility began auditing the dietary carts on [DATE] to ensure tray carts are not left unattended in the dining room. All food stored in the dining room is secured in a locked refrigerator. The facility provided ongoing education to visitors to report to staff when bringing in food. The staff label and date the food and store it in the locked refrigerator in the dining room. Observations on [DATE] verified all food items were secure.

Based on clinical record review, facility documentation, and interviews for 1 of 3 resident's receiving specialized respiratory services (Resident #361), the facility failed to provide education on specialized respiratory equipment, complete respiratory assessments, follow physicians orders for ventilator settings resulting in a finding of immediate jeopardy. The findings include: Resident #361 was admitted to the facility on [DATE] at 12:00 PM with a [DIAGNOSES REDACTED]. An admission assessment date 2/2/17 identified that the resident was alert and oriented, required extensive assistance with Activities of Daily Living (ADL's), had a [MEDICAL CONDITION] and required oxygen. Review of physician's orders dated 2/2/17 directed to inflate the pilot balloon of the Trilogy machine (a machine that provides continuous or intermittent ventilator support) to 10 cubic centimeters (cc) when placing the resident on the machine, and to deflate the pilot balloon when removing the resident from Trilogy machine. The goal tidal volume should be set at 450, E-pap 5, respiratory rate 16, inspiratory pressure range 5-15 with oxygen at 40% at bedtime, The Trilogy machine may be used during the day as needed when the resident's oxygen saturation level was below 90% and to administer oxygen at 40% [MEDICAL CONDITION] when the trilogy machine is not in use. A care plan dated 2/3/17 identified that the resident had a [MEDICAL CONDITION] related to impaired breathing mechanics with interventions including to suction as ordered, administer respiratory treatments as ordered, have [MEDICAL CONDITION] consults as needed and to monitor for changes. A) Review of a nurses note dated 2/2/17 at 10:30pm written by Licensed Practical Nurse (LPN)#7 identified that the resident complained of shortness of breath, was suctioned twice, his/her head of bed was elevated, with oxygen saturations decreasing from 92%, 88% and then 60%, (normal oxygenation is between 90 and 100%). The resident identified that he/she was short of breath and anxious, the supervisor was notified and the resident was placed on the Trilogy machine with little effect. Subsequently, the resident was transferred to Hospital #1 at 10:30 PM. Review of nurses notes dated 2/3/17 at 1:13 AM written by RN#7 (Registered Nurse/Supervisor) for the resident's short of breath episode at 10:30pm identified that he/she was called to the resident's room for a report of a low pulse oxygenation level. Upon arrival, the resident was sitting at the edge of the bed, with increased anxiety, clenched fists, and an unrelaxed posture. The resident was motioning that he/she was not getting enough oxygen, the pulse oxygenation was ranging from low 60's to low 70's [MEDICAL CONDITION]. The resident was then switched to the Trilogy machine, the cuff was inflated with little effect on the oxygen saturations, and no effect on the resident's comfort level. The cuff pressure was adjusted down to 5 milliliters (ml) until oxygen saturation improved to the 80's, the cuff was titrated back up to 9 ml maintaining saturations in the 80's, the resident remained uncomfortable with no improvement of oxygen saturations. Resident #325 continued to have unstable oxygen saturations. Further review identified that 1:1 monitoring and cuff adjustments were maintained until emergency medical services arrived. Interview with RN#7 on 4/3/17 at 3:30 pm identified that he/she was the supervisor on 2/2/17 for the 3:00 to 11:00 PM shift, and although he/she had documented in his/her nurses note that he/she had decreased cuff pressure from 10 ml to 5 ml and then titrated the cuff pressure up to 9 ml (the physician's order directs the cuff pressure to be at 10 when the trilogy machine is in use), he/she had never touched the trilogy machine, because he/she had never seen the Trilogy machine and was not educated by the facility prior to the resident's arrival on 2/2/17 on how to operate the machine. RN#7 identified that it was LPN#7 who was titrating the cuff pressure. RN#7 further identified that he/she was asked to come in for an in-service on the machine on 2/3/17 at 2:30 PM (the day after the resident arrived at the facility, and the day after the resident was sent to the emergency department) by the Assistant Director of Nursing (ADNS), and stated that he/she was late and missed the in-service, and when he/she reported to work was told by the ADNS to google the information on the Trilogy machine. Interview with LPN#7 on 4/3/17 at 2:45 PM identified that he/she did not recall what happened on the evening of 2/2/17 with Resident #361, and/or if he/she was in-serviced on the Trilogy machine prior to the resident's arrival on 2/2/17, but could identify that he/she would not have touched the machine because he/she didn't know how to use it. Interview with the Respiratory therapist (RT) #1 on 4/4/17 at 11:30 AM identified that the trilogy machine is considered a non-invasive ventilator. Further interview identified that when the resident was connected to the Trilogy machine, this was the only way for the resident to maintain an airway. RT#1 identified that a nurse should not be adjusting the resident's cuff pressure, and the cuff should remain inflated to 10 ml while connected to the Trilogy machine. RT#1 further identified that if the cuff pressure if adjusted to 5 ml it would cause a cuff leak and cause the air pressure to go out through the mouth and not into the lungs, and cause the lungs to not be properly ventilated. Interview with Medical Doctor (MD) #7 on 4/5/17 at 10:00 AM (the facility pulmonologist) identified that the trilogy machine is a non-invasive ventilator. MD #7 indicated that he/she had given the facility the ventilator settings for Resident #364. Further interview identified that the resident had extreme respiratory impairment, dependent on a ventilator at home and his/her respiratory effort was insufficient mostly at night requiring the ventilator, but did require some daytime ventilation. MD#7 identified that he/she would prefer that it would be a respiratory therapist that would be titrating the cuff pressure, but as a general rule, the cuff pressure should not be adjusted and/or dropped because if there is not an appropriate seal in the airway, the air will be pushed out of the oral pharynx instead of the lungs, and the effectiveness of the ventilator would be much less. Interview with the Regional Clinical Manager (oxygen company #1) identified that the company had done in-servicing on the trilogy machine on 1/25/17 for the facility nursing staff. Further interview identified that the company was again called on 2/3/17 (the day after the resident arrived) by the facility to request an in-service on the Trilogy machine for additional nursing staff. Interview with the DNS on 4/5/17 at 2:30pm identified that he/she was unable to locate any in-service documentation and/or was not sure if LPN#7 and RN#7 had attended the in-servicing. Review of the user manual for the Trilogy machine identified that the machine provides continuous or intermittent ventilator support, and is a restricted medical device designed for use by respiratory therapists and/or other trained individuals. The resident was sent to Hospital #7 for evaluation and returned the on 2/3/17. B). Review of an intra-agency referral report from hospital #7 dated 2/3/17 directed the resident's ventilator oxygen to be set at 50% (previous setting 40%), and when the resident is off the ventilator, it directed to increase the oxygen to 50% (previous setting 40%) with [MEDICAL CONDITION]. Review of a nurse's note written on 2/3/17 at 6:08 PM identified that the resident had returned from the hospital at 2:30pm in the afternoon, and oxygen saturations were in the mid 80's to low 90's. Review of progress notes dated 2/3/17 written by (Advanced Practice Registered Nurse) APRN#7 identified that the evening before the resident had [MEDICAL CONDITION] and was sent to the emergency department, the resident was experiencing acute respiratory distress with [MEDICAL CONDITION], shortness of breath and tachypnea, therefore a call was placed to MD#7 (pulmonologist) and APRN#7 was advised to increase the pressure settings on the ventilator to 500 (previous setting 450) and to change inspiratory pressure range to 5-20 (previous setting 5-15). The progress note identified that these changes were discussed with the respiratory therapist, nursing and family, however, the physician's orders were not carried out by the facility. Review of nurse's notes dated 2/8/17 at 5:15am identified the resident was hooked up to the Trilogy Ventilator and started to complain of shortness of breath, appeared anxious, and had a pulse oxygenation of 66%, a heart rate of 132-138 (normal heart rate is 60-80 beats per minute), a respiratory rate of 28-32 per minute (normal respiratory rate would be between 12-20), and was suctioned for a small amount of secretions. A nebulizer treatment was given and saturations increased to 88%, the resident repeatedly requested to be transferred to the hospital. Further review identified that 911 was called and the resident was transferred to the hospital at 6:45 AM. Interview with APRN#7 on 4/5/17 1:45 PM identified that on 2/3/17 he/she was asked to evaluate the resident because he/she was having difficulty breathing. He/she contacted MD#7 and was told to increase settings on Resident #364's ventilator. APRN#7 identified that he/she did not write the recommendations in the physician's orders because it was discussed with the respiratory therapist and he/she had thought RT#2 had increased the settings on the ventilator. Interview with RT#2 on 4/5/17 at 2:15 PM identified that he/she was the respiratory therapist on duty on 2/3/17 and was not aware of the recommendations from the emergency roiagnom on [DATE] to increase the oxygen to 50% on the ventilator and/[MEDICAL CONDITION], RT#2 further identified that he/she had never used a Trilogy machine before, and had not adjusted the Trilogy machine settings on 2/3/17 per MD#7's recommendations because he/she was unaware of how to unlock the settings on the trilogy machine, but thought that the settings were locked and could only be unlocked by the oxygen company. Interview with the Regional Clinical Manager for Oxygen Company #1 on 4/6/17 at 9:45 AM identified that if changes in the ventilator settings are needed, the facility should have called the company, it would have been made a priority and someone would be out within a few hours, if not sooner. Furthermore, the company did not receive any calls from the facility to adjust the ventilator settings. Interview with MD #7 on 4/5/17 at 10:00 AM (pulmonologist) identified the recommendations made by the hospital on [DATE] to increase the oxygen and the recommendations to adjust the settings on the ventilator were ordered in an effort to better ventilate and improve oxygenation for the resident. C) Review of the medical record failed to identify the resident had been seen and/or assessed by the facility pulmonologist in accordance with facility policy and/or respiratory therapist until 2/6/17. Review of a respiratory therapy patient assessment form dated 2/2/17 identified the residents' demographics, diagnosis, and medical history were completed, however, lacked a respiratory assessment by the respiratory therapist. Further review of the respiratory flow sheets dated 2/6-2/8/17 identified that only a risk assessment was completed identifying the resident's risk for severe respiratory distress. A comprehensive assessment by the respiratory therapist was not completed until 2/6/17 (four days after admission). Interview with RT#1 on 4/5/17 at 3:00 PM identified when the resident arrived at the facility, he/she had made sure the suction was in the room and was close to the resident, and made sure the emergency supplies were in the room, but did not complete the respiratory assessment, and could not identify why it had not been done. RT#1 further stated he/she works Monday through Thursday on the 7:00 to 3:00 PM shift, and the resident was admitted on a Thursday afternoon, he/she was off the next day. Additionally, RT#1 identified that he/she had not completed the respiratory assessment form until 2/6/17, but dated it 2/2/17 because that was the date that the resident was admitted . RT#1 further identified the respiratory assessment should have been completed within the first few days of admission. Interview with the Administrator on 4/5/17 at 3:45 PM identified the facility had a respiratory program, although there are no guidelines that the facility follows this program, there are 4 pulmonologists connected with the program, 1 of them rounds every week in the facility. The facility also employs a full-time respiratory therapist Monday - Friday on the 7:00-3:00 PM shift, with coverage from the oxygen company #1 for emergencies. Further interview with the administrator identified that he/she assumed that the trilogy machine was a Bi-pap machine, however, the trilogy machine per manufacturers guidelines was being utilized as a ventilator for the resident. Review of the facility policy identified that residents who have a [DIAGNOSES REDACTED]. In addition, the respiratory therapist may be consulted by nursing to complete a respiratory screening. Subsequently, DPH requested and received an immediate action plan that identified that the facility would not admit any residents who required the use of the Trilogy machine. In addition, all licensed staff and respiratory therapy staff will be educated and competencies created for the use of the trilogy machine, non-invasive ventilation equipment and [MEDICAL CONDITION]/respiratory assessments.

Based on review of clinical records, review of facility documentation, review of facility policies, observations, and interviews, for four of eight residents reviewed for pressure ulcers, (Residents #12, #32, #46, and #251), the facility failed to ensure preventive measures were in place for a resident who was identified at risk for skin breakdown (Resident #251) and/or facility failed to follow a physician's orders [REDACTED].# 12) and/or failed ensure that care to the pressure ulcer was completed promptly when the resident was found to be incontinent of stool (Resident #32) and/or failed to ensure that wound care to the resident's pressure ulcer was provided in a manner to promote healing (Resident #46). The findings include: 1. Resident #251 (R #251) had [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified that R #251 required extensive assistance with transfer, extensive assistance with bed mobility, and was totally dependent on staff for dressing, toilet use and personal hygiene. The Braden scale assessment dated [DATE], identified R #251 had a score of sixteen, indicative of moderate risk for pressure ulcer development. The admission nursing assessment further identified that R #251's skin was intact at the time of admission. The care plan dated 2/17/16 identified that R #251 had limited physical mobility related to difficulty with standing with interventions that included Hoyer lift transfers, to provide supportive care and assistance with mobility as needed. R #251's care plan was revised on 2/24/16 and indicated that the resident now had an alteration in skin integrity related to a Stage II left lateral heel wound, a Stage II medial heel wound, and a Stage II right heel wound. Interventions included to provide heel lift boots while in the wheelchair, a low air loss mattress per manufacturer settings, and to off load bilateral heels while in bed. Interview with RN #2 on 3/3/16 at 8:40AM indicated that R #251's Braden scale on admission identified that R #251 was at risk for skin breakdown and therefore, a turn and reposition order and an order to off load heels should have been in place. Review of the clinical record lacked documentation to reflect that interventions were consistently in place and/or implemented prior to the resident's development of three Stage II pressure ulcers. RN #2 indicated that an order for [REDACTED]. Interview with the ICN on 3/3/16 at 8:10 AM indicated that upon admission, R #251 was identified through assessment to be at risk for breakdown and therefore interventions should have been in place to prevent breakdown. 2. Resident #12 (R #12) had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that R #12 had a BIMs score of three out of fifteen, indicative of severe cognitive impairment, and required extensive assistance by one person for all dressing which included how the resident put on, fastens, and takes off all items of clothing. Review of R #12's clinical record identified a nursing weekly skin assessment dated [DATE] which identified that the resident's skin was intact. A nursing note dated 2/29/16 at 8:42 AM identified that a new pressure ulcer was discovered during morning care and was located at the right great toe. The area was described as an intact blister and measured at 2.0 cm by 3.0 cm. The nursing note further identified that R #12 had discomfort when the area was palpated, though no drainage was noted. The Infection Control Nurse (ICN) nurse was contacted and measured the wound on 2/29/16. The newly identified pressure area to R #12's right great toe was measured at 1.3 cm x 1.6 cm and classified as a Stage I pressure area. The physician was notified and subsequent orders dated 2/29/16 directed nursing staff to apply skin prep to the right great toe every day for seven days, apply a blanket cradle to the resident's bed, and that no shoes were to be worn until further notice. In addition, a podiatry consult was ordered for a new shoe fitting for R#12. Review of R #12's Care Plan dated 3/1/16 directed nursing staff to have the resident wear non-skid socks at all times and that no shoes be worn until further notice. Review of facility documentation which included the nursing twenty four hour report on 3/1/16 and 3/2/16 identified that R #12 was not to wear shoes. Observation of R#12 on 3/2/16 at 9:30 AM observed the resident seated in his/her wheelchair. R #12 was wearing shoes on both feet. Interview with LPN #1 at the time of the observation identified that he/she was unaware that R#12 had a current pressure ulcer and was never informed that R#12 had any pressure areas. Interview with the ICN nurse during the time of the observation stated that R #12 had a pressure ulcer on the right great toe and R#12 should not be wearing shoes. Subsequent to surveyor inquiry, R #12's shoes were removed. Observation of the great right toe with the ICN nurse on 3/2/16 identified a large, reddened area on the right great toe. Non-skid socks were placed on the resident's feet following the observation. 3. Resident #32 (R #32) had [DIAGNOSES REDACTED]. Review of the clinical record including the care plan dated 12/4/15, identified that R #32 had developed a community acquired, unstageable sacral wound and a facility acquired Stage IV right ischium pressure ulcer with interventions that included to provide a pressure relieving mattress and treatment per physician orders. Review of the annual MDS assessment dated [DATE] identified that R #32 had severe cognitive impairment, required extensive assistance for bed mobility and was totally dependent on staff for all other activities of daily living. In addition, the MDS assessment identified that R #32 had an indwelling urinary catheter and was always incontinent of stool. Review of the wound care progress notes dated 2/23/16 identified that R #32 had an unstageable 3.5 cm by 4.0 cm by 1.2 cm sacral pressure ulcer and a Stage IV pressure ulcer on the right ischial that measured 2.3 cm by 3.0 cm. by 1.5 cm. Physician orders [REDACTED].#32's pressure ulcers to include cleansing of both areas with normal saline, to apply skin prep to the periwound area, followed by loosely applied silver alginate to the wound bed, and to cover the wounds with bordered foam gauze. On 3/2/16 at 9:55 AM, the surveyor requested to observe R #32's dressing on the sacral and right ischial wounds. Upon repositioning of the resident by Nursing Assistant #5 (NA#5) and NA #6 at 10:01 AM, the resident was found to be incontinent of a large amount of soft stool. NA #5 and NA #6 proceeded to provide incontinent care and in the process, identified that R #32's dressing on the sacral wound was moderately soiled with stool that had seeped beneath the dressing and that the dressing on the resident's right ischial wound had completely dislodged. At 10:10 AM, NA # 6 left the resident's room stating that he/she was going to let the nurse (LPN #3) know about the resident's dressing. Upon NA #6's return to the room within two minutes, NA #6 stated that LPN #3 told him/her that he/she was doing the medication pass and that he/she would come in and do the dressing later. Interview with NA #6 at that time identified that NA #6 reported to LPN #3 that R #32's dressing was not clean. NA #5 and #6 continued to complete R #32's incontinent care. NA #6 left the room again for less than one minute and upon return, stated that he/she again let LPN #3 know that the reisdent's dressing was not clean. Observation of LPN #3 from 10:20 AM to 11:00 AM identified that LPN #3 continued to pass medications and did not enter R #32's room to check on the reported soiled dressing. At 11:00 AM, the surveyor approached the Unit Manager and Infection Control Nurse (ICN) to report the incident. Subsequent to surveyor inquiry, the Unit Manager and ICN went to the resident's room, The resident was observed to have the same soiled dressing on the sacral area and the dislodged right ischial dressing had not been replaced. The Unit Manager and ICN subsequently provided care to the resident's pressure ulcers. Multiple attempts to interview LPN #3 on 3/2 and 3/3/16 were made. Interview with the ICN on 3/3/16 at 2:00 PM identified that he/she questioned LPN #3 as to why he/she did not respond to NA #6's report regarding R #32's soiled dressing. The ICN stated that LPN #3 indicated that NA #6 only reported that the resident had been incontinent. 4. Resident #46 (R #46) had [DIAGNOSES REDACTED]. Review of the Braden Scale (assessment used to identify the resident's risk for developing pressure ulcers) dated 10/5/15 identified that R #46 was at low risk for pressure ulcers. Review of the clinical record including the care plan dated 12/4/15 identified that R #46 developed an unstageable left heel pressure ulcer with interventions that included to provide a pressure relieving mattress and treatment to the pressure ulcer including skin prep daily and to off load heels. Review of the wound care progress notes dated 12/30/15 identified that R #46 had an unstageable left heel ulcer that measured 2.0 centimeters (cm) by 4.0 cm by 0.1 cm in depth. The wound care documentation identified that the wound presented with 100% eschar with no signs of infection. Review of the quarterly MDS assessment dated [DATE] identified that R #46 had a BIMs score of fifteen out of fifteen, indicative of intact cognition and required extensive assistance for bed mobility, transfers, and personal hygiene. Physician orders [REDACTED]. Review of the wound care progress notes dated 2/26/16 identified that R #46 had an unstageable left heel ulcer that measured 0.6 cm by 1.3 cm by 0.2 cm in depth. The wound care documentation identified that the wound now presented with 50% slough, 50% granulation, and moderate serous drainage with no current signs of infection. Observation of R #46's dressing change on 3/2/16 at 9:10 AM identified that R #46 was sitting up in a wheelchair and requested not to be returned to bed to have his/her dressing changed. Based on the location of the wound and the resident's position, LPN #2 was unable to visualize the wound, attempted to retrieve a mirror used for that purpose though was unable to locate it, and so instead used the resident's personal mirror. LPN #2 placed the mirror directly on the floor. The mirror was observed to be covered with a light film and smudged fingerprints with crumbs and debris stuck to the glass. LPN #2 proceeded to place a plastic bag on the floor next to R #46's left foot and paper towels retrieved from the resident's bathroom were placed under the resident's left foot. LPN #2 applied gloves and removed the resident's dressing. An approximate 3.0 cm circle of serosanguineous drainage was present on the removed dressing. Without the benefit of washing his/her hands, LPN #2 removed the soiled gloves, applied a second pair of gloves, and proceeded to cleanse the resident's open wound with normal saline and applied skin prep around the perimeter of the wound while holding the soiled mirror in his/her gloved left hand. Although LPN #2 attempted to discard the saline soaked gauze used to cleanse R #46's wound into the plastic trash bag on the floor, one of the gauze pieces landed on the paper towels that had been placed under R #46's left foot. LPN #2 returned the mirror to the floor, stood up, and went back to the treatment cart where without the benefit of washing his/her hands, applied another set of gloves. During that time, R #46 stated, It's hard to hold my foot up and was observed to rest his/her uncovered left foot on the paper towels where the gauze used to cleanse his/her foot had been inadvertently discarded. LPN #2 returned from the treatment cart after applying silversorb to a clean gauze, dabbed the ointment on the wound, and applied a covered dressing. LPN #2 then gathered the paper towels, discarded all materials into the plastic bag, and removed the bag and mirror from the floor. Interview with LPN #2 on 3/2/15 at 11:15 AM identified that although hand sanitizer was not kept directly on the treatment cart, hand sanitizer was available on the wall in the resident's room. LPN #2 stated that although he/she usually washed his/her hands between glove changes, he/she could not explain why he/she had not done so during the treatment to R #46's left heel pressure area. Review of the Facility's Licensed Practical Nurses Job responsibility directed in part that the LPN ensures that the resident's care plan is appropriately implemented by all parties. Review of the Certified Nursing Assistant Job responsibility directed in part that CNA's should observe the residents and reports to the charge nurse immediately if any unusual conditions, accidents, and/or incidents occur. Review of facility policy on pressure ulcers directed in part that residents with an actual pressure ulcer will have a care plan implemented that documents an interdisciplinary approach as well as following facility protocols and appropriate preventive measures. In addition, the policy directed that the licensed nurse was responsible for administering treatments and to ensure that all resident dressings were in place during the shift worked. The policy further directed that the nursing assistants were responsible for reporting missing dressings immediately to the charge nurse and that the licensed nurse was responsible for replacing the dressing if soiled, loose, or falls off.

Based on a review of clinical records, facility documentation, staff interviews, and review of facility policies and procedures, for two of four sampled residents (Resident #60 and #400) who were reviewed for medication administration, the facility failed to ensure the resident was free from a significant medication error. The findings include: 1. Review of the clinical record identified Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] identified the resident had severely impaired cognition. Review of facility documentation dated 12/16/14 identified at 8:00 AM, LPN #2 administered medications that were ordered for another resident. The medications Resident #60 received on 12/16/14 at 8:00 AM in error included; [MEDICATION NAME] 100 mg po, Klonopin 0.25 mg po, [MEDICATION NAME] 5 mg po, [MEDICATION NAME] 40 mg po, [MEDICATION NAME] 40 mg po, [MEDICATION NAME] 250 mg po, Cialis 5 mg po, Vesticare 10 mg po, Vitamin C 100 mg po and Senna 8.6 mg po instead of the routine medications that were prescribed for 8:00 AM. Resident #60's blood pressure was 156/81 mm/hg at 8:00AM and decreased to 110/58 at 10:00 AM. At that time, the resident was lethargic with general weakness and was transferred to an acute care hospital for evaluation at approximately 10:15 AM. Review of the hospital documentation dated 12/16/14 identified Resident #60 was examined, blood work was obtained and s/he was monitored via telemetry and sent back to the facility on [DATE]. Interview with LPN #2 on 3/16/15 at 2:00 PM indicated she checked the medications that she poured into the medicine cup with the Medication Administration Record [REDACTED]. LPN #2 identified she realized she made an error when she looked at the room number and it did not match the room number on the MAR. Interview with the Director of Nursing on 3/16/15 at 3:00 PM indicated LPN #2 failed to follow the five rights of medication administration which resulted in a medication error. The facility policy entitled, Medication Administration, directed in part to prepare medication dosage as stated on the MAR following standard nursing practice. The policy directed that the nurse would check the medication against the medication sheet for dosage, time, route, medication and patient before preparing, after preparing and prior to the administration of the medication. Further review of the policy indicated the nurse would identify the resident by asking his/her name and checking the identification bracelet. 2. Resident #400's [DIAGNOSES REDACTED]. The Admission Record identified that Resident #400 was admitted on [DATE]. The hospital discharge summary identified that on 3/7/15 Resident #400's Sodium level was 138 (normal range 137-144) and the Potassium level was 4.5 (normal range 3.6-5.1). The physician's orders [REDACTED]. A physician's orders [REDACTED]. The laboratory report dated 3/12/15 identified that the resident's Sodium level was 136 and the Potassium 5.3. The Advanced Practice Registered Nurse (APRN) note dated 3/13/15 identified mild [MEDICAL CONDITION] and the plan was to decrease the potassium supplement to 20 mEq daily. A physician's orders [REDACTED]. The laboratory report dated 3/16/15 identified the blood specimen collected at 6:30 AM indicated a Sodium level of 131 and the Potassium level of 6.8. The APRN progress note dated 3/16/15 identified that Resident #400 was seen due to critical blood work values. A physician's orders [REDACTED]. sound and intravenous fluids 5% [MEDICATION NAME] with Normal Saline at 80 cubic centimeters per hour times four liters. The laboratory report dated 3/16/15 specimen collected at 3:30 PM identified a Potassium level of 7.3. The nurse's note dated 3/16/15 at 10:13 PM identified that the repeat Potassium level was 7.3 and subsequent to notification the APRN directed to transfer Resident #400 to the hospital. The Reportable Event Form dated 3/20/15 identified that on 3/16/15 at 10:00 AM a medication error was identified. The investigation identified that the orders to decrease the Potassium from 40 mEq to 20 mEq a day and decrease the [MEDICATION NAME] 40 mEq from twice a day to once a day were transcribed incorrectly. In a written statement the charge nurse Licensed Practical Nurse (LPN) #7 identified that she had received the new orders from the APRN to decrease the Potassium on 3/13/15. LPN #7 indicated in the statement that she did not discontinue the previous order for Potassium 40 mEq. Review of the March 2015 Medication Administration Record [REDACTED]. The hospital discharge summary dated 3/20/15 identified that Resident #400 had been admitted on [DATE] to the intensive care unit for acute kidney injury with a creatinine of 2.4 usual baseline was 0.8-1.1 and [MEDICAL CONDITION] potassium level was 6.9 on admission. In the Emergency Department (ED) the resident received [MEDICATION NAME] and Insulin. Interview with the Regional Corporate Registered Nurse on 3/30/15 at 9:20 AM identified that LPN #7 was suspended and then terminated at the conclusion of the investigation. Interview with the Director of Nurse on 3/30/15 at 9:50 AM identified that one of the unit nurses picked up on the error on 3/16/15 when LPN #7 was off that day. Subsequent to the 3/16/15 incident the licensed nurses were inserviced regarding the policy on medication transcription.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #7) who exhibited an inappropriate behavior towards other residents, the facility failed to monitor and/or provide the necessary supervision to prevent sexual abuse. The findings include: Resident #7's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #7 had severe cognitive impairment, wandered daily, exhibited behavioral symptoms not directed towards others, e.g. disrobing, pacing, public sexual acts, required limited assistance with ambulating and utilized a walker for mobility. The resident care plan dated 12/19/13 identified that Resident #7 was at risk for wandering with an intervention to utilize a wander guard. The revised care plan dated 12/20/13 indicated that Resident #7 had episodes of inappropriate behavior with male residents on 6/3/13, 7/15/13, 12/8/13 and 12/20/13. Interventions directed thirty minute checks, psychiatry follow up, close observation when sleeping, to monitor the resident and male peers during programs and while in close physical proximity to each other and monitor for changes in mood and/or behaviors. A physician's orders [REDACTED]. Review of the Behavior and Intervention Monthly Flow Record from 12/30/13 through 3/17/14 identified Resident #7's targeted behaviors were inappropriate social behaviors and intrusive. Episodes occurred monthly from three occasions to twelve occasions. The nurse's progress note dated 3/7/14 at 6:38 AM identified that at 3:00 AM Resident #7 was redirected from a male resident. The psychiatric note dated 3/7/14 identified Resident #7 had increased pacing at night and confusion with a subsequent increase in the medication [MEDICATION NAME]. The Advanced Practice Registered Nurse (APRN) progress note dated 3/10/14 identified Resident #7 was seen to evaluate medication change status [REDACTED]. Review of the March 2014 Behavior and Intervention Monthly Flow Record from 3/1/14 through 3/17/14 identified five incidents of inappropriate social behavior in which Resident #7 was redirected. The nurse's progress note dated 3/17/14 at 6:00 PM identified Resident #7 had brought another resident (Resident #10) to his/her room, removed the resident's pants as well as his/her own pants and proceeded to kiss and fondle Resident #10 in an inappropriate sexual manner. Resident #7 stopped when discovered by the Nurse Aide (NA). One to one observations were initiated and subsequently Resident #7 was transferred to the hospital for an evaluation. Upon further review, the clinical record identified that Resident #7 had made inappropriate sexual advances towards Resident #10 in the past, most recently in December 2013. Review of Resident #10's clinical record identified that Resident #10 had severe cognitive impairment. The hospital discharge summary dated 3/25/14 identified Resident #7 had a [DIAGNOSES REDACTED]. Interview with NA #5 on 12/10/14 at 11:45 AM identified that he was the 3-11 PM hall monitor and was responsible for keeping Resident #7 in the dining room and preventing the resident from sneaking out. NA #5 indicated that Resident #7 would regularly get up, approach residents and try to hug and kiss them. NA #5 identified that this behavior continually occurred over the past year, one to two times a week. NA #5 state that he would immediately attempt to intervene and Resident #7 had been sexually inappropriate to NA #5 especially when he took the resident to the bathroom. NA #5 identified that on 3/17/14 he was the hall monitor and he does not know how Resident #7 was able to get past him and leave the dining room. When NA #5 started to look for Resident #7 he first looked in Resident #10's room because Resident #7 was always approaching Resident #10. NA #5 found Resident #7 and Resident #10 in Resident #7's room. Resident #7 was undressed and inappropriately touching Resident #10. Resident #10 was noted to have a sad and fearful look. NA #5 called out for the nurse who came into the room and separated the residents. Interview with the Unit Manager Registered Nurse (RN) #1 on 12/10/14 at 10:40 AM identified that the staff attempted to provide one to one monitoring but it was very difficult. Staff would try to keep Resident #7 in the dining room during the day and involved with recreation. However, Resident #7 was very sneaky, would attempt to leave and staff would follow. Resident #7 continued to approach the male residents and staff would redirect. Interview and review of the resident care plan with the Director of Nurses (DON) and the Director of Clinical Operations on 12/15/14 at 12:10 PM identified that at the time of the 3/17/14 incident the care plan directed that Resident #7 be on close supervision outside room when sleeping and every thirty minute checks. However, review of the physician orders [REDACTED]. Review of the Behavior Monitoring documentation with the DON and the Director of Clinical Operations identified inappropriate social behavior as a target behavior for Resident #7 and five instances were documented from 3/1/2014 through 3/17/14. However, on interview they could not define what this meant and failed to identify that there were subsequent revisions to the care plan. b. The behavioral health follow-up dated 10/24/14 identified Resident #7 had poor impulsive control however was behaviorally stable since 9/3/14 and recommended the discontinuation of the thirty minute checks. The nurse's progress note dated 11/6/14 at 6:13 AM identified a nurse aide reported to the charge nurse that she witnessed Resident #7 standing at the bedside of a resident, Resident #21 and displayed inappropriate contact with the resident's breast. Subsequent to the 11/6/14 incident a physician's orders [REDACTED]. The psychiatric progress note dated 11/11/14 identified Resident #7 with sexual disinhibition, poor impulse control and exhibits predatory behavior. Review of the nurse aide care card revised 11/17/14 directed every 30 minute checks and the monitoring of behaviors and re-direction when needed. Redirect resident if seen with Resident #10. Interview with NA #6 on 12/10/14 at 12:00 PM identified that during rounds on 11/6/14 she went to check on Resident#7 and observed the roommate Resident #21 completely naked. Resident #7 was inappropriately fondling Resident #21's breasts. NA #6 indicated that the staff attempt to constantly monitor Resident #7 but it was often impossible. During the night there was limited staff and they could not monitor the resident all the time. Resident #7 would wander into other resident rooms. NA #6 identified that when Resident #7 was awake the resident must be watched at all times. Interview with the psychiatrist on 12/12/14 at 2:30 PM identified that Resident #7 had a [MEDICAL CONDITION] that resulted in poor impulse control and was difficult to manage. Resident #7 was sexually disinhibited and could not be treated with medication alone. Resident #7 appeared to be stable and then the behavior would increase again. There must be a combination of the right environment and medication. The psychiatrist further identified that Resident #7 required one to one observations to ensure the safety of the residents on the unit and the resident should be placed in a facility with less vulnerable residents. Review of facility policy identifies that all residents of the facility have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

1. Based on clinical record review, interviews, and review of facility investigative reports for two (R#6 and R#7) of three residents reviewed for incidents of resident to resident abuse, the facility failed to provide supervision for a resident who had assaulted another resident resulting in harm, and failed to protect the resident who was assaulted from further assaults. The findings include: R#6's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified that R#6 had moderately impaired cognition, was short tempered, and easily annoyed. The MDS further identified that R#6 required supervision for transfers and ambulation. Review of the resident care plan dated 5/6/13 identified R#6 as resistive to care related to dementia with interventions to give clear explanations and praise when behavior is appropriate. R#6 resided in the same room as R#7. R#7's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified that R#7 had severe cognitive impairment and required extensive physical assistance by two persons for bed mobility. The resident care plan dated 5/10/13 identified R #7 with impaired cognition with interventions that included to provide consistent care givers to decrease confusion and assist with all decision making. Review of a facility investigation dated 5/16/13 identified that on 5/15/13 at approximately 11:00 PM, NA #3 responded to a call light coming from R#6's and R#7's room. When NA #3 entered the room, the NA observed a pillow and blanket covering the face of R#7 and removed them. NA #3 asked R#6 what happened and R#6 responded that he/she was trying to quiet the "dog" because he/she wanted to sleep. NA#3 left the room to get a nurse, leaving R#6 at the bedroom doorway and R #7 unsupervised in the bed. NA#3 went down the hall to alert LPN #1 about the incident. When NA#3 and LPN#1 returned to the room, LPN#1 observed that R#6 had again covered R#7's head with a pillow and removed it. The supervisor was contacted, R#7 was moved to another room, and R#6 was placed on one to one observation. R#7 was examined by the charge nurse who noted multiple reddened areas on both cheeks and the forehead. R#6 was transported to an acute care hospital, evaluated, determined that he/she was not a threat to self or others, and returned to the facility with no new orders. Review of R#7's medical progress note by APRN #1 dated 5/16/13 identified that R#7 was reported to have trauma to the face after another resident put a pillow over R#7's face. APRN#1 examined R#7 and noted ecchymosis and petechiae secondary to trauma. Interview with NA#3 on 7/12/13 at 10:45 AM identified that he/she responded to R#7's "touch "alarm at approximately 11:00 PM. NA#3 stated that R#7 was not capable of using a standard alarm and the touch alarm was very sensitive and would alarm when touched by a pillow or sheet. When NA#3 entered the room he/she observed that R #7's face was covered by a pillow and blanket. NA#3 stated that he/she removed the blanket and pillow form R#7's face and went out into the hallway with R#6. However, NA#3 stated that he/she left R#6 in the hallway and rushed to get the nurse who was in the medication room. NA#3 stated that when he/she and LPN#1 returned to the room, LPN#1 observed that R#7's head was covered again with a sheet/pillow. Interview with LPN#1 on 7/11/13 at 12:35 PM identified that when he/she entered the bedroom, R#7's face was again covered by a pillow and possibly a sheet as well. Interview and review of the facility documentation with the Director of Nursing on 7/11/13 at 3:40 PM identified that initially staff reported that R#6 was able to be viewed from the corridor when NA#3 left to get a nurse. However, subsequent to facility investigation it was noted that R#6 was left unattended and not in the line of vision of any staff member. Subsequently, NA#3 and all other staff members were counseled and/or reeducated regarding leaving an assaultive resident unattended. 2. Based on clinical record review, interviews, and review of facility investigative reports for two (R#4 and R#5) of three residents reviewed for elopement, failed to accurately assess and closely monitor a resident to prevent an elopement, and failed to ensure that the care plan was updated to include the resident's noncompliance with safety measures. The findings include: a. R#4's [DIAGNOSES REDACTED]. The admission elopement assessment dated [DATE] identified R#4 as a low risk for wandering. Review of nurse's notes dated 6/28/13 identified that at 7:00 PM the charge nurse was notified that R#4 was not in his/her room and the wheelchair alarm was sounding. The rooms and surrounding areas were searched and R#4 could not be located. The police were contacted and with the assistance of the canine unit, the resident was located in a wooded area up the street from the facility 1.5 hours later. A body audit dated 6/29/13 identified R#4 sustained a left lateral knee abrasion, a right upper heel abrasion and bilateral upper extremity purpura. R#4 was transferred to another unit, a wanderguard was placed on R#4, and every fifteen minute checks were initiated. Interview with NA#1 on 7/8/13 at 2:10 PM identified that R#4's family had visited around dinner. At approximately 6:45 PM, NA#1 picked up R#4's dinner tray and he/she was sitting in a wheelchair in the room. At 7:00 PM, the chair alarm sounded and when NA#1 responded to the alarm, R#4 was not in the room. NA#1 searched the immediate area, could not locate R#4 and reported this to the charge nurse. The charge nurse directed NA#1 to check the first and second floors, then check outside of the building to try and locate R#4. NA#1 returned to the unit around 7:30 PM without finding R#4. At approximately 7:30 PM, a Dr. Hunt was initiated. Interview with the Nursing Supervisor on 7/8/13 at 3:00 PM identified that he/she was notified that R#4 was missing at 7:30 PM and at that time the Dr. Hunt was initiated. Interview with the Charge nurse on 7/9/13 at 1:30 PM identified that he/she was alerted that R#4 was missing at 7:00 PM. At that time he/she searched the nearby rooms, the front lobby, passed the offices and checked the gazebo. On the way back to the nurse's station he/she passed the supervisor and alerted him/her but then went back to the unit to call the family. The Charge Nurse called both the daughter and son and determined that R#4 was not with them. The Supervisor was contacted again and informed that R#4 still could not be located. Interview with the a member of the local police department on 7/10/13 at 10:00 AM identified that they were notified at 7:38 PM that a resident was missing. Interview with the Director of Nursing on 7/8/13 at 2:00 PM identified that when a resident could not be notified, the expectation was to immediately check the unit, and if the resident is still missing, a Dr. Hunt should be initiated. Review of a facility policy directed that when a resident is missing, search the room, bathroom and unit. If the resident is not found, an announcement for Dr. Hunt should be paged and repeated three times. b. R#5' s [DIAGNOSES REDACTED]. A clinical assessment dated [DATE] identified R#5 as requiring limited assistance with transfers and ambulation, was alert, oriented to person and verbally appropriate. A wandering risk evaluation (WRE) dated 6/8/13 identified R#5 as a moderate risk and a repeat WRE dated 6/18/13 identified R#5 as a low risk to wander. Review of the resident care plan dated 6/11/13 identified R#5 as a high risk for falls related to lack of awareness of safety needs, confusion, gait and balance issues, and a history of falls. The care plan identified potential cognitive issues related to Hepatic [DIAGNOSES REDACTED] with interventions to anticipate needs and monitor for periods of lethargy. Review of the physician orders [REDACTED].#5 required an assist of one for transfers and ambulation with a rolling walker. Review of nurse's notes dated 7/6/13 identified that R#5 left the facility unescorted. A search of the facility and grounds was initiated and the resident was located down the street. Review of the facility investigation identified that NA#4 had assisted the resident into his/her wheelchair at 2:10 PM and the chair alarm was functioning. At approximately 2:15 PM the nurse aide returned to check on R#5 and discovered that R#5 was not there and the chair alarm had been turned off. NA#4 could not locate the resident and a search was initiated. Interview with LPN#3 on 7/9/13 at 2:30 PM and NA#2 on 7/9/13 at 2:15 PM identified that R#5 was alert and oriented and had a history of [REDACTED]. Interview with NA#4 on 7/11/13 at 3:30 PM identified that R#5 had been non-compliant with the chair alarm all day. Interview and review of the clinical record with the DNS on 7/9/13 at 2:30 PM identified that the chair alarm had been placed as a reminder for the resident not to ambulate without supervision. However, the care plan had not been revised to reflect R#5's noncompliance with the use of the chair alarm. In addition, R#5's wandering risk assessments dated 6/18/13 was reviewed and identified as inaccurate because the use of anti-depressants and anti-psychotics had not been included. The inclusion of the antidepressants and antipsychotics would have identified R#5 as a moderate fall risk. 3. Based on clinical record review, interviews, and review of facility investigative reports for one (R#8) of three residents reviewed for accidents the facility failed to position the resident safely to prevent a fall. The findings include: R#8's [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] identified severely impaired cognition and required extensive two person assist for bed mobility. The resident care plan dated 3/14/13 identified R#8 with impaired mobility with need for assistance with transfers related to decreased strength and endurance and impaired cognition. Interventions included the use of an adaptive wheelchair, encourage resident to get out of bed every day, reposition for comfort, half side-rails for bed mobility, and check every shift for safety. Review of a facility investigation dated 4/28/13 identified that at 8:00 AM, NA#5 lowered R#8's side rail and then turned to get an item from the closet while the bed was in the high position. At that time, R#8 rolled off the bed onto the floor. Review of nurse's notes dated 4/28/13 identified R#8 sustained three abrasions to the nose, one on the left eyebrow and blood was on the floor. R#8 was transferred to an acute care hospital and returned with a [DIAGNOSES REDACTED]. Interview with RN#6 on 7/12/13 at 12:30 PM identified that on the morning of 4/28/13, he/she was called to R#8's room and observed R#8 lying on the floor bleeding from the face. A dressing was applied to stop the bleeding, 911 was called and the resident was transferred to an acute care hospital. NA#5 reported to RN#6 that he/she had turned around and the resident rolled off the bed. RN#6 stated that he/she observed that the bed was in the high position and the siderails were down. Subsequent to the event NA#5 received corrective counseling regarding providing a safe environment during care. NA#5 was unable to be interviewed. 4. Based on observation and interviews, the facility failed to provide safe storage of medications. The findings include: On 7/2/13 at 8:35 AM, surveyor observation in the hallway of Station 1, identified numerous medications left unattended on top of the medication cart. R#3 was sitting in a wheelchair close to the medication cart. R#3's [DIAGNOSES REDACTED]. The medications observed were the following: Allopurinal 100 mg, Norvasc 10 mg, Aspirin 81 mg, Calcium with Vitamin D 600-400 mg, Docazosin Mesylate 2 mg, Fenofibrate 200 mg, Lasix 20 mg, Glipizide 10 mg, Lamotrizen 50 mg, Vitamin C 500 mg, and Magnesium 400 mg. Interview with RN#1 on 7/2/13 at 1:30 PM identified that he/she was aware that the medications should not have been left unattended, but he/she needed to answer the phone immediately. Interview with the Director of Nursing on 7/2/13 at 2:00 PM identified that RN#1 has been educated regarding the practice of leaving medications unattended. Review of facility policy directs that medications are not to be left on top of an unattended medication cart.

Based on clinical record review, observation, interview and review of facility policy for one of three (Resident# 360) sampled residents reviewed for pressure ulcers, the clinical record lacked comprehensive assessments of a pressure ulcer. The finding includes: Resident#360 [DIAGNOSES REDACTED].The hospital discharge summary dated 1/4/13 identified a left buttock pressure ulcer measuring 0.5cm by 0.5cm with a depth less than 0.25cm and a coccyx pressure ulcer 0.5cm by 0.2cm with a depth less than 0.25cm.The physician orders [REDACTED]. The 30 day Minimum Data Set assessment dated [DATE] identified moderately impaired cognition, required extensive assistance with bed mobility, transfers, was frequently incontinent of stool and was free of pressure ulcers. The care plan initiated 1/23/13 identified a potential for pressure ulcer development due to immobility with interventions which included to administer treatments as ordered, monitor for effectiveness and to follow facility protocol for the prevention and treatment of [REDACTED]. The nursing admission assessment dated [DATE] identified abrasion like areas to bilateral buttocks and no pressure areas. A review of the weekly body audits completed by licensed staff from 1/5/13 to 3/18/13 continued to identify abrasions/excoriations on the buttocks with no pressure areas; however no changes in the treatment plan were identified. On 3/14/13 Resident #360 was evaluated by the Consulting Wound Care Physician and was assessed as having a stage two pressure ulcer on the sacrum measuring 5.0cm by 1.5cm by 0.1cm. and recommendations were made to change the treatment to cleanse the area with normal saline and apply Suprasorb dressing two times a day. Interview with the ADNS on 4/3/13 at 10:30AM identified Resident #360 was assessed as having an excoriation on the buttocks rather than a pressure ulcer upon admission and therefore no measurements were documented. Interview with the DNS on 4/3/13 at 1:10PM identified the expectation for a resident admitted with a pressure ulcer would be to have wound measurements completed weekly by an RN and a consultation with the facility wound nurse. The DNS further identified that the clinical record lacked weekly assessments of the pressure ulcer. Review of the facility skin care program identified that a pressure ulcer record will be started upon admission and/or discovery of a new open area and updated weekly following the assessment.

Based on observation, review of the clinical records, facility investigations, facility policies and procedures and interviews for one of two sampled residents reviewed for falls resulting in injury, (R #4), the facility failed to ensure that the residents' environment remained free of accident hazards. The findings include: R #4's [DIAGNOSES REDACTED]. R #4 resided on a secure Alzheimer's Special Care Unit. Fall Risk Assessments dated 12/01/10 and 02/14/11 identified scores of 12 and 24 with directions that a resident who scores a 10 or higher was at risk of falls and, additionally, consider environmental risk factors in resident's interventions. Risk factors identified were an increasing number of falls in the last 90 days, behaviors, elimination with assistance, change in balance status from no balance problem on 12/01/10 to not able to attempt test without physical help, change from no orthostatic changes noted to less then 22 mmHg drop in pressure noted, 1-2 medical conditions present and 3 or more medications taken. RCP's dated 12/23/10 at 2:15 PM, 12/23/10 at 5:45 PM, 1/23/11 identified falls with interventions that included, in part, wheelchair with alarm, hipsters on at all times, except with care, and Physical Therapy screen. A healing right pubic rami fracture was identified following the fall of 01/23/11. An MDS assessment dated [DATE] identified difficulty making self understood and difficulty understanding, highly impaired vision, cognitively impaired with severely impaired decision-making, disorganized thinking, altered level of consciousness, total assistance of 2 staff for transfer, total assistance of 1 staff for locomotion off unit, dressing, eating, personal hygiene, and bathing; extensive assistance of 2 staff for bed mobility and walking in the corridor, extensive assistance of 1 staff for walking in room, locomotion in corridor; wheelchair, always incontinent, non-verbal signs of pain 1-2 days in the last 5, antipsychotic and antianxiety medications, physical therapy services, and no restraints. Review of a Rehabilitation Screen/Evaluation Request dated 02/21/11 identified a request to adjust the leg rests for R #4. The findings, documented by the rehab technician, identified that the leg rests were too short and he/she lengthened them by 3 inches. The technician identified that R #3 looked comfortable and the nursing staff was informed of the adjustment. Review of a nursing progress note dated 02/21/11 at 2:00 PM identified that R #4 was transferred from the Special Care Unit to Station 4 due to the resident's need for intravenous therapy, pending placement of a PEG tube. A Restraint Use assessment dated [DATE] documented by RN #5, identified a risk for falls related to a history of falls due to physical limitations, medications, and dementia, behavioral problems that include restlessness, pain behavior, recent change in meds, rapid fluctuation in mental status with alternate measures attempted before restraining that included one to one diversional activities, reapproach for behavioral issues, PT/OT for exercise, low bed with mat, blue wedge for positioning. There were no documented recommendations from PT or OT. Non- restraint interventions included bed and wheelchair alarms. A physician's telephone order given by APRN #2 on 02/22/11 and received by RN #5, directed out of bed (OOB) to modified tilt-in-space wheelchair with pelvic self release seat belt for pelvic positioning, check every 1/2 hour and remove and reapply every 2 hours and transfer via Hoyer lift due to cognitive decline. An RCP dated 02/22/11 identified the problem of Impaired Mobility related to decreased strength. impaired cognition, pain and dementia with interventions that included, in part, provide appropriate level of assistance to promote resident safety, monitor safety in wheelchair, PT/OT evaluation and treatment as needed and Hoyer lift transfer. A telephone order by Physician #3 received and documented by RN #5 on 03/03/11, directed to discontinue the wheelchair belt. A revision to the Impaired Mobility RCP dated 03/11/11 included the intervention of assistance of two for transfer and ambulate as tolerated by nursing. Review of Physical Therapy documentation identified that R #4 received Physical Treatment from 02/15/11 through 03/22/11. Review of a facility investigation dated 03/14/11 identified that at 6:55 PM, a NA heard the bed alarm and found R #4 on the floor mat on his/her right side with his/her face against the legs of the pole supporting the PEG tube pump. R #4 sustained lacerations to the chin and lip that required sutures. Care Plan revision included changing from continuous to bolus feeding to eliminate the need for a bedside pole. Review of a facility investigation dated 03/26/11 identified that on 03/26/11 at 2:55 PM, R #4 was reclined in a modified tilt-in-space wheelchair, sitting across from the nursing station. He/she was observed to stand up from the chair and lunge forward, falling forward and striking face on the floor. Injuries included left facial laceration, left periorbital contusion, left orbital blow-out fracture, left subconjunctival hemorrhage, left shoulder contusion, orbital floor fracture, comminuted fractures of anterior ant lateral maxillary wall, fracture of the zygomatic arch, fracture of the orbital wall. No brain trauma was identified. On 03/29/11 swelling of the left wrist was identified and R #4 was transferred to the Emergency Department for further assessment. Minimally displaced left distal radius and left ulnar styloid fractures were diagnosed . Interview with Physical Therapist #3, the Rehabilitative Services Coordinator, on 07/08/11 at 2:00 PM identified that assessment for the appropriate use of a modified custom wheelchair would require a rehab screen and/or evaluation by someone with Rehab training. Interview with the Rehab Technician and Acting Rehab Program Manager on 07/08/11 at 4:00 PM identified that the Rehab Department did not issue the modified tilt-in-space chair to R #4, but, it was already on the resident unit when the Rehab Technician was requested to adjust the leg rests and, further, nurses were very involved in positioning and might obtain a used chair from storage, trial the chair, then request a screen for adjustment. Interview with RN #5, the Station 4 Unit Manager, on 07/08/11 at 1:30 PM identified that he/she thought that Rehab Services would be involved with the decision to issue a modified wheelchair to R #4. The modified wheelchair was a comfort measure for R #4 who required tube feeding and rarely moved. Interview with LPN #3, the charge nurse on Station 4, on 07/13/11 at 3:30 PM identified that he/she had witnessed R #4's fall on 03/26/11. LPN #3 was sitting at the nursing station and observed R #4, sitting in the modified wheelchair with the leg rests on, and the seat tilted at a 45 degree angle. R #4 moved fast, stood up, bearing weight briefly, leaned forward, looking forward as if responding to an hallucination and fell with the impact greater on one side of the face. LPN #3 identified that he/she was unaware that R #4 ambulated at all, but that he/she was a stand/pivot assistance of 2 for transfers. LPN #3 was not involved in the assessment/evaluation process that resulted in the removal of the self releasing seat belt for pelvis positioning. Review of facility documentation and interviews failed to provide evidence that Rehab Services participated in a comprehensive assessment for the need for a modified wheelchair with leg rests and a self releasing belt for positioning and/or the the assessment that resulted in the decision to discontinue the self releasing belt.

Based on clinical record review, observations, facility documentation and interviews for 1 of 3 sampled residents (resident #1) at risks for falls, the facility failed to provide adequate supervision and assistance to prevent an accident. The findings include: 1. Resident #5's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated that Resident #5 had no short term or long term memory loss, was independent with cognitive skills for daily decision making, required extensive assistance from staff with activities for daily living including transfers. The resident's care plan dated 7/14/10 indicated that the resident was at risk for falls related to history of falls, poor safety and refusing to use a wheelchair. Interventions included a customized wheelchair with tilt in space with pelvic belt and a 24-hour positioning plan. Additionally, facility documentation indicated that the resident required a Sarita lift for transfers and had been on 15-minute checks for safety since 5/17/10 and 15-minute checks on the 7-3 and 3-11pm shifts only from 7/15/10. a. Review of facility's documentation indicated that on 7/1/10, Resident #5 hit his/her head while being transferred by NA #5 and NA #6 with a Sarita lift from the wheelchair to the bed. Although no injuries were identified, NA #6's documentation indicated that the straps of the pad were unhooked on both sides during the transfer and the resident's head went back while NA#6 supported Resident #5's arm. Facility staff failed to ensure that the lift pad was hooked appropriately. Review of the facility's policy on the Sarita Lift indicates that staff should the check equipment prior to transfer to ensure a safe transfer, to ensure the sling is pulled well down onto the attachment lugs and to secure before attempting to lift the resident. b. Facility documentation identified that on 7/12/10 at approximately 4:50PM, NA #8 and NA #6 repositioned the resident in the wheelchair. Resident #5 was found on the floor at the foot of the wheelchair at 5pm. Facility investigation identified that the resident stated that he/she leaned forward to get something and slid off the chair. Facility documentation identified that the resident was seated in another resident's wheelchair on two static air cushions without dycem. The resident was sent to the hospital for an evaluation with no injuries identified. Upon return from the hospital, a physical therapy evaluation was done and the plan of care was revised. Facility staff failed to utilize the appropriate cushions and/or wheelchair to prevent the resident from sliding out of the wheel chair. c. Review of the clinical record indicated that Resident #5 had not walked in 1 year but he/she was now making continuous attempts to stand up without staff. The nurse's note dated 8/22/10 identified that at times between 9:30am through 1:30 pm, the resident was angry, yelling at staff, uncooperative with care, slid down from his/her wheelchair, and had punched a nurse aide in the face. Documentation further identified that the resident also had a history of [REDACTED]. Facility documentation dated 8/22/10 at approximately 2:00 PM identified that Resident #5 was observed attempting to stand up with a walker from the wheelchair and without staff assistance. Interview with Supervisor #1 on 9/2/10 at 12:30 PM indicated that on 8/22/10 at 2:15PM he/she attempted to take the walker from Resident #5 but he/she became agitated, so Supervisor #1 decided to allow Resident #5 to keep the walker and reproach the resident later. Supervisor #1 further indicated that the resident remained in the wheelchair and that Resident #5 was given Ativan 0.5mg by mouth by Licensed Practical Nurse (LPN) #1 at 2:40PM after redirecting the resident. Supervisor #1 indicated that it was not unusual for Resident #5 to seek attention and because Resident #5 appeared calmer and he/she thought Resident #5 was safe. The resident's chair alarm had gone off and Supervisor #1 removed the walker from the resident and placed it on the other side of the unit at approximately 2:55pm. Supervisor #1 went to give report to the oncoming supervisor and staff called out that the resident had fallen. The clinical record indicated that although the Ativan was given, Resident #5 continued to stand without the staff's assistance. An interview with NA # 2 on 9/1/10 at 4:25pm identified that at 2:30pm, the resident "wasn't calm" and that the resident wanted to walk. Further review of the clinical record indicated that the facility failed to provide adequate supervision when the resident exhibited unsafe behavior. At approximately 3pm on 8/22/10, the clinical record indicated that Resident #5 fell to the floor and complained of neck pain. The resident was transferred and admitted to the hospital with [REDACTED].