Every finding on record at Beacon Brook Center for Health & Rehabilitation

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the record was complete and accurate to include physical therapy directions regarding use of a gait belt. The findings include: Resident #1 had a diagnosis of falls, and anemia. The admission MDS dated [DATE] identified Resident #1 had a BIMS of 15 indicating intact cognition, was dependent for toileting, and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 1/13/2026 identified deficit in functional mobility and a potential for falls. Interventions directed assistance of one (1) staff for transfers. Advanced Practice Registered Nurse (APRN) note dated 1/27/2026 at 9:45 AM identified a fall on 1/27/2026 with a skin tear on the left knee and right forearm. The note identified Resident #1 was alert and oriented to baseline with pupils equal, round, and reactive, and cranial nerves intact. Multiple Steri-Strips were applied to right forearm skin tear, which appears clean, dry, and intact. The left knee abrasion was noted with steri-strips (Band-Aid to help close cuts/tears), over the laceration area. Denied pain, continue Tylenol as needed, continue to monitor. Facility reportable event form dated 1/30/2026 at 6:40 PM identified Resident #1 fell on 1/27/26 while transferring from his/her bed to a wheelchair due to weakness and buckling of his/her legs. Record review failed to identify a gait belt was used during the transfer or was required to transfer the resident. Interview and record review with the Director of Rehabilitation on 2/18/2026 at 11:22 AM identified Resident #1 received physical therapy prior to the fall and on 1/27/2026, Resident #1 required an assist of one (1) staff for transfers and required use of a gait belt. The Director of Rehabilitation was unable to provide documentation or communication to nursing that a gait belt was required for transfers. Interview with Physical Therapist (PT) #1 on 2/18/2026 at 12:20 PM identified he was the primary Physical Therapist who provided therapy for Resident #1. PT #1 stated prior to the fall, Resident #1 required assist of one (1) staff for transfers and required the use of a gait belt for transfers. Further, PT #1 stated he did not document in his physical therapy notes that a gait belt was required to be used when transferring Resident #1 because he thought it was a facility policy to use a gait belt. Interview and record review with the Director of Nursing (DNS) on 2/18/2026 at 1:10 PM identified at the time of the fall on 1/27/2026, Resident #1 required assist of one (1) staff for stand pivot transfers. During the transfer Resident #1's knees buckled and he/she fell to the floor, sustaining the skin tears. The DNS stated there was no physician order or care plan that directed use of a gait belt, and the facility did not have a policy that directed use of a gait belt for a one (1) person transfer. Further, the DNS stated there was no communication from therapy that directed use of a gait belt, and if Physical Therapy required a gait belt to be used they should document the recommendation and notify nursing. Review of facility Charting and Documentation Policy dated January 2025 directed in part, to provide a complete account of the patients total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care.

Based on review of the clinical record, facility policy and interviews for 1 of 24 sampled residents (Resident #41) reviewed for advanced directives, the facility failed to ensure advanced directives were consistent throughout the clinical record. The findings include:Resident #41's was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (a rare muscle injury where your muscles break down), epilepsy (seizure disorder) and major depressive disorder. A facility Advanced Directive Consent/Acknowledgement and Release Form signed by Resident #41 and LPN #9 on [DATE] identified Resident #41 did not want Cardiopulmonary Resuscitation (CPR), Artificial Respiration and Artificial Nutrition administered. The signed form was retained in Resident #41's medical record.An admission physician's order dated [DATE] at 5:38 AM and [DATE] at 10:45 PM directed to provide CPR for Resident #41 (a discrepancy with the Advanced Directive Consent form signed by Resident #41 and Licensed Practical Nurse (LPN) #9 on [DATE]). An admission progress note written by Advanced Practice Registered Nurse (APRN) #1 and dated [DATE] at 8:15 AM indicated the code status was reviewed with Resident #41 and he/she requested to be do not resuscitate (DNR)/do not intubate (DNI). The progress not indicated measures concerning DNR/DNI were discussed with the resident with all questions and concerns addressed and documentation was updated with the resident's request.APRN #1's progress note dated [DATE] at 9:30 AM identified Resident #41's Code Status as RN (registered nurse) May Pronounce/Do Not Intubate/Cardio Pulmonary Resuscitation/Do Not Attempt Resuscitation/DNR.APRN #1's progress note dated [DATE] at 8:30 AM identified Resident #41's Code Status as Cardio Pulmonary Resuscitation (a discrepancy with the Advanced Directive Consent form signed by Resident #41 on [DATE] and APRN #1's progress note of [DATE]).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #41 had intact cognition and required partial/moderate assistance with toileting, bed mobility and transfers. The Resident Care Plan (RCP) dated [DATE] identified Resident #41's Advanced Directive Guidelines were Code Status: Full Code/CPR/DNI/RNP (a discrepancy with the Advanced Directive Consent form signed by Resident #41 on [DATE] and APRN #1's progress note of [DATE]). Interventions included to honor advanced directives as directed by the resident and to review advanced directives with the resident on admission and at least quarterly. Interview and review of the clinical record with LPN #3 on [DATE] at 10:08 AM identified if Resident #41 was to be found unresponsive, CPR would be administered Resident #41 based on what was listed in the computer and on the resident's face sheet (while the advanced directive form in the resident's medical record directed Resident #41 was a DNR/DNI). LPN #3 indicated the physician's order in the computer and on the face sheet was incorrect and she was unable to indicate the reason the physician's order was not written to reflect Resident #41's wishes to be a DNR/DNI. LPN #3 identified she would immediately address Resident #41's advanced directives with the physician and make the necessary corrections. Subsequent to surveyor inquiry, a physician's order dated [DATE] directed Do Not Resuscitate, no artificial respiration, and no artificial nutrition and the RCP was updated on [DATE] to reflect a Code Status of DNR/DNI/no artificial respiration/no artificial nutrition for Resident #41.Interview and review of the clinical record with the DNS on [DATE] at 8:51 AM identified when Resident #41 signed the Advanced Directive form to be a DNR/DNI on [DATE], LPN #9 should have contacted the physician and obtained a new order to change the residents code status from CPR to DNR/DNI. The DNS was unable to indicate the reason LPN #9 did not follow through on obtaining a physician's order and she was unable to identify why APRN #1's progress notes were inconsistent regarding Resident #41's code status. Interview and review of the clinical record with APRN #1 identified when she reviewed code status with Resident #41 on [DATE] and the resident indicated he/she wanted to be a DNR/DNI, she did not review the resident's orders and was not aware Resident #41's order reflected he/she was to be provided CPR. APRN #1 indicated when Resident #41 signed the Advanced Directive form to be a DNR/DNI on [DATE], LPN #9 should have contacted the physician and obtained a new order to change the residents code status from CPR to DNR/DNI. APRN #1 identified she had failed to ensure the resident's choice to be a DNR/DNI was reflected in the physician's orders and was consistently documented in her progress notes in Resident #41's clinical record. Interview with LPN #9 on [DATE] at 10:58 AM identified she had signed the Advanced Directive form with Resident #41 on [DATE] which reflected the resident choice to be a DNR/DNI. LPN #9 indicated after signing the form with Resident #41 she gave the admission packet to the nursing supervisor and assumed the nursing supervisor would have contacted the physician for a new order. LPN #9 indicated she was not aware Resident #41 was to be administered CPR based on what was listed in the computer and on the resident's face sheet. LPN #9 identified the nursing supervisor would review and obtain any necessary orders and she was unsure why that was not done. Review of facility policy, Advanced Care Planning Code Status, dated 2/25, directed upon admission the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident and a physician's order must be written accordingly. The healthcare provider who is provided with consent for an order not to resuscitate must promptly issue an order not to resuscitate. When the consent of the resident has been obtained and the DNR decision has been made, the directive shall be written as a formal order by the healthcare provider in the medical record.

Based on observation, resident/staff interviews, and facility policy, the facility failed to ensure that food items were maintained at a palatable and appetizing temperature at time of serving. The findings include: Food Committee Meeting Minutes from 1/13/25, 2/24/25, 4/21/25, 5/19/25, 6/16/25, and 7/23/25 identified resident complaints of cold food.On 1/2/25 at 12:20 PM a test/temperature tray was conducted with the Director of Dietary and the following was identified:At 12:26 PM the test tray was prepared and plated in the kitchen located on the basement floor. The test meal was plated on a heated dish, placed in a plastic base, covered with a plastic dome, and put onto a meal tray. The meal tray was then placed in a closed meal delivery truck with other resident trays. The meal delivery truck left the kitchen at 12:27 PM for its destination to the second-floor unit.At 12:29 PM (2 minutes after leaving the dietary department), the meal delivery cart arrived at the second-floor (hallway 1), where multiple staff members were observed distributing trays to residents.At 12:39 PM (12 minutes after leaving the dietary department) the food cart proceeded to the second-floor, hallway 2, and staff members were observed passing trays to residents in that area.At 12:48 PM (22 minutes after leaving the dietary department) the last resident tray was passed, and temperatures of the test tray were taken by surveyor with a calibrated thermometer in the presence of the Dietary Manager (who did not bring a thermometer) identifying the following:Battered Fried Fish internal temperature was 118.9 degrees FahrenheitRoasted Tomatoes internal temperature was 106.9 degrees FahrenheitOven [NAME] Potatoes internal temperature was 104.5 degrees FahrenheitAn interview with the Dietary Manager conducted on 1/5/25 at 10:21 AM confirmed indicated that hot food should be served at a minimum temperature of 120 F to ensure palatability (which is a discrepancy with facility policy related to food temperature).The facility's Culinary Services: Food Temperature Measurement policy, revised March 2022, indicates that food held between 41 F and 135 F is considered within the 'Danger Zone.' The policy defines proper food temperature as both safe and appetizing to the resident. It further specifies that food temperature measurements may be conducted during receiving, storing, cooking, holding, serving, cooling, and reheating.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #13) reviewed for pressure ulcers and for 1 of 1 resident (Resident #15) reviewed for a tracheostomy, the facility failed to wear Personal Protective Equipment (PPE) during wound and tracheostomy care. Additionally, for 1 of 2 residents (Resident #29) reviewed for skin conditions, and for 1 of 1 residents (Resident #60) reviewed for dialysis, the facility failed to implement enhanced barrier precautions (EBP). The findings include: 1.Resident #13 was admitted to the facility in December 2023 with diagnoses that included dementia, spectrum beta lactamase (ESBL) bacteria in urine (highly antibiotic-resistant bacteria in urine) which is a multidrug resistant organism (MDRO) and stage 3 pressure ulcer. The reentry Minimum Data Set assessment dated [DATE] identified Resident #13 was unable to participate in a Brief Interview for Mental Status due to severe cognitive impairment, was dependent on staff for all activities of daily living, required maximum assistance with bed mobility and had a Stage 3 (full thickness skin loss with or with dead tissue) pressure ulcer. Physician's orders dated 12/16/25 directed Enhance Barrier Precautions (EBP) for chronic urinary catheter, history ESBL in the urine and a Stage 3 pressure ulcer to the sacrum. The treatment to the sacrum wound was to pack the wound using Dakin's solution (antimicrobial solution) and gauzed once a day and as needed. The Resident Care Plan dated 12/21/25 identified Resident #13 was on EBP for urinary catheter, Stage 3 pressure ulcer, and history of ESBL in the urine. Interventions included EBP for the duration of stay related to a history of ESBL in the urine and chronic urinary catheter, and to don (put on) a gown and gloves when performing high contact care activities. Observation on 12/30/25 at 10:00 AM noted Resident #13 had signage outside of his/her room regarding the need for EBP, a set up for personal protective equipment (PPE) was by the entrance to the room and a bin for soiled PPE was on the inside of the room before exiting the room. Observation on 12/31/25 at 12:30 PM noted RN #3 (Wound Care Nurse) assisting with Resident #13's dressing change. RN #3 had only gloves on for PPE and was not wearing a gown. However, all other 3 nursing staff in Resident #13's room had on full PPE (gown, gloves and facemask). Initially, RN #3 was to take photographs of Resident #13's sacrum wound but then proceeded to assist nursing staff with repositioning Resident #13 on his/her side two times during the dressing change. RN #3 then proceeded to take photographs of Resident # 13's sacral wound. RN #3 did not wash her hands or change gloves during this process. Resident #13's EBP were in place not only for his/her Stage 3 pressure ulcer but for a urinary catheter and a history of ESBL in the urine. Interview with RN #3 on 12/31/25 indicated that she should have put on full PPE as she provided hands-on assistance to Resident #13 during the dressing change. In addition, Resident #13 was on EBP for a urinary catheter and history of ESBL. Review of the facility policy, Precautions to Prevent Infection, dated 6/2024, directed residents with wounds and at risk for increased MDRO transmission should be placed on EBP. Examples of wounds included chronic wounds and diabetic ulcers. In addition, signage regarding the particular type of precaution was to be utilized. Review of the memorandum, Centers for Medicare and Medicaid Services (CMS) Guidance on Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, directed that EBP expands the use of personal protective equipment to donning of gown and gloves during high-contact resident care activities for residents with chronic wounds. 2.Resident #15's diagnoses included chronic respiratory failure, history of stroke, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 had a feeding tube, required tracheostomy care, required suctioning, and was dependent with personal hygiene, bed mobility and transfers. The MDS assessment failed to identify Resident #15's cognitive patterns/mental status. The Resident Care Plan (RCP) dated 12/30/25 identified Resident #15 had increased susceptibility for infection related to presence of a tracheotomy. Interventions included EBP as ordered, notify the Medical Doctor (MD) if Resident #15 developed signs and symptoms of infection. The RCP identified Resident #15 required EBP due to an indwelling medical device, feeding tube, and trach. Interventions included to bundle high contact activities whenever possible, and don a gown and gloves when performing high contact care activities including care or use of the indwelling medical device (trach). Observation of Resident #15's room on 12/30/25 at 11:30 AM noted Resident #15 had a trach with oxygen via a trach mask and EBP signage was posted on the left side of the doorway prior to the entrance of the room. Observation of Licensed Practical Nurse (LPN) #6 on 1/2/26 at 7:35 AM identified she was providing tracheostomy care which included suctioning of Resident #15's trach and changing the gauze around the area without the benefit of wearing a gown. Interview with LPN #6 at that time identified Resident #15 was on EBP, she should have been wearing a gown and could not convey the reason she did not wear a gown while performing trach care. LPN #6 further identified the gowns were located on the linen cart in the hallway and observation of the linen cart confirmed gowns were available for use. Interview with the Director of Nursing Services (DNS) on 1/2/26 at 9:05 AM identified residents who were on EBP were identified by signage on the doorway. The DNS identified a gown and gloves should have been worn by LPN #6 when she provided trach care and suctioned Resident #15. Review of the clinical record failed to identify a physician order for EBP. Review of the Enhanced Barrier Precautions policy directed, in part, EBP are indicated for residents with indwelling medical devices (trach). The policy directed PPE for EBP included gown and gloves worn during high contact resident care activities that included device care. The policy directed that residents on EBP were identified by signage on the doorway and designation in the Kardex within the electronic medical record. Review of the facility policy, Precautions to Prevent Infection, dated 6/2024, directed residents with wounds and at risk for increased MDRO transmission should be placed on EBP. Examples of wounds included chronic wounds and diabetic ulcers. In addition, signage regarding the particular type of precaution was to be utilized. 3. Resident #29's diagnoses included type 2 diabetes mellitus with foot ulcer, chronic ulcer of the left ankle, and methicillin resistant staphylococcus aureus (MRSA) infection. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 was cognitively intact and had a lower extremity impairment on one side. The MDS indicated Resident #29 required substantial/maximal assistance with bed mobility, toileting and transfers and had a diabetic foot ulcer requiring application of a dressing. The Resident Care Plan dated 10/29/25 identified Resident #29 had a non-pressure ulcer related to diabetes and a multi drug resistant organism (MDRO) with infection/colonization of Methicillin-Resistant Staphylococcus Aureus (MRSA) in the left ankle wound. Interventions included to apply the wound treatment as ordered and conduct weekly wound evaluations with wound clinic follow-up as indicated. Further interventions included the use of a disposable gown and gloves during physical contact with the resident. The RCP failed to indicate and include Enhanced Barrier Precautions (EBP) for Resident #29. Review of the facility skin and wound evaluation documentation dated 12/3/25 identified Resident #29 had a diabetic wound to the left lateral ankle that was acquired at the facility on 10/4/24. The evaluation indicated the wound had moderate serosanguinous exudate (thin, watery, pinkish, or light red wound drainage) and was slow to heal. A physician's order dated 12/15/25 directed to cleanse the left lateral ankle with Saline, dry and apply skin prep to the peri wound (surrounding the wound) area then apply Collagen to the wound and cover with a dry protective dressing (gauze pad and gauze wrap) three times per week and as needed if the dressing became soiled or dislodged. Observations on 12/29/25 at 10:20 AM and 12/30/25 at 10:30 AM identified that although Resident #29 was receiving wound care for a chronic diabetic ulcer of the left lateral ankle, the outside of Resident #29's room failed to indicate posted signage for Enhanced Barrier Precautions (EBP). Wound care observation, interview, and review of the clinical record on 12/31/25 at 10:50 AM with the wound care nurse (RN #3) and the nursing supervisor (RN #4) identified Resident #29 failed to have a physician's order and signage outside of his/her room indicating the need for EBP. RN #3 and RN #4 identified although Resident #29 had a chronic diabetic ulcer, he/she was not on EBP because only residents with draining wounds and an MDRO needed to be on EBP. RN #3 was observed to provide wound care and although she was wearing gloves for wound care, she failed to wear a gown during the dressing change. After the wound care observation revealed wound drainage and review of the clinical record indicated Resident #29 had an MDRO, RN #3 and RN #4 indicated they were unsure why Resident #29 had not been placed on EBP and they would need to check with the Infection Preventionist (IP) nurse. Subsequent to surveyor inquiry, an observation on 1/2/26 at 7:53 AM identified EBP signage had been posted outside of Resident #29's room. Interview and review of the clinical record with the Director of Nursing Services (DNS) on 1/2/26 at 8:53 AM identified Resident #29 should have been on EBP for his/her wound and that posted EBP signage was not required outside of the resident's room because the nursing staff wound know the resident was on EBP per the resident's care plan and kardex. The DNS indicated it would have been the responsibility of the charge nurse or IP nurse to make sure the resident was put on EBP. The DNS further identified she was unsure why Resident #29 did not have signage outside the room and did not have a physician's order for EBP and she would need to check with the IP nurse. Interview with the IP nurse (LPN #4) on 1/2/26 at 10:30 AM identified Resident #29 should have been on EBP for his/her wound and MDRO history. LPN #4 indicated all residents on isolation precautions, including EBP, required signage outside of their room and it was her mistake that Resident #29 was not put on EBP. Review of the Nurse Aide (NA) care card/kardex for Resident #29, dated 1/5/25, indicated Enhanced Barrier Precautions (EBP) for a wound with multi-drug resistant organism (MDRO) and a history of MRSA/wound. The NA care card/kardex directed EBP- don gown and gloves when performing high contact care activities including dressing, bathing, transferring, changing linens, assisting with toileting, or changing brief, care or use of indwelling medical device and providing wound care. Review of facility policy, Enhanced Barrier Precautions (EBP), dated 4/1/24, directed EBP was indicated for all residents with a wound (any skin opening requiring a dressing) and the resident would remain on EBP until resolution of the wound. The policy further directed chronic wounds including diabetic ulcers were included. Review of the facility policy, Precautions to Prevent Infection, dated 6/2024, directed residents with wounds and at risk for increased MDRO transmission should be placed on EBP. Examples of wounds included chronic wounds and diabetic ulcers. In addition, signage regarding the particular type of precaution was to be utilized. Review of the memorandum, Centers for Medicare and Medicaid Services (CMS) Guidance on Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, directed that EBP expands the use of personal protective equipment to donning of gown and gloves during high-contact resident care activities for residents with chronic wounds. 4. Resident #60's diagnoses included end stage renal disease (ESRD), extended spectrum beta lactamase (ESBL) (a drug resistant bacteria) resistance, and a need for assistance with personal care. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was severely cognitively impaired and was dependent for transfers, toileting, and bed mobility. Additionally, the MDS identified Resident #60 was receiving hemodialysis. The Resident Care Plan (RCP) dated 12/29/25 identified a problem with ESRD and a left arterio-venous shunt (an indwelling medical device used for dialysis access) requiring Enhanced Barrier Precautions (EBP). The RCP indicated Resident #60 had an infection/colonization with a multi-drug resistant organism (MDRO) of ESBL in the urine. Interventions included EBP for the duration of stay related to a targeted MDRO, and to don (put on) a gown and gloves when performing high contact care activities including bathing, dressing, assisting with toileting/changing brief and transferring the resident. Observation of Resident #60's room on 12/30/25 at 10:30 AM identified EBP signage was posted on the door frame which directed staff must wear gloves and a gown for high contact care activities including bathing, dressing, assisting with toileting/changing brief and transferring the resident. The Nurse Aide (NA) care card/kardex identified Resident #60 was on EBP for a left arterio-venous shunt and a MDRO/ESBL in the urine. The kardex further directed staff to don a gown and gloves when performing high contact care activities including bathing, dressing, assisting with toileting/changing brief and transferring the resident. Observation, interview, and review of the clinical record with NA #4 on 12/31/25 at 9:35 AM identified NA #4 was providing personal care for Resident #60 and was not wearing appropriate Personal Protective Equipment (PPE) (no isolation gown). NA #4 indicated she had provided Resident #60 with incontinent care, a bed bath, dressed Resident #60 and transferred him/her into the wheelchair without the benefit of an isolation gown. NA #4 identified she was not aware Resident #60 was on EBP and did not check her assignment before providing care. NA #4 indicated she had made an error and although she saw the posted EBP signage outside of the room she thought it was for the other resident in the room and not Resident #60. Observation and interview with Licensed Practical Nurse (LPN) #3 on 12/31/25 at 10:05 AM identified EBP signage was posted outside of Resident #60's room. LPN #3 indicated although she did not tell NA #4 that Resident #60 was on EBP, NA #4 should have checked her assignment on the computer before providing care for Resident #60. LPN #3 identified NA #4 should have worn an isolation gown when she provided personal care to Resident #60. Interview and review of the clinical record with the Director of Nursing Services (DNS) on 1/2/26 at 8:53 AM identified for resident's on EBP, nursing staff should don an isolation gown and gloves when providing personal care. The DNS indicated NA #4 should have known what PPE was required and should have donned an isolation gown when providing personal care for Resident #60. The DNS identified she was unsure why the NA did not wear the appropriate PPE and she would need to provide further education to NA #4. Interview with the Infection Preventionist (LPN #4) on 1/2/26 at 10:30 AM identified for resident's on EBP, nursing staff should don an isolation gown and gloves when providing personal care. Th IP nurse indicated NA #4 should have known what PPE was required and should have donned an isolation gown when providing personal care for Resident #60. The IP nurse identified she would need to provide further education to the nursing staff. Review of the facility policy, Infection Prevention and Control Policy, dated 6/2024, directed EBP requires gown and glove use for residents with an MDRO and indwelling medical devices (including hemodialysis catheters) during high risk resident care activities (identified as dressing, bathing, transferring, providing hygiene and changing briefs/assisting with toileting). Review of the facility policy, Enhanced Barrier Precautions, undated, directed EBP precautions were indicated for residents with an MDRO and indwelling medical devices. An isolation gown and gloves should be donned when performing high contact care activities such as bathing, dressing, providing hygiene, changing briefs/assisting with toileting and transferring of residents. Review of the memorandum, Centers for Medicare and Medicaid Services (CMS) Guidance on Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, directed that EBP expands the use of personal protective equipment to donning of gown and gloves during high-contact resident care activities for residents with indwelling medical devices and MDRO's.

Based on observation and interviews for 1 of 5 (Resident #42) reviewed for dining, the facility failed to ensure a dignified dining experience. The findings included: Resident #42 was admitted to the facility in July 2022 with diagnoses that included dementia, anxiety, and dysphagia (difficulty swallowing).The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 was severely cognitively impaired and required set up assistance for meals and moderate assistance with activities of daily living.The Resident Care Plan dated 11/5/25 identified Resident #42 had swallowing difficulty with interventions that included to provide adequate time to consume meals, assist as needed, no rice, honor food preferences, monitor for any signs of difficulty swallowing, monitor for malnutrition, and document amount eaten.Physician's orders dated 11/24/25 directed to provide easy to chew food textures (mechanical soft) with regular liquids. Observation of the 2nd floor main dining room on 12/29/25 at 12:35 PM identified there were 13 residents seated there for lunch. Resident #42 was seated at a table in the back of the dining room with another resident (Resident #41). Resident #41 received his/her meal tray at 12:35 PM but Resident #42 did not receive his/her meal tray until 1:05PM (waiting 30 minutes while Resident #41 was eating. Nurse Aide (NA) #10 identified that Resident #42's tray was not on the dining room cart. At 12:47 PM, NA #10 called the kitchen to notify that Resident #42 did not have a meal tray and needed a lunch meal. Resident #42 continued to sit at the table with only beverages and no offers of a snack from staff while waiting for his/her lunch. At 1:05 PM a lunch tray of chopped ham, mashed potatoes and vegetables arrived from dietary staff for Resident #42. At the same time, NA #10 brought Resident #42's meal tray that was located on another cart from Brookview unit. Observation on 12/29/25 at 1:05 PM noted Resident #42 immediately started to consume his/her meal, a half hour after the other residents were served their lunch. All residents in the dining room except for 2 residents had finished their lunch and were eating dessert. All other residents had started to exit the dining room when Resident #42's lunch meal was provided.Interview with NA #10 on 12/29/25 at 1:08 PM identified that she located Resident #42's tray on the cart when she finished providing the residents on the unit their meal. NA #10 stated that Resident #42's meal tray was not usually on the unit cart but on the dining room cart and was unsure why his/her tray was placed on the wrong cart. However, she stated that sometimes a tray was missing or put on the wrong cart from the kitchen. Interview with the Director of Food Services on 12/31/25 at 1:20 PM identified that the Dietary Aide prints out the meal tickets for residents that eat in their rooms and residents that eat in the dining room. The tickets are then sorted and placed on the appropriate meal cart. She stated that Resident #42's meal ticket inadvertently got placed on the wrong cart and was unsure how it happened as she assisted with the meal line on 12/29/25. Furthermore, the Director of Food Services stated that when dietary receives a call for a meal when serving, the turnaround time is usually 15 minutes. She also indicated that there are food items in the cabinet and in the refrigerator in the dining room and the nursing assistants can provide a snack for a resident if waiting for a meal. She indicated that Resident #42 should have not waited 1/2 hour for his/her meal while all the other residents in the dining room were eating and that he/she should have been offered a snack by the nursing assistants.A review of the Resident Preferences Dining Policy dated 1/22 directed, in part, Residents have the right to choose their schedules for dining, with whom they prefer to eat and where they prefer to sit. A method will be in place to assist staff in identifying residents such as meal tickets, a dining roster or other community specific processes. The information will be kept in a location that is easily accessible to staff and not in the public view.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #29) reviewed for accidents the facility failed to follow the plan of care for a resident with a history of falls. The findings include: Resident #29's diagnoses included a displaced fracture of the left lower leg, repeated falls, and a history of falls.A fall evaluation dated 2/15/25 identified Resident #29 was a high fall risk, was unsteady and had unsafe behaviors. The fall evaluation indicated Resident #29 had intermittent confusion and disorientation and a visual impairment.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 was cognitively intact and required substantial/maximal assistance with bed mobility, toileting, and transfers. The MDS also indicated Resident #29 had a lower extremity impairment on one side.The Resident Care Plan (RCP) dated 10/29/25 identified Resident #29 had impaired mobility and muscle weakness and was at risk for falls related to an impaired sense of balance, an unsteady gait, and being legally blind. Interventions included to provide a low bed and floor mats and to ensure the bed was left at an acceptable height.The Nurse Aide (NA) care card/kardex identified Resident #29 was a high fall risk and required a low bed and floor mats.Observations on 12/29/25 at 10:20 AM and 1/2/26 at 7:32 AM noted Resident #29 in bed and without the benefit of a low bed and floor mats. Resident #29's bed was not in a low position and the resident had his/her eyes closed.Observation, interview, and review of the clinical record with NA #8 on 1/5/26 at 8:30 AM identified Resident #29 was in bed and without the benefit of a low bed and floor mats. Resident #29's bed was not in a low position and the resident was awake. Review of the NA care card/kardex with NA #8 indicated Resident #29 was a high fall risk and was to be in a low bed with fall mats on the floor. NA #8 proceeded to search the resident's room for the floor mats but was unable to locate them. NA #8 identified she was aware Resident #29 needed floor mats and she saw them in the resident's room before, was unsure what happened to them and would need to ask the nurse. Observation and interview with LPN #8 on 1/5/26 at 8:37 AM identified Resident #29 was in bed and without the benefit of a low bed and floor mats. Resident #29's bed was not in a low position and the resident was awake. LPN #8 indicated she was aware Resident #29 was a high fall risk, was to be in a low bed with fall mats on the floor and she was unsure why the bed was not in a low position and the fall mats were not in the room. LPN #8 identified the mats may have been removed for cleaning and she would need to call maintenance. Interview and review of the clinical record with the DNS on 1/5/26 at 10:13 AM identified Resident #29 was a high fall risk and per the plan of care should have had a low bed and fall mats in place. The DNS indicated she was unsure why the resident was in a regular bed (which was not in a low position) and did not have fall mats in place. The DNS identified it would have been the responsibility of the NA or charge nurse to ensure, while the resident was in bed, the bed was in a low position and the fall mats were on both sides of the bed.Review of facility policy, Fall Prevention Program, dated 3/2023, directed residents at risk for falls would be identified on the CNA kardex/assignment and for residents at high risk for falls, the care plan would have interventions initiated to prevent falls. Interventions and fall prevention measures would be developed and incorporated into the resident care plan and CNA kardex/assignment.

Based on interviews, review of the clinical record, and review of facility policy for 1 of 1 sampled resident (Resident #109) reviewed for issues with care, the facility failed to revise the resident's care plan following a staff-related grievance that resulted in a change to how care was delivered. The findings include:Resident #109's diagnoses included chronic obstructive pulmonary disease, type two Diabetes Mellitus, generalized anxiety disorder, and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #109 was cognitively intact, independent with eating, required set-up assistance for oral hygiene, and was dependent for toileting, bathing, dressing, and transfers. A Resident Care Plan (RCP) dated 10/8/25 identified Resident #109 experienced anxiety with interventions that included to provide reassurance and implement supportive psychiatric and social services. Additionally, the RCP identified Resident #109 exhibited accusatory behavior with interventions to provide redirection, 2 staff for care and provide a supportive approach with trigger monitoring. On 12/5/25, Resident #109 filed a grievance stating that three named Nurse Aides (NAs) were at times unkind and made him/her uncomfortable. The grievance documented that the NAs were educated, removed from Resident #109's assignment and restricted from entering the resident's room. The grievance further indicated that Resident #109 verbally agreed to the plan on 12/9/25 which resulted in a change to the resident's assigned staff and how daily care was provided.A social work progress note, dated 12/10/25 at 10:44 AM, completed as a routine assessment of mood, assessed that Resident #109 demonstrated good insight into his/her emotional state, effectively utilized available support systems, and presented as cooperative with an anxious mood and congruent affect.Review of the RCP failed to reflect the RCP had been revised to include Resident #109's complaint of NAs being unkind and interventions to prohibit 3 NAs from providing care to him/her as noted on a grievance form (which was not part of the clinical record and kept in a Grievance Log binder).Interview on 1/5/26 at 12:45 PM with the DNS indicated that staff assignments were adjusted at Resident #109's request and that she did not expect a revision to the resident's care plan following the 12/5/25 incident. She further stated that the facility did not add individual incidents, with dates, to resident care plans. This practice was inconsistent with prior care plan updates for Resident #109 related to other incidents on 6/14/24, 10/8/24, and 12/21/25. The DNS also stated that removal of staff from a resident's care team was not documented in the care plan but tracked on the nursing supervisor's schedule and communicated to involved staff, and that she did not expect behavioral intervention updates to reflect care team changes related to the 12/5/25 incident because the resident's anxiety behaviors continued.The Baseline/Comprehensive Person-Centered Care Plan (CPCCP) Policy, last revised in March 2023, required the CPCCP to be reviewed and revised upon changes in the plan of care or resident status and when new problems, goals, or interventions were identified. The facility failed to revise Resident #109's care plan to reflect the care team intervention implemented on 12/9/25, resulting in noncompliance with facility policy.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #41) reviewed for unnecessary medications, the facility failed to ensure administration of the correct medication according to professional standards of practice. The findings includeResident #41 had diagnoses that included rhabdomyolysis (muscle injury where the muscles break down), pain in left hip, and anxiety.An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #41 was cognitively intact and was dependent on staff for oral/personal hygiene, toilet use and bathing. The MDS further identified Resident #41 was not taking opioid medication.The Resident Care Plan identified Resident #41 had the potential for pain related to rhabdomyolysis, pain in the left ankle, joints of the left foot, the left hip and left shoulder. Interventions included to administer medication per orders, evaluate the effectiveness of pain interventions and monitor/document the side effects of pain medication. Additionally, the RCP identified Resident #41 was administered pain medications (Tramadol) without a physician order on 12/1/25.A Reportable Event (RE) Form dated 12/1/25 at 9:00 PM identified Resident #41 was administered Tramadol (an opiod analgesic used to treat moderate to severe pain) 50 milligrams (mg) by Licensed Practical Nurse (LPN) #10 without a physician's order. The RE further identified there was no injury or distress to Resident #41, the Advanced Practice Registered Nurse (APRN) was notified, the responsible party was notified, and actions taken were to monitor Resident #41 for any change in condition.An APRN progress note dated 12/1/25 at 11:38 PM identified she saw Resident #41 via video observation for a medication error. The note identified Resident #41 was given Tramadol 50 mg at 9:00 PM but he/she did not have an order for that medication. The note identified the medication error was not noted for a couple hours until the nurses were checking the narcotic count. The note identified Resident #41 had been asleep most of the night without complaints but was easily awakened for the APRN visit. The note identified Resident #41 was at baseline physical and cognitive status with stable vital signs.A nursing note dated 12/2/25 at 12:42 PM identified Resident #41's responsible party was notified of the medication error and Resident # 41 was alert with no distress noted.Review of the Medication Administration Record (MAR) from 12/1/25 through 12/31/25 failed to identify documentation that Resident #41 was administered Tramadol 50 mg on 12/1/25. An Investigation Statement obtained by the facility, written by LPN #10 and dated 12/1/25 identified Resident #41 had requested pain medication with his/her nighttime medications. The statement identified LPN #10 had added Tramadol 50 mg to Resident #41's other medications due to a name mix up. The statement identified the nursing supervisor was notified.Review of a Controlled Substance Disposition Record that was included with the investigation of the medication error identified the Tramadol 50 mg administered to Resident #41 on 12/1/25 was prescribed for a different resident. The disposition record identified LPN #10 signed out a dose of Tramadol 50 mg at 8:00 PM on 12/1/25, but it was not Resident #41's name on the disposition record.Review of an Inservice Attendance Sheet signed by LPN #10 included with the investigation of the medication error identified LPN #10 was educated on the 5 rights of a medication pass. The education directed to be sure to utilize the 5 rights of a medication pass to avoid potential errors, and a medication should be checked on the MAR prior to administration to ensure there is an existing order. The education failed to identify what the 5 rights of medication administration were.Interview with the Director of Nursing Services (DNS) and the Assistant DNS (ADNS) on 1/3/26 at 1:40 PM identified LPN #10 should not have administered Tramadol to Resident #41 without a physician order for that medication. The ADNS identified Resident #41 requested pain medication and LPN #10 had seen the Tramadol medication in her medication cart and thought it was Resident #41's medication. The ADNS identified the medication error had been identified when the nurses were completing the narcotic count at the end of the 3:00 PM to 11:00 PM shift and that was when LPN #10 had realized the medication given to Resident #41 was not ordered and was a different resident's medication. The ADNS identified there were no ill effects to Resident #41 as a result of this medication error and that the pharmacy had not been notified of the medication error. The ADNS further identified that as a result of LPN #10 giving Tramadol 50 mg to Resident #41 that was ordered for a different resident, she had provided education to LPN #10 on the 5 rights of medication administration.Review of the Medication Pass Policy directed, in part, administration of medications must be documented at the time of the medication pass. The policy directed when PRN medications are administered documentation is to include: date and time of administration, dose and route of administration, symptoms or pain scale for which medication was given, and signature of person administering the medication. The policy directed that the 6 rights of medication administration were: right resident, right drug, right dose, right dosage form, right route, right time.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #13 and Resident #41) reviewed for activities of daily living (ADL's), the facility failed to provide nail care for residents who required assistance with personal care. The findings include: 1. Resident #13 was admitted to the facility in December 2023 with diagnoses that included dementia, cerebral infarction (stroke) with left side weakness, and malnutrition. The re-entry Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a short/long term memory problem and was dependent on staff for all activities of daily living. The Resident Care Plan dated 12/18/25 identified a deficit in ADLs/self-care related to weakness, left hemiparesis, and the need for assistance with personal care. Interventions included to provide assistance with feeding, assistance with all personal hygiene, physical and occupational therapy as needed. Physician orders dated 12/20/25 directed out of bed to a tilt and space wheelchair, splint to left hand, on in the morning (AM) and off in afternoon (PM) as tolerated, physical therapy and occupational therapy as needed. Observation on 12/30/25 at 9:38 AM noted Resident #13 was out of bed in a wheelchair in the recreation area with a splint in place to the left hand. Resident #13's fingernails on both hands were noted to be jagged, lengthy and in need to be trimmed. Observation on 12/31/25 at 12:00 PM noted Resident #13 to be out of bed in a wheelchair in the dining area with nails still jagged, lengthy and in need to be trimmed. Observation and interview with Nurse Aide (NA) #9 on 1/2/26 at 9:41AM (after Resident #13 received AM care by NA #9) noted Resident #13's nails were still lengthy and needed to be trimmed. NA #9 stated that Resident #13 should have nails trimmed on his/her shower day and that the nurse aides were responsible for trimming fingernails. NA #9 was unsure why Resident #13's nails were lengthy and needed to be trimmed. NA #9 indicated that indeed Resident #13's nails were long and in need of trimming. NA # 9 indicated that she did not attempt to trim Resident #13's fingernails when she provided AM care on 1/2/26. After surveyor inquiry, NA #9 trimmed Resident #13's fingernails. Interview with the DNS on 1/2/26 at 12:30 PM identified that the facility had conducted an audit of residents' fingernails to identify any residents that needed fingernails to be trimmed. A review of the list with the DNS on 1/2/26 at 12:30 PM identified that Resident #13's name was not on the list. The DNS indicated that maybe Resident #13 was care planned for refusals related to care and that is why he/she may not have been on the list. The DNS indicated that the assigned NA was responsible to ensure a resident's fingernails were trimmed on shower days or as needed and refusals were reported and documented. 2.Resident #41 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (a rare muscle injury where your muscles break down), muscle weakness and need for assistance with personal care. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #41 was cognitively intact and required partial/moderate assistance with toileting, bed mobility and transfers. The Resident Care Plan (RCP) dated 12/29/25 identified Resident #41 required assistance with personal care due to muscle weakness and chronic musculoskeletal pain. Interventions included to provide the resident with substantial/maximal assistance with personal hygiene. Observation and interview with Resident #41 on 10/29/25 at 11:03 AM identified his/her fingernails on both hands were untrimmed and very lengthy. Resident #41 indicated he/she did not like to keep his/her fingernails that length, and he/she was unable to trim them by him/herself. Resident #41 identified he/she had not had his/her fingernails trimmed since admission to the facility and when he/she had asked staff to trim his/her fingernails, he/she was told by staff they did not have the time. Resident #41 further indicated although his/her shower was supposed to be every Thursday, he/she did not get showered weekly and therefore fingernails were never trimmed. An additional observation and interview with Resident #41 on 12/30/25 at 10:00 AM identified Resident #41's fingernails on both hands were untrimmed and very lengthy. Resident #41 indicated again that he/she did not have his/her fingernails trimmed since he/she came to the facility. Interview and observation with Nurse Aide (NA) #3 on 12/30/25 at 2:54 PM identified she was responsible to trim Resident #41's nails and did not trim them because after providing morning care she ran out of time. NA #3 indicated Resident #41 did not refuse care, was always on her assignment and she was aware the resident's fingernails were very lengthy due to his/her nails not being trimmed since admission. NA #3 identified Resident #41's weekly shower was scheduled for Thursdays on the 7:00 AM to 3:00 PM shift. She further indicated when she provided Resident #41 a shower, the resident asked to have his/her fingernails trimmed but the facility did not have nail clippers available, so she was unable to trim the resident's fingernails. NA #3 further indicated she would forget to trim Resident #41's fingernails during personal care but would trim them now. Subsequent to surveyor inquiry, an observation and interview with Resident #41 on 12/30/25 at 3:00 PM identified the resident's fingernails on both hands were trimmed, short and was happy NA #3 had trimmed his/her fingernails. Interview and review of the clinical record with the DNS on 1/2/26 at 8:45 AM identified resident's fingernails should be trimmed when needed and should be checked and trimmed with weekly showers. The DNS indicated it was the responsibility of the assigned NA to provide nail care and nail clippers were provided on the units in the supply room. Review of the RCP with the DNS identified Resident #41 required assistance with personal care and failed to identify the resident refused care. The DNS indicated she would need to determine why Resident #41 never had his/her fingernails trimmed and would review nail care and showers with the NA's. Review of facility policy, CNA Standard of Care/Information Sheet, dated 3/23, directed routine care was to be provided by the nursing assistants and daily morning care included nail care daily as needed.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1of 1 resident reviewed for positioning/mobility, the facility failed to follow physician orders regarding skin protection (Resident #14) and for 1 of 5 residents, (Resident #125) reviewed for dining, the facility failed to ensure meal supervision and feeding by staff was provided in accordance with physician order and the plan of care, resulting in a choking incident. The findings include: 1.Resident #14's diagnosis included hemiplegia and hemiparesis following a cerebral infarction affecting left side, dysphagia, and diabetes. The quarterly Minimum Data Set (MD) dated 11/21/25 identified Resident #14 was cognitively intact and was dependent on staff for eating, showering, toileting, dressing, and transfers: The MDS further identified Resident #14 was at risk for developing a pressure ulcer requiring a pressure reducing device for the bed and chair. A physician's order dated 12/2/25 directed to apply a bed cradle to bottom of the bed at all times. A physician's order dated 12/2/25 directed to place offloading boots to bilateral feet at all times and to check skin integrity every shift. The Resident Care Plan (RCP) dated 12/2/25 identified Resident #14 had the potential for skin breakdown. Interventions included placing a bed cradle when the resident was in bed, offload heels with bilateral heel boots at all times and checking skin integrity every shift. Observation on 12/30/25 at 10:21 AM identified Resident #14 was in bed with one heel protector on the left leg, there was not a bed cradle in place, his/her bilateral lower extremities were elevated on a pillow while in bed, and the sheets were on top of the resident's toes. Observation on 12/30/25 at 2:45 PM identified Resident #14 was in bed with no bed cradle in place on the bed. The bed cradle was noted to be on the floor of the room by the dresser, only one heel protector was in place to Resident #14's left leg and the sheets were hitting the resident's toes. Observation on 12/31/25 at 9:12 AM identified Resident #14 was in bed, the bed cradle was not in place, the bed cradle was noted to be on the floor of the room by the dresser, the right heel protector was not in place, and the bed sheets were hitting the resident's toes. Interview with Nurse Aid (NA) #5 on 12/31/25 at 2:30 PM identified Resident #14 was to wear 1 heel protector, and the other foot was to be elevated on a pillow. NA #5 further identified that the bed cradle was on the floor but was unsure of how to place the cradle on the bed and had never asked how the cradle was to be placed on the bed. Additionally, NA #14 identified she had cared for Resident #14 for a while and had never seen a second heel protector in Resident #14's room. On 12/31/25 at 2:35 PM, interview and review of the NA care card with NA #5 identified Resident #14 was to have offloading boots to the bilateral feet at all times, to check skin integrity every shift, and the bed cradle was to be placed at the bottom of the bed at all times. Interview with Licensed Practical Nurse (LPN) #5 on 12/31/25 at 2:38 PM identified the physician order for Resident #14 was for a bed cradle to be placed at the bottom of the bed and offloading boots to bilateral feet at all times. She was responsible for following physician's orders and to provide oversight. Although she was aware she was responsible she could not identify the reason it was not done. LPN #5 also identified Resident #14 has had a past history of skin breakdown, and the orders of a bed cradle and offloading boots were for protection and prevention of skin breakdown. Interview with the DNS on 1/1/26 at 9:37 AM identified Resident #14 had a physician order to have offloading boots to bilateral feet at all times, and the bed cradle was to be placed at the bottom of the bed at all times. The DNS identified the nurse on the unit was responsible for oversight. Although a policy was requested for heel protectors and the bed cradle the DNS identified the facility did not have one. 2.Resident #125's diagnoses included dementia, chronic obstructive pulmonary disease (COPD), and seizure disorder. The Resident Care Plan dated 9/17/2025 identified Resident #125 had a potential for aspiration and weight loss due to missing teeth, and unintentional weight loss. Interventions directed to encourage to eat in the dining room, provide a full feed to promote food intake, attention to meal task providing verbal encouragement, eat when upright and 30 minutes after meals, eat at a slow rate, small bites and chew thoroughly. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #125 had a Brief Interview for Mental Status (BIMS) score of 9 indicating Resident #1 was mildly cognitively impaired, required substantial assistance when eating, and did not display signs and symptoms of a possible swallowing disorder. A physician order dated 11/20/2025 directed a consistent carbohydrate regular diet, regular texture, thin consistency (liquids) for risk of malnutrition. Physician order dated 12/6/2025 directed to assist with all meals and Speech Therapy consult difficulties swallowing for weight loss, and consistent carbohydrate regular diet, regular texture, thin consistency (liquids) for risk of malnutrition. Speech therapy (ST) note dated 10/2/2025 identified mastication (chewing) mildly extended, good oral clearance noted without signs of aspiration, required max verbal cues to encourage oral intake; frequently distracted/benefitting from supervision to improve oral intake. Discussed concerns with nursing staff on duty regarding weight loss and need for increased supervision and encouragement with meals. Speech therapy note dated 11/12/2025 identified adequate textural breakdown, mastication, and oral clearance with no signs of aspiration. ST note dated 11/13/2025 identified staff educated regarding strategies to promote oral intake, and staff verbalized good understanding and signed inservice sheet. discharge date [DATE]. The Facility Reportable Event (RE) form dated 12/6/2025 at 1:20 PM identified on 12/6/25 staff observed Resident #125 exhibiting sudden drooling of fluid and seizure like activity while seated in wheelchair in room. Staff noted a piece of chicken fell from Resident #125's mouth and immediately assessed the resident's airway. Resident #125 was actively breathing with some coughing noted, back blows and abdominal thrust were initiated per facility policy. Resident #125 continued to maintain spontaneous respirations throughout, although was unresponsive. Emergency services were called, and Resident #125 was transferred to the hospital. Meal ticket and food checked on tray was consistent with current diet orders. A nursing note written by RN #1 dated 12/6/2025 at 2:14 PM identified Resident #125 was cyanotic (bluish coloration to skin), had reduced responsiveness with weak hand grasps, oxygen saturation was 82 percent (%) (COPD diagnosis normal greater than 90 percent) and oxygen was applied via a non-rebreather mask at 15 liters per minute. Back and abdominal thrusts were performed without any visible food being dislodged, and Resident #125 was transferred to the hospital at 1:20 PM Emergency Medical Services (EMS) run sheet dated 12/6/2025 identified EMS was notified at 12:58 PM and arrived at the facility at 1:02 PM. The report identified Resident #125 was breathing, not responsive, and responded to painful stimuli. Staff reported they believed Resident #125 was choking and had a syncopl episode, but when placed on the floor he/she pinked up and started breathing normally. The report further identified the pulse was 88 with an initial rhythm and Resident #125 was not a cardiac arrest, patient is breathing. Started to develop a slow heart rate, and was a cardiac arrest, CPR was initiated and continued until arrival to hospital. Hospital note dated 12/6/2025 identified Resident #125 presented after witnessed choking episode and lost pulses en route with EMS. Initial laryngoscopy attempted patient was noted to have large food bolus within the glottic opening (main airway valve to the lungs; space between the vocal cords in the larynx). Foreign body was removed with [NAME] forceps, and the patient was intubated. Three (3) rounds of epinephrine were administered with compressions via [NAME] device, and defibrillation as indicated and was admitted to the ICU. The hospital Discharge summary dated [DATE] at 11:32 AM identified Resident #125 was admitted on [DATE] after choking on meat, subsequently suffered cardiac arrest in the ambulance in route to the hospital ED and a cardiac rhythm was re-established after approximately fifteen (15 minutes). Intubation (placement of a tube through the mouth and into the airway) was completed in the Emergency Department (ED) but brain injury due to lack of oxygen was suspected. Resident #125 continued to be unstable for the next few days and despite aggressive intervention. Resident #125 suffered a cardiac arrest and expired on 12/8/2025 at 10:40 AM. The Facility RE summary dated 12/8/2025 identified Resident #125 required to be fed meals to promote oral intake and attention to meal task. Due to a respirator outbreak in the facility, communal dining was on hold. NA #1 brought the lunch tray to Resident #125 and placed it off to the side until resident was able to have assistance with feeding. The summary identified Resident #125 was currently hospitalized and the facility identified the meal tray should not have been left with Resident #125 until staff were ready to assist with feeding. Interview and record review with Speech Language Pathologist (SLP – therapist) #1 on 12/29/2025 at 11:51 AM identified she saw Resident #125 for therapy related to decreased intake and weight loss. SPT #1 stated Resident #125 did not display evidence of dysphagia (swallowing difficulty) although chewing was mildly extended likely due to missing teeth. Resident #125 had good oral clearance and required maximum verbal cues to encourage food intake due to easily distracted. SLP #1 recommended supervision with meals to improve Resident #125's food intake and stated Resident #125 did not exhibit impulsive behaviors regarding food or eating too quickly; her recommendations were to enhance food consumption and to cue Resident #125 to stay on task. SLP #1 stated staff had not reported any further concerns regarding Resident #125's eating habits to her. Interview and record review with NA #2 on 12/29/2025 at 12:45 PM identified on 12/6/2025 about 1:00 PM she was exiting the room next to Resident #125's room when she observed Resident #125 sitting up in the wheelchair with his/her arms straight out to either side of his/her body moving with jerking motions. NA #2 stated she thought Resident #125 was having a seizure and she called out for help, and LPN #1 and LPN #2 responded to the room. NA #2 observed Resident #125's bedside table to the right side of the chair with the lunch tray on top. NA #2 stated when she moved the bedside table, she observed the cover for the meal plate had been removed from the dish, and she saw small cut-up pieces of chicken on the plate. Interview and record review with LPN # 2 on 12/29/2025 at 12:10 PM identified she was the Charge Nurse on the unit when she responded to NA #2's call for help on 12/6/2025. She observed Resident #125 slumped forward in the wheelchair and she immediately repositioned Resident #125 back to a seated position. LPN #2 stated she observed Resident #125 drooling from his/her mouth that appeared to contain small food particles. Resident #125 was unresponsive but appeared to be trying to cough or breath. LPN #2 began to perform abdominal thrusts, and an oral finger sweep produced more drool and no food particles. RN #1 and LPN #1 came into the room and assisted to place Resident #125 on the floor. LPN #2 stated she did not need to move the bedside table to provide care for Resident #125 during the incident. Interview and record review with LPN #1 on 12/29/2025 at 11:46 AM identified she responded to the room and observed LPN #2 attempting to move Resident #125. RN #1 (nursing supervisor) arrived, and they both assisted LPN #2 to lower Resident #125 to the floor. LPN #1 stated Resident #125's color was dusky and improved when Resident #125 was placed on the floor. Resident #125 appeared to be breathing, had a weak rapid pulse with an oxygen saturation by pulse oximetry of 82 % (normal 90% or above). LPN #1 completed a finger sweep after turning Resident #125 on his/her side without any food noted. LPN #1 directed staff to call 911, and she and RN #1 applied oxygen via a non-rebreather mask at 15 liters per minute and obtained vital signs. Resident #125's color improved; blood pressure was 148/82, pulse was 86 and blood sugar was 258. Interview, record review and review of the investigation summary dated 12/8/2025 with the DNS and RN #2 (regional nurse), on 12/29/2025 at 2:00 PM identified Resident #125 required to have meals supervised or full feed (staff member to stay with Resident to assist feeding) due to poor oral intake at meals and inability to stay on task. NA #1 was expected to be with Resident #125 when eating, to assist and cue as per ST recommendations and consistent with Resident #125's care needs. The facility investigation included a follow up interview with NA #1 that identified she did not review the care card prior to her shift on 12/6/2025. NA #1 had dropped off Resident #125's tray, leaving it on Resident #125's bedside table to the side of Resident #125 who was sitting up in the wheelchair. NA #1 had identified that she had cut up the chicken, replacing the lid on the plate and left the room to feed another resident because communal dining was suspended at the time. The DNS stated the tray should not have been distributed to the room by NA #1 until NA #1 was able to assist the resident with the meal. The DNS stated NA #1 was aware that Resident #1 was a supervised or full feed that required supervision for meals; review of education dated 11/12/2025 (prior to the incident) identified NA #1 signed inservice attendance that addressed Resident #125's care need of being a full feed with meals to promote oral intake for cuing and attention to meal task with small bites. Although attempted, NA #1 and RN #1 were unavailable for interview during the survey. Facility documentation review identified staff education was initiated on 12/7/2025 and included to check the resident Kardex to ensure to follow the resident's plan of care for eating strategies, and not to pass trays to residents until a staff member was ready to assist with the meal. Audits were initiated on 12/8/2025 and a QAPI meeting was held on 12/8/2025, to review the quality initiative. Based on review of facility documentation and interview with the DNS, past non-compliance was identified.

Based on review of clinical record, interviews, facility documentation and facility policy for 1 of 3 (Resident #13) residents reviewed for pressure ulcers, the facility failed to ensure that an alternating air pressure mattress was implemented timely per facility policy. The findings include:Resident #13 was admitted to the facility in December 2023 with diagnoses that included dementia, cerebral infarction (stroke) with left side weakness, and malnutrition.The readmission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was severely cognitively impaired, required maximum assistance with bed mobility and was at risk for developing a pressure ulcer. A Braden Scale (tool to assess the risk for development pressure injury) was used to determine Resident #13's risk for developing a pressure ulcer dated 9/14/25 and 10/14/25 identified Resident #13 was at mild risk developing a pressure ulcer. There were no further Braden Scale assessments completed since 10/14/25.Physician's orders dated 9/15/25 directed a wound care consultant as needed, skin prep to the bilateral heels daily, weekly skin checks, and magic cup (high calorie ice cream) twice a day.The Resident Care Plan dated 9/26/25 identified a problem with being at risk for skin breakdown. Interventions included to apply skin prep to bilateral heels, assist with changing position every 2 hours, assist and provide incontinent care every 2 hours and as needed, dietitian evaluations as needed, nutritional supplements as order and weekly skin checks. A revision to the RCP dated 10/3/25 (after the development of pressure ulcers) included a Stage 3 (full-thickness skin loss/ with or without dead tissue) pressure ulcer to sacrum related to compromised nutritional status, edema, immobility, and sensory impairment. Interventions included assistance with changing position every 1 hour, (may use wedge) when in bed, tilt and space wheelchair and change position every 2 hours using tilt mechanism, report signs and symptoms of infection, provide frequent incontinent care, treatment as ordered, and wound evaluations until resolved. The wound consultant's initial wound evaluation dated 10/8/25 identified Resident #13 had a Stage 3 pressure ulcer to left buttock and sacrum. The left buttock measured 1.3 cubic centimeters (cm) length by 1.6 cm width with no depth. The Stage 3 sacrum wound measured 3.6 cm length by 2.5cm width by 0.1cm depth with moderate amount of serosanguinous (thin, watery bloody) fluid. Additionally the wound bed had 30% granulation (healthy, red tissue), 70% slough (yellowish, soft material from dead or dying tissue) and was in need of debridement (removal of damaged tissue).The wound consultant note dated 10/29/25 identified Resident #13's left buttock opening had healed on 10/15/25 and required only barrier cream (cream that restores and strengthens the skin). However, the sacrum wound was deteriorating, debridement was performed and it was discussed with nursing to offload the area as much as possible. Interview with Registered Nurse (RN) #3 (wound nurse) on 12/31/25 at 12:30 PM identified Resident #13 did not have a low air loss mattress (mattress composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of shifting in bed) placed on his/her bed until 11/625 (35 days after the pressure ulcers were identified). She indicated that Resident #13's position was being changed every hour by nursing staff when in bed. RN #3 indicated that she was responsible for initiating the low air loss mattress and that in retrospect, she should have had low air loss mattress placed on the bed before 11/6/25 and it should have been placed on the bed when the pressure ulcers were identified.A review of the Pressure Injury Prevention Policy dated 3/23, directed, in part, the prevention and treatment of pressure injuries begins with identification of the resident's risk of developing a pressure injury based on a comprehensive evaluation of the resident's skin integrity and any existing predisposing factors upon admission and thereafter. Evaluate the resident's specific factors and changes in the resident's condition that may impact the development and healing of a pressure injury. Implement and monitor, and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and if a pressure injury is present, provide treatment and services to heal, prevent infection and the development of additional pressure ulcers. To promote prevention injury and promote healing of existing wounds by implementing appropriate support services. One stage 3 pressure ulcer indicates the use of alternating pressure mattress. A review of the Admission/re-admission Policy dated 3/23 directed, in part, licensed nurses will complete a Braden/[NAME] evaluation for all residents upon admission/re-admission and initiate preventive measures based on identified risk factors. Risk factors may also be identified through MDS 3.0 assessment process, hospital discharge summary, physician orders, rehab notes consult reports and/or lab studies. The Braden/[NAME] Evaluation will be completed weekly for 4 weeks post admission/readmission.

Based on review of the clinical record, facility documentation, interviews and facility policy for the only sampled resident (Resident #13) reviewed for bowel and bladder incontinence/catheter, the facility failed to ensure Urologist orders were implemented for changing a urinary catheter. The findings included:Resident #13 was admitted in December 2023 with diagnoses that included obstructive and reflux uropathy (blockage in urinary system), urinary retention, and history of extended spectrum beta lactamase (ESBL) bacteria in urine (highly antibiotic-resistant bacteria in urine).The discharge Minimum Data Set, dated [DATE] identified that Resident #13 was unable to participate in a Brief Interview of Mental Status due to severe cognitive impairment, required moderate assistance with activities of daily living, and had an indwelling urinary catheter.Physician's orders dated 4/8/25 directed to replace indwelling urinary catheter size 16 French with 10 cubic centimeters (cc) [NAME] if removed/leaking or plugged as needed, change catheter drainage bag from straight drainage to leg bag when out of bed, and may irrigate catheter with 60 cc of sterile saline if leaking or plugged as neededThe Care Plan dated 4/8/25 identified that Resident #13 had an indwelling foley catheter/stents secondary to obstructive uropathy with urinary catheter replacement in hospital on 4/9/25. Intervention included follow up with urology as ordered, keep catheter bag and tubing positioned lower than the level of the bladder and away from the entrance doorway, monitor for signs and symptoms of urinary tract infection and notify physician, keep urinary collection bag off the floor, privacy cover over collection bag, and enhanced barrier precautions. The Care Plan failed to reflect how often the urinary indwelling catheter needed to be changed and size of the catheter. The Advanced Practitioner Registered Nurse (APRN) #1 progress note on 4/8/25 at 9:45AM identified Resident #13 had a fever of 103 Fahrenheit, with body shivering, concentrated urine and decreased urine output. Resident #13 had dislodged urinary stents which his/her urologist was aware of stent concern. APRN #1 ordered intravenous (IV) antibiotic (Ceftriazone 1-gram intermuscular dose on 4/8/25 then continue via IV for 4 days). APRN #1 indicated that Resident #13 was at high risk for urinary infection related to stents and needed closed monitoring. APRN #1 indicated that Resident #13 was already scheduled to visit urologist on 4/9/25. A nurse's note dated 4/9/25 at 8:09PM identified that Resident #13 continued with elevated temperature, chills, and had nausea and vomiting. An order was obtained to send Resident #13 to the hospital for an evaluation.APRN #4 progress note dated 4/17/25 at 9:30AM identified that Resident #13 was readmitted from the hospital on 4/16/25 after being treated for a urinary tract infection and stent removal. A call was placed to urology office by APRN #4 regarding urinary catheter management. Urology office directed to have urinary catheter remain in place and urologist will evaluate on 4/28/25 when Resident #13 had scheduled follow-up visit.Resident #13's office visit notes by APRN #2 (Urology APRN) dated 4/28/25 identified that Resident #13's urinary catheter must be changed every 4 weeks at the facility. APRN #2 indicated that Resident #13 should have a follow-up visit in 12 months for a renal ultrasound.APRN #1's follow up progress note related to urology recommendations dated 5/1/25 at 10:30AM identified that Resident #13 continued with chronic urinary foley catheter and that catheter was to be changed every 4 weeks per facility protocol.A nursing note by LPN #3 dated 5/12/25 indicated that a call was placed to urology office to determine if the urinary catheter foley was changed on 4/28/25 when Resident #13 had an office visit. An order was obtained by LPN #3 to change foley catheter every 4 weeks from urology office. However, a physician's order was obtained on 5/21/25 to discontinue urinary catheter change every 4 weeks and to change urinary catheter if it is removed, dislodged or plugged. Interview and review of the clinical record with LPN #3 on 1/2/26 at 1:15PM indicated that she was not aware of urology orders to change urinary catheter every 4 weeks. She indicated that she was unsure if the urinary catheter was getting changed at the facility or at the urology office. LPN #3 reviewed current physician's orders and indicated that urinary catheter was only to be changed if became dislodged/plugged or leaked. LPN #3 indicated that she was not aware of the facility's policy on changing urinary catheters, but it was nursing responsibility to change urinary catheters.A reinterview with LPN #3 on 1/2/26 at 1:25PM indicated that she did not recall calling the urology office or obtaining an order for the urinary catheter changes. An interview with DNS on 1/2/26 at 1:35PM indicated that it was facility policy not to change urinary catheters on a regular scheduled basis and that they are only to be changed as needed. The DNS indicated the facility is trying to move away from regular scheduled changes of urinary catheters. The DNS indicated that Resident #13's current order was to change the urinary catheter as needed.An interview with APRN #2 on 1/2/26 at 1:41PM via telephone indicated that she was not aware that the facility was not changing Resident #13's urinary catheter every 4 weeks. APRN #2 stated that due to Resident #13's history and risk factors for infection that the urinary catheter must be changed every 4 weeks. In addition, APRN #2 indicated that she wrote on consult sheet when Resident #13 had a follow up visit that urinary catheter must be changed every 4 weeks and that the facility had contacted the office on 5/12/25 and had spoken to LPN #3 giving an order to change urinary catheter every 4 weeks. Furthermore, APRN #2 indicated that she would expect that the facility would have contacted the office prior to changing the order as she would not have approved an order to change the urinary catheter as needed. Interview with APRN #1 on 1/5/26 at 12:30PM indicated that she follows Resident #13 and works closely to prevent hospitalizations for Resident #13. APRN #1 indicated that she was aware that Resident #13's catheter orders were to change on an as needed basis and that urology's recommendation was for every 4 weeks. She indicated that although she was aware of the order change, it was nursing's responsibility to have notified the urology office/practitioner when the order was changed to as needed. Interview with RN #4 on 1/5/26 at 12:45PM indicated that it was nursing's responsibility to notify the urology's office when the order for the urinary catheter was changed from every 4 weeks to as needed. RN #4 indicated that she is not sure why it was not done but she was not the supervisor on the floor during that timeframe. RN #4 indicated that it was her practice to notify consulting practitioners when their recommendations are not followed by the facility. A review of the Urinary Catheterization Policy dated 4/24 directed, in part, the interval between catheter changes should be determined by the individual patient's needs. Indications for changes may include mechanical dysfunction or blockage of the urinary catheter system, and contamination of the closed system. Indwelling catheters should not be changed at arbitrary fixed intervals. Although requested, a policy on consulting practitioners was not provided.

Based on clinical record review, facility documentation, facility policy and staff interviews for 1 of 1 resident (Resident #14) reviewed for hospice, the facility failed to review and respond to pharmacy recommendations in a timely manner. The findings include:Resident #14's diagnoses included schizoaffective disorder, bipolar, and post-traumatic stress disorder.A physician order dated 5/14/24 and currently in effect directed Lurasidone HCL (an antipsychotic medication used to treat schizophrenia and bipolar disorder) 40 milligrams (mg) once a day.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact and was dependent on staff for all activities of daily living. Additionally, the MDS identified Resident #14 was administered antipsychotic medication, antianxiety and antidepressant medication.A Resident Care Plan (RCP) dated 2/26/25 identified Resident #14 had the potential for behavior problems related to schizoaffective disorder, bipolar and post traumatic stress syndrome. Interventions included to complete a comprehensive psychiatric evaluation yearly at minimum, anticipate and meet the resident's needs, and mental health counseling.The Pharmacy medication regimen review dated 3/4/25 (first request) identified Resident #14's last Abnormal Involuntary Movement Scale (AIMS) and the recommendation was to be completed every 6 months. Also, identified APRN #3 disagreed as she cannot reevaluate Resident #14 because Resident #14 was receiving hospice services.The Pharmacy medication regimen review dated 4/1/25 (second request) identified Resident #14's last AIMS was completed on 9/6/24 and the recommendation was to be completed every 6 months. Also, identifying hospice residents were not exempt as AIMS needed to be completed to monitor for adverse effects of antipsychotic drugs, please consider ordering or performing. The response to pharmacy recommendations by APRN #3 was that she couldn't see the resident because Resident #14 was receiving hospice services.The Pharmacy medication regimen review dated 5/1/25 (third request) identified Resident #14's last AIMS was completed on 9/6/24 and the recommendation was to be completed every 6 months. Also, identifying hospice residents were not exempt as AIMS needed to be completed to monitor for adverse effects of antipsychotic drugs, please consider ordering or performing. The response to pharmacy recommendations by APRN #3 was that she couldn't see the resident because Resident #14 was receiving hospice services.The Pharmacy medication regimen review dated 7/1/25 (fourth request) identified Resident #14's last AIMS was completed on 9/6/24 and the recommendation was to be completed every 6 months. Also, identifying hospice residents were not exempt as AIMS needed to be completed to monitor for adverse effects of antipsychotic drugs, any provider or Registered Nurse may perform. Please consider ordering or performing. The response to pharmacy recommendations by APRN #3 was that she couldn't see a resident because Resident #14 was receiving hospice services.Review of 7 Pharmacy medication regimen review forms dated 9/5/24 through 7/1/25 recommended completing an AIMS with the response to pharmacy recommendations by APRN #3 was that she couldn't see a resident because Resident #14 was receiving hospice services.Interview with the DNS on 1/2/26 at 9:29 AM identified she was unsure of how often an AIMS evaluation should be completed or if a resident on hospice could have an AIMS evaluation. Also, identifying the oversight of the Pharmacy recommendation was to be completed by the Assistant Director of Nursing Services (ADNS).Interview with APRN #3 on 1/2/26 at 11:20 AM identified a resident with a certain hospice provider cannot have an AIMS completed, she was told this by the hospice provider but could not identify the staff member's name.Interview with the Senior Care Administrator from the hospice agency on 1/2/26 at 11:45 PM identified the hospice provider would not go against the facility policy and an AIMS test should have been completed.Interview with the DNS on 1/2/26 at11:50 AM identified a nurse can complete an AIMS evaluation.Interview with the Assistant Directive of Nursing (ADNS) on 1/2/26 at 1:22 PM identified hospice was responsible for completing an AIMS and that an AIMS was completed 8/20/25 (after 7 pharmacy recommendations for completion of an AIMS). Also, identifying she herself was trained to complete an AIMS evaluation and the expectation was that APRN #3 would communicate that she could not complete an AIMS due to Resident #14 being on hospice. The ADNS could not recall having a conversation with APRN #3. The facility did not have a policy on AIMS evaluations but identified she was responsible for reviewing the Pharmacy medication review recommendations and an AIMS evaluation should have been completed in March 2025 (it was completed on 8/20/25).Review of the policy for Pharmacy Medication Review dated 4/2023 identified the medication regime of each resident should be reviewed monthly, findings, recommendation are communicated to those with responsibility to implement the recommendations and to answer in a timely fashion. Also, identifying the consultant pharmacist will submit their monthly recommendations reports to the DNS and follow up on the recommendations to verify that appropriate action has been taken and or responded to within a reasonable time frame.

Based on review of the clinical record, facility documentation, and interviews for 1 of 2 (Resident #116) reviewed for positioning/mobility, the facility failed to provide rehabilitation services as recommended by the orthopedic physician. The findings included:Resident #116 was admitted to the facility in September 2024 with diagnoses that included pain to lower back, right shoulder, and left thigh, effusion of left knee (swollen joint), and spondylosis cervical region (fracture of vertebrae). The annual Minimum Data Set assessment dated [DATE] identified Resident #116 had intact cognition and was independent with all activities of daily living.The Resident Care Plan dated 9/16/25 identified Resident #116 had actual/potential for pain related to chronic pain syndrome, right shoulder bursitis, left knee effusion, lumbar spinal stenosis, and cervical spondylosis. Interventions included to administer medications as ordered for pain, identify and treat resident' existing conditions, monitor and document probable causes of each pain episode and remove and limit causes whenever possible, splint and brace to left knee, and physical/occupational referrals as ordered.Physician orders dated 10/27/25 directed an orthopedic consult for left knee pain.The clinical record indicated that Resident #116 was referred to an orthopedic on 10/27/25 based on results of a Magnetic Resonance Imaging (MRI) of the left knee performed on 9/23/25. Resident #116's MRI results indicated a complex tear of the meniscus (torn cartilage), sprain of lateral ligament, and small bone marrow contusion involving the lateral proximal tibia. Resident #116's orthopedic physician responded to the referral request with a recommendation on 11/4/25 to have Resident #116 start with physical therapy and if no positive outcome, then refer to orthopedic. The clinical record lacked documentation that a referral for physical therapy was initiated for the left knee in November 2025.Interview with Resident #116 on 12/30/25 at 11:15 AM indicated that he/she was having significant pain to his/her left knee and that he/she had not received any therapy for his/her left knee recently. Resident #116 indicated that he/she thought that MRI revealed some type of tear to the left knee and that he/she was supposed to receive physical therapy.Interview with the DNS on 1/5/26 at 9:10 AM identified that she was not aware of the orthopedics' recommendation for physical therapy and that the standard process was that nursing would complete a communication sheet to therapy indicating an order for physical therapy. The DNS indicated that she could not locate any communication to therapy regarding the recommendation for physical therapy from the orthopedic office. The DNS indicated that it was nursing's responsibility to notify physical therapy if there was a recommendation for services and she was unsure of why it was not completed.Interview with Occupational Therapist (OT) #1 on 1/5/26 at 9:20 AM identified that Resident #116 had not received any physical therapy in November 2025 or December of 2025 for his/her left knee. OT #1 could not locate a referral or a nursing to therapy communication sheet for November 2025 regarding Resident #116's left knee. OT #1 indicated that the last referral received was on 10/9/25 for recent Resident #116's weight loss. OT #1 indicated that nursing would either provide therapy with a communication sheet requesting a resident to be seen or a copy of the actual referral/order for physical therapy. OT #1 indicated that at a minimum, therapy would have conducted an evaluation of Resident #116 related to the orthopedics recommendation for physical therapy had they been notified. Interview with Advanced Practice Registered Nurse (APRN) #1 on 1/5/26 at 12:30 PM indicated that she was not aware that Resident #116 did not receive physical therapy for the left knee. She indicated that although she initialed and dated the orthopedic fax sheet recommendation for physical therapy on 11/4/25 it was her expectation that nursing would follow up on the recommendation to ensure the referral was made to physical therapy.Although requested a policy on physical therapy and nursing to therapy communication was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled resident (Resident #107) reviewed for falls, the facility failed to provide the required notification of the transfer/discharge to the state Ombudsman's office. The findings include: Resident #107's diagnoses included chronic obstructive pulmonary disease, dementia, and spinal stenosis.The Resident Care Plan (RCP) dated 7/5/25 identified Resident #107 had the potential to fall with interventions that included to assist Resident #107 with transfers and ambulation as ordered, and to wear appropriate footwear when ambulating or when the resident was in the mobilized wheelchair. Additionally, the RCP identified Resident #107 had a deficit of functional mobility due to weakness with ambulation. Interventions included to provide and use a mechanical lift with transfers with 2 staff and provide positioning while out of bed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #107 had a severe cognitive impairment, was dependent with bed mobility, transfers, dressing, toileting, eating, and personal hygiene.A nursing note dated 10/12/25 at 10:09 PM identified Resident #107 fell on [DATE] at 3:10 PM and sustained a laceration above the right eyebrow and was sent to the hospital at 3:30 PM.A nursing note dated 10/12/25 at 10:48 PM identified Resident #107 was admitted to the hospital.A nursing note dated 10/14/25 at 7:45 PM identified Resident #107 returned to the facility (2 days after being transferred to the hospital) with a laceration to the left side of his/her forehead with 5 sutures in place.On 12/31/25 at 12:55 PM an interview with Social Worker (SW) #1 identified that she started working at the facility on 11/24/25 and notification to the Ombudsman was not sent for Resident #107 because SW#1 did not have access to the electronic portal for submitting. SW #1 identified the social workers were responsible for notifying the Ombudsman's office of all transfers/discharges and that she has full access to the portal now.On 12/31/25 at 1:05 PM an interview with the DNS identified that the social workers were responsible for notifying the Ombudsman of all transfer/discharges. Subsequent to surveyor inquiry, the facility updated the Ombudsman's office through the electronic portal on 1/1/26 regarding Resident #107's transfer/discharge to the hospital on [DATE].On 1/05/2026 at 9:09 AM an interview with SW #1 identified that she submitted the notification of the transfer/discharge of Resident #107 to the Ombudsman on 1/1/26 because she did not have access to the portal at the end of November. Also, identifying SW#1 did notify the Administrator on 11/26/25 that she did not have access to the portal but couldn't remember when she gained access to the portal.Review of the facility's Admission, discharge policy dated 6/2025 identified the facility was to provide each resident with a safe transition of care that meets the resident's established goals. Also, identifying the Ombudsman's office was to be notified of discharges per state and federal regulations.

Based on record review and staff interview for 1 of 6 sampled residents (Resident #2) review for Pre-admission Screening Resident Review (PASRR), the facility failed to notify the PASRR agency to complete a Level 2 screen for a resident with a psychiatric diagnosis. Resident #2 was admitted to the facility on [DATE] from another long-term care facility with diagnoses that included psychotic disorder with hallucinations related to physiological conditions, Parkinsons disease and hypertension.A Level 1 PASRR screen dated 2/1/19 (transferred with Resident #2 from the previous long term care facility) identified Resident #2 had no psychiatric history and therefore a Level 2 evaluation was not required.Psychiatric progress notes written by an Advanced Practice Registered Nurse (APRN) dated 10/20/25 identified Resident #2 had a psychotic disorder, stable on current psychiatric medications, resident denies psychiatric history, despite previous psychiatric diagnoses.On 1/5/26 at 10:18 AM, interview and clinical record review with the Social Worker (SW) failed to identify the PASRR agency had been notified of a need to complete a Level 2 assessment for Resident #2's psychiatric diagnosis. SW further identified the psychiatric group notifies her verbally when residents develop a new psychiatric diagnosis. The SW further identified that she would be responsible for notifying the PASRR agency, but she was not employed at the facility during that time frame.Subsequent to surveyor inquiry, the facility notified the PASSR agency on 1/6/26, a Level 1 screen was completed, resident was approved for long term and indicated a Level 2 was not indicated. Facility policy regarding Pre admission Screening and Resident Review dated April 2023 indicated routine clinical record reviews and facility communication assists the facility to identify residents with newly evident or possibly serious mental disorder or a related condition after admission to the facility.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure supervision was provided in accordance with the resident plan of care, to prevent a resident incident. The findings include: Resident #1 had a diagnosis of dementia, major depressive disorder, anxiety, and cognitive communication deficit. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severely impaired cognition, and was independent with ambulation. The Resident Care Plan (RCP) dated 5/20/2025 identified the family approved a relationship with Resident #2. Interventions directed staff to supervise Resident #1 when resident visits Resident #2. Resident #2 had a diagnosis of dementia, anxiety, depression, and cognitive communication deficit. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS of three (3), indicating severely impaired cognition, and was independent with ambulation. The RCP dated 5/15/2025 identified the family approved a relationship with Resident #1. Interventions directed social services visits as indicated and directed every 15-minute checks. Facility reportable event dated 5/14/2025 at 9:50 AM identified NA #2 observed Resident #1 and #2 sitting on a couch next to each other and Resident #2 commented to Resident #1 you will never look as good as you used to. Resident #1 became upset and attempted to stand to move away. Resident #2 grabbed Resident #1's arm and stated he/she was not going anywhere. Resident #2 was placed on one-to-one (1:1) observation and transferred to the hospital for evaluation. Facility summary dated 5/19/2025 identified when Resident #1 had attempted to walk away from the couch, Resident #2 held onto Resident #1's arm. Resident #1 was assessed with no injuries identified. Resident #2 returned from the hospital with no new orders. The residents both resided on the same floor, and after the incident, Resident #2 was moved to another floor. 1. The nursing note dated 6/13/2025 at 10:55 PM identified a NA observed Resident #1 in bed with another resident, and both residents had no clothes on. When the nurse observed both residents in the room, they were fully dressed. An assessment was completed for Resident #1, no injuries were noted and no signs of bruising or swelling to the peri area was noted, and the resident denied discomfort. Facility reportable event incident report dated 6/13/2025 at 10:35 PM identified Resident #1 was observed lying in Resident #2's bed with Resident #2 without clothing on. Resident #1 had a BIMS of four (4) and Resident #2 had a BIMS of three (3), both indicated severe cognitive impairment. The residents were separated, an assessment was completed for Resident #1 and identified no injuries, and then the residents were dressed. Both residents yelled at staff to leave them alone because they are adults and should be able to lay down in bed together. Both residents were placed on 1:1 observation. The facility investigation identified NA #1 was completing unit rounds and had observed Residents #1 and #2 sitting together in Resident #2's room with the door open. NA #1 then went to provide care for a resident located about four (4) doors down. Approximately 15 to 20 minutes later, NA #1 left the other resident room and walked down the hall to check on Residents #1 and #2 and observed the door to Resident #2's room was closed. NA #1 knocked on the door, entered the room, and observed Residents #1 and 2 in Resident #2's bed without wearing any clothing. NA #1 separated the residents and directed them to get dressed. Nursing note dated 6/13/2025 at 11:09 PM identified Resident #2 refused a body assessment. Record review identified although Resident #1's care plan directed to supervise Resident #1 when he/she visited with Resident #2, and staff were aware the residents were together on 6/13/2025, review failed to identify that supervision was provided timely in accordance with the plan of care when the residents were observed together in the room on 6/13/2025. Interview and record review with RN #1 on 6/26/2025 at 12:11 PM identified she was called to Resident #2's room around 8:45 PM because NA #1 had reported Resident #1 and Resident #2 were found in bed together naked. Upon arriving in the room, both residents were dressed after directed by staff. An assessment was completed for Resident #1, and no injuries were noted. Resident #2 refused an assessment and stated he/she was fine. RN #1 then called the Director of Nursing (DON) and notified the required parties. RN #1 stated the residents were supposed to have constant supervision when they were together, and she did not know why NA #1 did not supervise the residents. RN #1 stated NA #1 should have stayed with the residents when she observed them alone in Resident #2's room. Interview with NA #1 on 6/26/2025 at 12:48 PM identified she first saw Resident #1 and Resident #2 together in the hallway at 8 PM and when she checked on the residents again, she found them in Resident #2's room around 8:25 PM. At that time both residents were fully clothed and were sitting on the bed. NA #1 then went to provide care for another resident and when she returned to check on the residents 20 minutes later, she observed them both in Resident #2's room, laying on the bed without any clothes on. NA #1 stated she did not witness either resident harm the other and did not witness any sexual acts being performed. NA #1 stated Residents #1 and #2 were supposed to be supervised when they were together and she thought they were supposed to be checked on every 15-minutes when they are together per the care plan. Interview and record review with the Administrator and Assistant Director of Nursing (ADNS) on 6/26/2025 at 1:22 PM identified RN #1/supervisor notified them that Resident #1 and Resident #2 were found in bed with no clothes on on 6/13/2025. Interview identified the resident assessments identified no injuries and staff indicated they did not observe any sexual acts were observed. The ADNS and Administrator indicated Residents #1 and #2 were allowed to be together in Resident #2's room, but they should have been supervised when they were together. Interview identified although NA #1 had checked on the residents, interview failed to identify why supervision was not provided, in accordance with the plan of care. Review of Baseline/Comprehensive Person-Centered Care Plan policy dated March 2023 directed in part, all clinical department heads are responsible to ensure implementation of the resident care plans.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three Residents (Resident #1) reviewed for nutrition, the facility failed to provide a timely Dietician evaluation to address a documented significant weight loss. The findings include: Resident #1 was admitted to the facility with diagnoses that included Diabetes Mellitus, dysphagia, anemia, heart failure and chronic kidney disease. The Resident Care Plan (RCP) dated 4/1/2025 identified Resident #1 had nutrition related diagnoses of increased nutrient needs, malnutrition, a chronic wound and altered gastrointestinal status due to constipation, nausea and reflux. The RCP directed to allow Resident #1 time to eat, line of sight supervision at meals and a ground texture, thin consistency diet. A Dietician evaluation dated 5/6/2025 identified Resident #1 as a high risk for weight loss/nutritional needs and noted a 5 % weight loss over a month and a 11.4 % weight loss over a 6-month time frame. A protein supplement and weekly weights were ordered. A weight dated 5/9/2025 at 2:26 PM was 130.9 pounds (lbs.). A reweight dated 5/23/2025 at 1:48 PM was 121 lbs. A 9.9 lbs. (7.6 %) weight loss in 2 weeks. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of 6), required maximal assistance for eating and was dependent for care. A reweight dated 6/2/2025 at 2:50 PM was 113.8 lbs. A 17.1 lbs. (13 %) weight loss in 3 weeks. A Nutrition note dated 6/3/2025 at 12:43 PM identified Resident #1 was seen for follow up and re-evaluation of weights. Resident #1's diet was house minced, moist and mildly thickened liquids noting intake at 0-100 % consumption of meals with a liquid protein supplement daily. Resident #1 had a stage 3 pressure wound to the right foot and unstageable pressure wounds to the sacrum and right lateral foot. A weight on 6/2/2025 was 113.8 lbs. with a weight on 5/2/2025 of 132.6 lbs. A severe weight loss times 1 month was identified. Recommendations included continuing with weekly weights and supplement changed to frozen nutrition cup three times a day. The liquid protein supplement was increased to twice a day. Interview with the Dietician on 6/18/2025 at 11:44 AM identified she last evaluated Resident #1 prior to 6/3/2025 on 5/6/2025 as part of a readmission review. She identified that she evaluated residents on admission, readmission, quarterly and for a significant change in condition including weight loss. She indicated she printed a weight/dietician report from the electronic medical record system (EMR) when in the facility and reviewed the report in the morning on her scheduled workdays (3 days per week) to determine what residents she needed to evaluate. She further indicated the nursing staff would add residents to her report through the EMR to notify her that an evaluation was needed. She identified she checked weights for high-risk residents such as Resident #1 when she reviewed the weight report each time she worked. She could not recall if she identified Resident #1's 5/23/2025 weight or weight loss. She indicated that there were a lot of residents on the weight report who were high risk and at times she had to prioritize who she would see. She identified that the 5/23/2025 weight of 121 lbs. was a 7.6 % loss in 2 weeks. She defined a significant weight loss as 5 % or greater weight loss in 30 days or 10 % weight loss in 6 months or 180 days. Interview with the Director of Nurses (DNS) on 6/18/2025 at 1:00 PM identified that a weight change of 5% or more should be reported to the supervisor who would contact the Dietician. She did not know why LPN #1 did not notify the supervisor of the weight change on 5/23/2025 and indicated the Dietician should have evaluated Resident #1 immediately or within a few days of the identified weight change. She did not know why the Dietician did not evaluate Resident #1 prior to 6/4/2025 as the weight reports that are generated included all of Resident #1's recorded weights. Attempts to contact LPN #1 were unsuccessful during the survey. The facility policy Weight policy and procedure dated 10/2023 directed in part significant weight change are verified and if the verified weight (reweigh) indicated a significant weight change, the interdisciplinary team will be notified and the plan of care revised as appropriate. Parameters for evaluating the significance of weight loss was 5 % in 30 days, 7.5 % in 90 days and 10% in 180 days. Although requested, the facility identified they did not have a policy that addressed the dietician evaluation of a significant weight loss.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1 and #3) reviewed for pressure injuries, the facility failed to complete and document skin risk assessment weekly post re-admission per facility protocol. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, peripheral vascular disease and sepsis. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of ninety-nine (99) indicative of impaired cognition, was at risk for developing pressure ulcers/injuries, was frequently incontinent of bowel and required extensive assistance of two staff with activities of daily living (ADL's). The care plan dated 9/3/24 identified Resident #1 had impaired skin integrity and was at risk for further skin breakdown with interventions that included a low air loss (LAL) mattress, educate on risks to wound healing, inspect skin during care, offload heels and keep blue boot on Resident #1 while in bed to prevent pressure on the heel. A skin assessment dated [DATE] identified Resident #1 had no new wounds. Resident #1 failed to have a skin assessment completed on 10/10/24. Review of Resident #1's medical record identified Resident #1 was sent to an in-patient psychiatric facility on 10/11/24 and then was admitted to the hospital from [DATE] - 11/9/24. Resident #1's discharge summary identified ulceration to the left anterior toe, anterior foot and distal planter. A physician's order dated 11/9/24 directed Braden scale (measures patients risk of developing pressure injuries) completed for four weeks on admission and then annual and as needed. The Braden scale dated 11/9/24 identified Resident #1 was a moderate risk. However, review of Resident #3's medical record did not identify weekly ski assessments thereafter for four (4) weeks in accordance with physicians orders. 2. Resident #3 was admitted to the facility with diagnoses that included metabolic encephalopathy and heart failure. The Braden scale dated 1/21/25 identified Resident #3 was a moderate risk. The admission assessment dated [DATE] identified Resident #3 was alert and orientated to person, place and time and had no impairments with ADL's. Review of Resident #3's medical record identified Resident #3 was in the hospital from [DATE] - 1/30/25. Review of Resident #3's medical record failed to identify Resident #3 had a Braden scale completed upon re-admission to the facility and weekly thereafter for four (4) weeks in accordance with physicians orders. The care plan 1/31/24 identified Resident #2 had a stage three pressure ulcer on the coccyx with interventions included encourage and assist to reposition off back frequently, treatment as ordered, weekly wound evaluation and low air loss mattress. Interview with the Clinical Director on 2/20/25 at 1:00 PM identified per policy, Braden evaluations are to be completed on admission/re-admission and then weekly for four weeks. Review of the pressure injury prevention policy directed the licensed nurse will complete a Braden/[NAME] evaluation for all residents upon admission/re-admission. The Braden/[NAME] evaluation will be completed weekly x 4 weeks post admission/re-admission.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from neglect and care was provided timely. The findings include: Resident #1 was admitted with diagnoses that included a stroke with hemiplegia/hemiparesis (weakness/loss of movement) affecting the right dominant side. A quarterly MDs assessment dated [DATE] identified Resident #1 BIMs was 99, indicating Resident #1 was severely cognitively impaired and could not complete the interview, and Resident #1 did not speak, rarely understood verbal content and had highly impaired vision. Resident #1 was at risk for pressure ulcers, was incontinent, was dependent for all care, required two (2) staff for bed mobility and transfers. The RCP dated 8/12/2024 identified Resident #1 was incontinent of bowel and bladder. The RCP directed to provide incontinent care every two (2) to three (3) hours and use of incontinent briefs. A facility incident report dated 10/21/2024 identified an event of neglect: on 10/21/2024 at 4:00 PM. The report indicated Resident #1 was aphasic (unable to speak), and required total care for ADLs, and it was observed that Resident #1's bed linen had a yellow dried ring under the resident's buttocks. Incontinent care was not provided for two (2) hours beyond the care planned time frame and NA #1 was suspended pending investigation. A facility event summary dated 10/25/2024 identified there were no known negative effects due to extended hours of before incontinent care was provided (beyond what was care planned). Resident #1's skin was intact without maceration, redness or open areas. Resident #1 was bathed and showered after the event was discovered. The summary indicated NA #1 was new to the facility and new to a long-term care setting, there was no intent, and education was provided for NA #1. RN #1's written statement dated 10/21/2024 identified at approximately 4 PM she observed Resident #1 lying in bed and the drawsheet was stained with a dry yellow ring under his/her buttocks, and the brief was soiled but drying, and was wearing two (2) briefs. Incontinent care was not provided in a timely manner. NA #1 written statement dated 10/21/2024 identified care was NA #1 provided personal care at 11 AM and placed one (1) brief under and one (1) brief over Resident #1. The statement further indicated although she repositioned Resident #1 after 11 AM, NA #1 was unsuccessful providing future care (during the shift) due to Resident #1 was resisting and she was struggling to complete her assignment. Statement review identified NA #1 did not provide care between 11 AM and 3 PM. Interview with RN #1 on 10/30/2024 at 11:33 PM identified she was the nursing supervisor on 10/21/2024 when about 4:00 PM, Resident #1's visitor (Person #1) requested her to look at Resident #1. RN #1 stated the draw sheet under Resident #1 had a large yellow ring, there were two (2) briefs both saturated with urine in place and Resident #1's clothing appeared dry without stains. Resident #1's skin had no open areas or visible redness, she immediately notified the DON and asked NA #3 to provide care (5 hours after incontinent care was provided by NA #1). She identified that incontinent residents should be provided incontinence care every two (2) hours. Interview with NA #1 on 10/31/2024 at 10:30 AM identified she was assigned Resident #1 on 10/21/2024 and was the only NA on that wing of the unit. NA #1 stated she had not worked in long-term care previously, had recently ended her orientation and had not worked with the residents on that unit. NA #1 stated she knew Resident #1 required two (2) staff for care, and needed to be repositioned and checked for incontinence every two (2) hours. NA #1 identified that she provided care at 11 AM by herself as she could not find any other available staff to assist her, so she did not get Resident #1 out of bed as per his/her routine. She continued that she attempted to turn and position Resident #1 every two (2) hours but could only turn him/her slightly to the side to tuck a pillow under him/her because she did not have a second staff to assist, and she did not check each time for incontinence. NA #1 stated went over to the other side of the unit to ask for help, but everyone seemed very busy, and she did not notify the nurse (LPN #2). Interview with LPN #2 on 10/30/2024 at 12:30 PM identified she was the charge nurse on 10/21/2024 on the day shift and she was not aware Resident #1 did not receive care timely. LPN #2 stated she was not notified that NA #1 was unable to provide the care timely and there other NAs available that NA #1 could have also asked for help. Interview with the DON on 10/30/2024 at 1:50 PM identified that she expected the staff to provide every two (2) hour incontinence care for dependent residents. NA #1 identified she provided incontinent care for Resident #1 on 10/21/2024 at 11:00 AM but did not provide any additional incontinence care for the remainder of her shift (4 hours from 11 AM to 3 PM) on 10/21/2024. The DON stated NA #1 was off orientation and the workload that day was too much for NA #1, and she fell behind. The DON stated NA #1 should have asked for help, and she was unable to explain why NA #1 did not ask for help or let other staff know that she could not complete her assignment. Further, LPN #1 should have checked in or followed up with NA #1 to ensure care was provided timely. Subsequent to the incident, NA #1 was provided with additional orientation time. The facility policy Abuse dated 12/2023 directed in part, that all residents have the right to be free from abuse and neglect. Neglect is defined as the failure of the facility its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Facility documentation review identified staff education was initiated on 10/21/2024 and included providing personal care and incontinent care timely and to report refusals of care to the nurse. Random audits were initiated on 10/21/2024 and a QAPI meeting was held on 10/24/2024. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record, review of facility documentation, and staff interviews for 1 of 1 sampled resident (Resident #101) reviewed for non-compliance with smoking, the facility failed to provide adequate supervision and failed to implement interventions to prevent an accident hazard after repeated incidents of noncompliance related to smoking. These failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #101 was admitted to the facility on [DATE]. The resident's diagnoses included cellulitis of abdominal wall, alcohol abuse and nicotine dependence. Resident #101 had a conservator of both estate and person. The Admission Smoking Evaluation assessment dated [DATE] identified no desire to smoke at the time of the admission. The Resident Care Plan (RCP) dated 3/14/24 identified both short- and long-term memory loss. Interventions included referring to time of day, date, and recent events with interactions, and to utilize simple direct communication, verbal cues, and task segmentation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #101 as moderately cognitively impaired and noted the resident utilized a walker for mobility. 2. Resident # 95 was admitted to the facility on [DATE] who shared a room with Resident # 101. The resident's diagnoses included dependency on supplemental oxygen and Chronic Obstructive Pulmonary Disease (COPD. The RCP for diagnosis of COPD dated 3/12/24 with a revision on 3/14/24. Interventions included administering oxygen at 2-3 liters/minute via nasal cannula continuously and to monitor effectiveness by checking saturation as indicated. The admission MDS assessment dated [DATE] identified the resident as cognitively intact, independent with self-care, utilized a wheelchair for mobility and noted continuous oxygen therapy. The physician admission orders dated March 3/13/24 through 4/22/24 directed to administer oxygen via nasal cannula at 2-3 liters /minute and to check pulse oximetry every shift. The social service notes dated 3/15/24 at 1:40 PM identified Social Worker (SW #1) observed Resident #101 and a visitor smoking in the visitor's car in the facility's parking lot. SW #1 indicated both were informed there is no smoking on facility's grounds even if the resident signed out on a Leave of Absence (LOA). SW #1 indicated she met with Resident #101's Conservator of Person and Estate (Resident # 95) who indicated s/he was unaware of Resident #101 smoking on LOA. The charge nurse and Administrator were made aware of the incident. Additionally, SW #1 advised the charge nurse to search Resident # 101 upon return to the facility. A review of the clinical record dated 3/15/24 through 3/20/24 failed to identify the facility conducted a new Smoking Evaluation Assessment when Resident # 101 was found smoking in the car on facility grounds. The social service notes dated 3/21/24 at 10:33 AM identified SW #1 met with Resident #101 as s/he attempted to leave the building to walk over to the street to smoke a cigarette. Resident #101 was advised s/he could not leave the facility on LOA without the responsible party's permission. SW #1 also advised Resident # 101 that smoking materials are not allowed or kept on his/her person. When asked to hand over smoking materials, Resident #101 aggressively threw a bag containing 2 cigarettes. Resident # 101 emptied her/his pocket, and two cigarette butts were found but no lighting material. Resident # 101 was escorted back to her/his room and the Director of Nursing Services (DNS) was updated. The RCP dated 3/22/24 for Resident # 101 identified a history of smoking with interventions which included offering nicotine patches, social services to address smoking cessation, social service to provide emotional support to address smoking cessation and to conduct every fifteen- minute checks. The social service notes by SW#1 of 3/26/24 at 11:12 AM identified she found a lighter on Resident #101's tray table. The charge nurse, supervisor, and DNS were made aware. However, the clinical record failed to provide evidence that interventions were implemented at the time of the non-compliance with the possession of smoking materials. The social services notes by SW #1 on 4/2/24 at 3:07 PM identified she spoke to Resident # 95 (conservator for Resident # (101) about transfer to a skilled nursing facility that permits smoking and Resident # 95 indicated s/he would speak to Resident # 101. A nurse's note on 4/4/24 at 5:05 PM identified Resident #101 returned from LOA at 5:00 PM, a room search was conducted, cigarettes and a lighter were found. Resident #101 was educated on the facility's no smoking policy. The clinical record failed to provide evidence that interventions were implemented at the time of the non-compliance with the possession of smoking materials. The nurse's notes dated 4/4/24 at 7:57 PM identified Resident # 101 returned from LOA at 5:00 PM. Upon Resident # 101 returning to the facility, the charge nurse entered the resident's room and noted a strong cigarette smell. When asked if s/he (Resident # 101) was smoking s/he denied smoking in the room. The charged nurse advised the resident s/he would need to be searched for cigarettes. Upon checking Resident # 101, a pack of cigarettes and lighter were found. Resident # 101 was educated on the importance of following facility rules and no smoking as well as safety when oxygen is in use. Resident # 101 expressed s/he was going to find a facility that allows smoking, and the supervisor was updated. The nurse's notes dated 4/4/24 at 10:25 PM identified Resident # 101 was found smoking again in her/his room by the charge nurse. Resident #101 was educated again that s/he cannot smoke in the facility or on facility grounds. Resident # 101 was educated again that Resident # 95 was in the room on oxygen and her/his smoking could cause a fire while smoking. Resident #101's smoking materials were confiscated. The nurse's note on 4/4/24 at 10:58 PM identified Resident #101 was found on her/his bed smoking a cigarette, room search conducted again identified another pack of cigarettes and two liquor bottles. Resident # 101 was intoxicated, and the staff was directed to transfer the resident to an acute care facility for an evaluation. The nurse's notes dated 4/4/24 also directed to conduct every fifteen- minute check. A nurse's note on 4/4/24 at 11:27 PM identified Resident #101 refused to go to the acute care facility and 15-minute check were maintained. A review of every fifteen- minutes check from 3/24/24 through 4/5/24 identified missing checks for 3/11/24 to 3/14/24, 3/22/24 to 3/31/24 and 4/1/24 to 4/3/24. The social services note dated 4/5/24 at 8:50 AM by SW #1 identified she and the Assistant Director of Nursing Services (ADNS) met with Resident # 101 as cigarettes, vape cartridges and empty alcohol containers were found in the resident's room. When questioned about the empty alcohol containers Resident #101 indicated s/he drank the alcohol at the facility. Resident # 101 was educated again on facility non-smoking policy. SW#1 informed Resident # 101 she had found a smoking facility that would take the resident. However, Resident # 101 declined transferring to a smoking facility. Upon further inspection of Resident # 101 bathroom, cigarettes were found in the trash and a strong smell of cigarettes was evident. Resident # 101 denies smoking in the bathroom and was educated that this behavior cannot continue. Resident # 101 was offered again a skilled nursing bed at a smoking facility which s/he declined and indicated s/he would call a friend to see if s/he could live with the friend. The social services notes by SW#1 on 4/5/24 at 12:22 PM identified she and the ADNS informed Resident #101 s/he would be receiving a room change. The reason for the room change was secondary to Resident # 101 smoking in the bathroom and Resident # 95 was on oxygen. SW#1 also explained the room change was to keep both residents safe. SW#1 discussed Resident # 101 moving to a smoking facility on Monday 4/8/24 and Resident # 101 declined and indicated s/he would sign out Against Medical Advice (AMA). Interview with SW #1 on 4/16/24 at 11:25 AM identified when Resident #101 leaves for LOA s/he returns to his/her apartment. SW #1 identified she believed Resident #101 continues to be a smoking risk and matters regarding smoking non-compliance have been reported to both Administrator and the DNS. Interview and clinical record review with the DNS 4/16/24 at 11:40 AM identified Resident #101 is conserved by Resident #95. The DNS identified Resident #101 has physician's orders for a LOA with a responsible party. The DNS also failed to identify any additional interventions to maintain safety of the residents as Resident #101 continued to smoke in the facility. The DNS identified the facility had concern with how to maintain Resident #101's Resident's Rights for LOA and safety and how to address the multiple non-compliance with smoking. The DNS indicated she recognized a pattern of non-compliance smoking shortly after Resident #101 returned from the LOAs at which time she spoke to the party who signs Resident #101 out of the facility for the LOAs. However, the DNS was unable to provide any documentation to support the conversation(s). The DNS indicated a smoking cessation patch was offered to Resident #101 however, the patch was declined. The DNS failed to provide documentation to support the cessation patch offering. Interview with the Administrator on 4/16/24 at 3:40 PM. identified she could not provide an explanation as to why a discharge notice for Resident #101 who was non-compliant with the smoking policy was not implemented and failed to provide any additional interventions to keep the residents of the facility safe. Interview and clinical record review with the DNS and the Administrator on 4/22/24 at 10:47 AM and 1:05 PM identified when Resident # 101 was admitted to the facility on [DATE] during the smoking evaluation the resident indicated s/he had no desire to smoke. Resident # 101 also refused smoking cessation patches. The DNS was unable to provide documentation that a smoking reassessment was conducted when Resident # 101 violated the smoking policy after admission. The Administrator indicated the facility was concerned with not violating Resident# 101's LOA and Residents Rights and they did not know how to manage the resident's non-compliance with smoking without violating the resident's right. The DNS indicated on 4/5/24 when Resident # 101 was noted smoking in the room with Resident # 95 who utilized continuous oxygen, the social worker offered a room change. Resident # 101 was offered several transfers to a smoking skilled nursing facility, but she kept declining. The DNS indicated although the facility had instituted every fifteen-minute checks on 3/11/24 per care plan for history of smoking, she was unable to provide the missing every fifteen-minute checks for 3/11/24 to 3/14/24, 3/22/24 to 3/31/24 and 4/1/24 to 4/3/24. The DNS also indicated s/he could not provide any additional interventions put in place to monitor the resident's non-compliance with smoking after every fifteen-minute check on 3/11/24 identified on the care plan. The DNS indicated staff did conduct occasional room searches. The DNS further indicated now that she thought about the incident, she could have instituted 1:1 monitoring for Resident # 101 smoking non-compliance. Interview with the Medical Director on 4/22/24 at 1:35 PM identified Resident # 101 was offered a nicotine patch but Resident # 101 declined because Resident # 101 did not feel s/he needed the patch. The Medical Director indicated s/he would expect the facility to follow the smoking policy as it pertains to non-compliance with smoking. The Smoke-Free Environment policy states that smoking by residents is prohibited in all indoors and on facility outdoor grounds. Residents who violate the smoking prohibition will have their contraband confiscated, counseled by social services, and be advised their right to seek alternate placement at a facility where smoking may be permitted. If the resident does not agree to observe the smoke-free environment policy and procedure, a discharge notice will be issued, and discharge planning will be implemented. The resident will be monitored to ensure compliance with the facility smoke-free environment policy until a safe discharge is arranged. The facility failure to supervise and implement interventions to address Resident # 101's several non-compliance with smoking and smoking in the presence of oxygen therapy resulting in a finding of Immediate Jeopardy. The Administrator was presented with the Immediate Jeopardy Template on 4/22/24 at 2:00 PM for F689 Free of Accident Hazards/supervision /devices. The facility submitted a removal plan on 4/22/24 with revision on 4-23-24 which included: 1. Any resident has the potential to be affected by this alleged deficient practice. 2. The facility policy titled Smoking Policy was reviewed and remains current. 3. All licensed staff prior to working were provided education on the facility smoking policy, all licensed staff was provided education on the use of oxygen present with a smoking resident, education provided on significant harm that could occurred, education provided on at risk factors involved in active smoking resident in the facility, staff educated on supervision needed to be provided with cognitively impaired residents who wishes to smoke. 4. All residents will be educated on the facility smoking policy and educated the facility is a non-smoking facility. Residents will be educated on risk factors involved with smoking materials, contraband usage in the facility. Current residents in the facility will be educated immediately, and all new admissions will be educated upon admission. 5. Smoking evaluations audits will be performed on all residents currently in the facility immediately, and quarterly, and any resident who chooses to smoke in the facility will be offered a transfer to a smoking facility, the resident will be assessed to determine if a nicotine patch is appropriate, audit will be conducted to ensure all assessments have been done for all residents, concerns for any resident will be addressed immediately and the physician and family will be notified of any concerns. 6. Random audits will be completed 5 times a week for one month, 3 times a week for one month and then weekly for 3 months. The results of the audit will be presented at Quality Assurance and Improvement Program as required. 7. The DNS or designee is responsible for the completion of this Plan of Correction. 8. The facility alleges the removal of the Immediate Jeopardy was on 4/22/24.

Based on observation, review of the clinical record reviews, facility policy, and interviews for 2 of 4 residents (Resident # 418) reviewed for pressure ulcers, the facility failed to perform wound care as prescribed by the physician to prevent further skin breakdown and for (Resident # 90), the facility failed to ensure weekly skin audits were completed in accordance with the facility policy. The findings included: 1. Resident #418 was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia (paralysis of the legs and lower body). The care plan dated 6/20/22 for at risk for further skin breakdown. Interventions included to inspect skin for redness, irritation or break down during care., to apply a low air loss mattress, offer turning and repositioning approximately every two hours and when needed, pressure reducing cushion/mattress when needed, weekly skin inspections and treatment as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #418 required extensive assistance from at least two people for bed mobility and transfers. Additionally, the MDS identified Resident #418 had two stage 3 pressure ulcers. The physician's orders 6/17/22 through 7/27/22 directed to offload heels every shift as tolerated. A wound physician progress note dated 8/2/22 identified a new wound on the left heel. The wound was noted as a Deep Tissue Injury (DTI) with maroon or purple discoloration. The wound measured 0.5 cm in length x 0.5 cm in width x 0.0 cm depth. The wound was noted with no drainage. New recommendations for treatment directed the application of skin prep, an abdominal pad dressing, and a rolled gauze dressing daily and when needed. A nursing pressure injury evaluation dated 8/3/22 indicated an initial evaluation for a left heel unstageable pressure ulcer with a healthy wound edge and no drainage. The size of the wound measured 0.5 cm L x 0.8 cm W x 0 cm D. The nursing evaluation further indicated the physician was notified and treatment orders included daily and as-needed dressing changes with skin prep, an abdominal pad dressing, and a kerlix (rolled gauze) dressing. The nurse's notes dated 8/3/22 at 4:13 PM identified a left heel Deep Tissue Injury (DTI) measuring 0.5 cm by 0.8 cm by 0.0 cm. Resident # 418 was seen by the wound specialist and denied pain. A new treatment order directed to apply skin prep, followed by kerlix change, encourage resident to keep heels offload. A wound physician's progress note dated 8/9/22 identified a left heel pressure injury was reclassified as a stage 2 pressure ulcer. The wound physician's progress notes further identified the wound as deteriorating. The wound had a moderate amount of sero-sanguineous drainage and measured 0.5 cm L x 0.5 cm W x 0.1 cm D. New recommendations for treatment included daily and as-needed dressing changes with Dakin's 1/4 strength, silver alginate with the application of a bordered foam dressing. A wound physician's progress note dated 8/16/22 identified a left heel stage 2 pressure ulcer was overall stable with a moderate amount of sero-sanguineous drainage and measured 0.5 cm L x 0.5 cm W x 0.1 cm D. New recommendations for treatment included daily and as needed dressing changes with Dakin's 1/4 strength, application of alginate, application of Medihoney, and application of a bordered foam dressing. A wound physician's progress note dated 8/23/22 identified a left heel stage 2 pressure ulcer with increased drainage and maceration that measured 2.0 cm L x 2.0 cm W x 0.1 cm D. New recommendations for treatment included daily and as-needed dressing changes with Dakin's 1/4 strength, application of Santyl, application of alginate dressing, and application of a bordered foam dressing. Additionally, the wound physician's progress note identified the wound was deteriorating and indicated facility staff were educated on proper dressing changes. A review of the nurse's notes and Treatment Administration Record (TAR) and the Medication Administration Record (MAR) from 8/1/22 through 8/30/22 failed to identify that a daily left heel dressing change was performed by staff from 8/2/22 through 8/23/22. The first documented dressing to the left heel pressure ulcer was on 8/24/22 with Santyl, calcium alginate, and a silicone dressing, 22 days after the left heel pressure ulcer was discovered and initial recommendations made by the wound specialist. On 4/16/24 at 2:39 PM, an interview and record review with the wound nurse Registered Nurse (RN#1) failed to identify physician's orders or treatment administration records for Resident #418's left heel pressure ulcer prior to 8/22/22. Additionally, RN#1 indicated although she was not the wound nurse in August 2022, she conducts rounds with the wound physician and transcribes wound orders into the computer based on physician's recommendations and progress note. On 4/17/24 at 11:32 AM, an interview and record review with the Director of Nursing Services (DNS) failed to identify dressing change orders for the left heel pressure ulcer from 8/2/2022 through 8/22/2022. The DNS further indicated she would expect the process would remain the same in which the wound nurse would round with the wound physician and transcribe physician's orders from the physician's notes and recommendations. On 4/17/24 at 12:19 PM, an interview with Licensed Practical Nurse (LPN#4) who provided care to Resident #418 on 8/3, 8/4, 8/13, 8/14, 8/17, and 8/18/22 indicated she remembered the resident but did not recall the resident's wounds or treatments involved. LPN#4 indicated her practice would include following the physician's orders in the electronic medical record and the TAR to determine what treatments to perform for a specific resident. On 4/17/24 at 12:21 PM, an interview with LPN#1, who provided care to Resident# 418 on 8/1, 8/2, 8/10, 8/11,8/15, and 8/19/22, identified s/he did not recall the resident. LPN#1 identified the TAR would direct her as to what treatments need to be performed for a specific resident. On 4/17/24 at 12:39 PM an interview with LPN#9 indicated she did not recall the resident. LPN#9 indicated she performs some dressing changes on the evening shift, and she would look at the physician orders and the TAR to determine what treatments are provided. On 4/17/24 at 1:50 PM, an interview and record review with the wound specialist (MD#3) identified wound specialist progress notes are recommendations and the facility is responsible for accepting the recommendations and transcribing physician's orders into the electronic medical records. MD#3 indicated although s/he was not involved in Resident # 418's care in August of 2022 s/he could not definitively identify that the lack of dressing changes to the left heel caused further breakdown of the pressure ulcer but indicated not following the recommended treatment could have been a contributing factor to further skin breakdown. On 5/1/24 at 1:49 PM an interview with RN#2 indicated she was training as a wound nurse in August of 2022. RN#2 indicated she would round with the wound specialist in August 2022 and transcribed orders from the wound specialist per recommendations. RN#2 indicated she remembered Resident #418 but did not remember the specifics of the resident's wounds or treatments. RN#2 was unable to indicate why the wound physician's orders were not in place for Resident #418's left heel pressure injury from 8/2/22 through 8/22/22. A review of the facility policy for Prevention and Management of Pressure Injuries indicated wound treatments are performed per physician's orders and the determination for dressing changes for stage 1 and stage 2 pressure ulcers are based on the individual physician's clinical judgement. 2. Resident #90's diagnoses included type 2 diabetes mellitus, quadriplegia, dissection of the vertebral artery, and stiffness of: the left and right hands, left and right elbows, and left and right shoulders. A physician's order dated 7/26/23 directed nursing staff to complete weekly skin checks on bath/shower day. The Norton Plus skin assessment dated [DATE] identified Resident #90 received a score of an 8 which indicated very high risk for pressure ulcers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 had severely impaired cognition, was dependent on staff for rolling left to right and chair to bed transfers, was frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers, and noted the resident had 1 stage 3 pressure ulcer. The physician's order dated 12/29/23 directed Traid to coccyx every shift. The pressure injury evaluation dated 1/6/24, completed by the Infection Control Nurse/Wound Nurse (RN #1), identified a new facility acquired stage 2 pressure injury to the coccyx measuring 2.0 Centimeter cm x 1.0 cm x 0.1 cm. The physician and responsible party were notified. The active physician's orders 12/20/23 through January 2024 direct for right lateral foot to cleanse with Normal Saline followed by collagen then silcone dressing daily and when needed dressing for autolytic debridement as needed for dislodgement or soilage. The care plan dated 1/16/24 identified Resident #90 at risk for skin breakdown. Interventions included: offloading heels every shift as tolerated, inspecting skin for redness, irritation, or breakdown, to offer turning and repositioning approximately every 2 hours, providing treatments as ordered, and conducting weekly skin inspections. The care plan dated 1/16/24 for right lateral foot stage 3 pressure ulcer. Interventions included skin checks per facility protocol and weekly wound care specialist consultations. The pressure injury evaluation document dated 2/27/24, completed by RN #1, identified a new facility acquired suspected deep tissue injury (DTI) to the ball of the left foot measuring 3.0 cm x 2cm x 0.0 cm. The physician and responsible party were notified. Observation of the right lateral foot during the survey identified the wound treatment was conducted as prescribed and wound healing. The nurse's notes dated 1/6/24 through 1/30/24 failed to reflect a new facility acquired stage 2 pressure injury to the coccyx measuring 2.0 Centimeter cm x 1.0 cm x 0.1 cm. The nurse's notes dated 2/27/24 noted Resident # 90 returned from a visit with a physician at which time a new order to start betadine daily to foot wounds and to follow up in one month. The pressure injury evaluation document dated 2/27/24 identified a facility acquired Deep Tissue Injury pressure area on the ball of the left foot that measured 3.0 cm by 2.0 cm by 0.0 cm. The ball of the left foot was noted with drainage and healthy surrounding skin. The nurse's note also failed to identify if any new pressure ulcers were reported to the nursing supervisor, wound nurse, or physician. A review of the clinical record dated 12/2023 through 3/20/24 identified 12 occasions Resident # 90's weekly skin audits were not performed per facility practice. Interview and clinical record review with Registered Nurse (RN #1) on 4/17/24 at 10:09 AM failed to identify Resident #90 had weekly skin audits conducted per the physician's order. RN #1 identified that she would expect weekly skin audits to be completed per the physician's order and facility policy, by the assigned nurse; any newly identified areas should be reported to her or the nursing supervisor for an assessment. RN #1 further identified in January 2024, she had identified a problem with weekly skin audits not being completed routinely by nursing staff; she began conducting chart audits of weekly skin audits and documentation, in the resident's clinical record. RN #1 indicated Resident #90 was at risk for developing pressure ulcers due to her/his medical comorbidities and decreased functional status, multiple preventative measures were in place including: off-loading boots to be worn at all times, repositioning every 2 hours, low air loss mattress set to his/her weight, getting the resident out of bed daily to a tilt in space wheel chair, the daily application of skin protectant cream, and treatment plans for identified pressure injuries and ulcers. Interview and clinical record review with the Director of Nursing Services (DNS) on 4/17/24 at 11:09 AM failed to identify Resident #90 had weekly skin audits conducted per the physician's order. The DNS indicated her expectation is that weekly skin audits are completed and documented by the charge nurse, per the physician's order and facility policy. The DNS further identified any concerns identified during the skin audit should be reported to the wound nurse who will conduct an assessment. Interview with Licensed Practical Nurse (LPN #8) on 4/17/24 at 11:28 AM identified Resident #90 was scheduled for weekly skin audits on Mondays, during the 3-11 PM shift. LPN #8 further identified the charge nurse is responsible for completing the skin audit during the scheduled shift. LPN #8 further indicated she works 7:00 AM to 3:00 PM on the unit, and there are different nurses that cover the unit during the 3-11 PM shift, including per diem nurses. LPN #8 further identified that weekly skin audits should be completed per the physician's order on the scheduled day/shift and if an area of concern is identified notifications should be made to the nursing supervisor, wound nurse, and Advance Practice Registered Nurse (APRN). Interview with the wound specialist consultant Medical Doctor (MD #3) on 4/17/24 at 12:10 PM identified Resident #90 was at risk for developing pressure injuries due to his/her lower body contractures which decreases arterial blood flow to the extremities and the contractures also limit how staff could reposition him/her. MD #3 further identified that his role at the facility relates to the treatment of pressure related wounds and injuries, but he would expect that the facility staff to follow facility's policies related to pressure ulcer prevention, including weekly skin assessments. Interview with the Medical Director (MD #1) on 4/17/24 at 12:36 PM identified Resident #90's impaired mobility and contractures were significant risk factors for developing pressure ulcers, which could take off quickly prior to detection. MD #1 further identified that he would expect weekly skin audits to be completed per the physician's order and facility policy. MD #1 indicated that pressure ulcers don't start off as stage 2 and that missing skin audits could play into later detection. The facility's Weekly Body Audit policy directs all residents to have a body audit to address any skin issues, on a weekly basis. If an alteration in skin integrity is discovered, the alteration will be documented on the weekly skin audit form as soon as the nurse observes the area. The policy further directs a licensed nurse to conduct a weekly body audit, looking for any alteration in skin integrity. It is recommended that this be completed on shower day. The licensed nurse will complete the weekly skin evaluation. In the interim, the nurse aide will report any identified skin impairment to the charge nurse. If a new area is discovered, the charge nurse is responsible for starting the appropriate documentation and notifying the unit manager or supervisor. If no alterations in skin integrity are found, the nurse will note this on the weekly body evaluation. 48880

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident # 1) reviewed for abuse, the facility failed to ensure adequate supervision was in place to prevent (sexual) abuse. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], intracranial injury with loss of consciousness unspecified duration, dementia with behavioral disturbance and Alzheimer's disease. The admission MDS dated [DATE] identified Resident # 1 had short and long-term memory problems, fluctuating inattention, trouble concentrating 7-11 days (out of 14 days), physical behavioral symptoms directed toward others 1-3 days, rejection of care 1-3 days, indwelling Foley catheter and ostomy appliance usage, required total dependence with one-two person assist for ADL's (activities of daily living) and antipsychotic use 7/7 days during assessment period. The care plan dated 4/18/2022 identified wandering. Interventions included wanderguard placement and redirect resident away from entering other residents' rooms. A physician's order dated 5/24/2022 directed to give [MEDICATION(S)] 25 milligram by mouth every 6 hours as needed for agitation. A physician's order dated 6/01/2022 /2022 directed to give Trazadone 25 milligram by mouth as needed for anxiety and 1 hour prior to bloodwork. Review of the grievance log identified on 4/8/22 Resident #2 had wandered into Resident #3's room. Review of the nursing behavior and progress notes identified the following: a. 5/30/22 (late entry) at 20:13 noted Resident #1 inappropriately touched writer by using a finger and sticking between writer's buttocks. Intervention included educated on keeping hands to self and not to touch anyone. Effect identified Resident #1 responded with a smile when issue addressed via interpreter and stated, I asked him to do it. PRN (as needed) [MEDICATION(S)] was refused. Outcome identified to make sure resident keeps a fair amount of distance between females and in eyesight. b. Nursing progress note dated 5/30/22 at 03:00 identified Resident #1 awake most of shift self-propelling in/out of other resident rooms, up/down hallways and requires line of site supervision to maintain safety. c. 5/31/22 at 06:53 noted Resident #1 awake, out of bed to wheelchair throughout shift. Agitation noted, grabbing various items from nurse station, throwing things, combative toward staff, self-propelling up/down hallways, in/out of other resident's rooms, touching their belongings. Resident also groping female staff inappropriately. Interventions included constant staff re-direction and PRN (as needed) [MEDICATION(S)]. Outcome identified no effect from both redirection and [MEDICATION(S)]. Resident continues behaviors throughout shift, staff continued with constant re-direct, resident awake and out of bed to wheelchair near nurse station at this time (06:53). d. Nursing progress note dated 5/31/2022 at 20:21 identified psych APRN (Advanced Practicing Registered Nurse) was updated regarding inappropriate behavior with females, continues to touch females on buttocks. New order for [MEDICATION(S)]. e. 6/1/22 at 06:53 noted Resident #1 awake first ½ shift, out of bed to wheelchair. Agitation/anxiety noted, grabbing various items from nurse station, and throwing them on floor or at staff. Combative toward staff. Resident #1 self-propelling up/down hallways and in/out of other resident's rooms. Resident continues to grab female staff inappropriately in an aggressive manner. Interventions included repeated re-direction and PRN (as needed) Trazadone. Outcome identified no effect from both Trazadone and constant staff re-direction, resident continued behaviors. Resident's behaviors finally ceased, asleep at this time (6:53). f. Review of an entity reportable event and facility documentation dated 6/4/2022 at 9:45PM identified staff was alerted Resident #1 was in Resident #2's room when Resident #2 was heard yelling and screaming. Upon staff entering Resident #2's room, Resident #1 was observed leaning over Resident #2's bed and quickly pulled hand away from Resident #2 and stated, I do nothing. Resident #2 stated Resident #1 had touched in between (his/her) breasts under (his/her) nightgown/pajamas. Resident #1 was seated in wheelchair with Hoyer pad ties tied to Resident #2's bed. Resident #1 was immediately removed away from and Resident #2 were immediately separated; Resident #1 was removed from Resident's #2's room and placed on 1:monitoring until sent to ER for evaluation. Review of staff statements dated 6/4/2022 identified Resident #1 was out of bed seated in wheelchair, observed in hallway outside of his/her room and was administered medication at 9:25PM. Social service interim progress note dated 6/7/2022 at 10:21 identified family consented for room change. Resident #1 was moved to another room on the same unit on 6/7/2022. Resident #2's diagnosis included [CONDITION(S)], contractures and anxiety. MDS dated [DATE] identified moderate cognitive impairment (BIMs score of 12), no mood or behavior problems, total dependence for activities of daily living (ADL's) with one/two person physical assist, frequently incontinent of bladder, always incontinent of bowel. Review of the psychiatric visit dated 6/6/22 identified Resident #2 on exam was fearful that Resident #1 may return and was also anxious and requested medication to decrease anxiety. Trazadone 25 mg 9 milligram by mouth every 6 hours as needed (PRN) x 14 days was ordered. Review of Behavioral Health Progress Note dated 6/9/22 (untimed) the LCSW noted Resident #2 was anxious and had increased anxiety related to Resident #1 returning to his/her room. Resident #2 was offered reassurance and clarification that Resident #2 is now on a different unit. Goals included decreased anxiety and increased coping with stressors. Review of the nursing post event summary dated 6/9/22 at 11:15PM identified Resident #2 was crying, was given emotional support and requested to call family member, which was done with staff assistance. Review of the entity reportable event summary report dated 6/9/22 at 12:00PM identified Resident #2 was given emotional support, was seen by psychiatric services and a PRN ( as needed) anti-anxiety was ordered. Interview and clinical record review with the Administrator and ADNS on 6/21/22 at 1:00PM, failed to provide documentation that Resident #1 was monitored when both sexually inappropriate touching of female staff and wandering in/out of other resident's rooms was identified on 5/30, 5/31 and 6/1/2. The Administrator further identified the nursing interventions that included keep a fair amount of distance between females and in eyesight and requires line of site of sight supervision to maintain safety were not implemented. Review of facility policy dated September 2020 directed in part the facility has a responsibility to ensure each resident has the right to be free from abuse. Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on a review of clinical records, facility documentation, interviews and review of the facility policy for one of two resident's (Resident #1) who alleged abuse, the facility failed to ensure that the resident was free from abuse. The finding included: Resident #1's (R#1) [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. The MDS identified that the resident was dependent on staff for mobility, transfers and ADL's. Review of a care plan dated 6/19/17 identified that R#1 was dependent for all ADL's with adjustment disorder with depressed mood. Interventions included to keep call bell in reach at all times, provide personal care and assist with bed mobility, position changes and transfers, allow resident to vent feelings and concerns and provide emotional support as needed. Resident #2's (R#2) [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated [DATE] identified that the resident had intact cognition with a BIMS score of 14 and was independent with transfers, ambulation and personal care. Review of facility documentation dated 7/13/17 identified that R#1 alleged that R#2 came into the room and made an inappropriate sexual gesture toward him/her that made him/her feel afraid and uncomfortable. The facility investigation noted that R#2 stated he/she goes into the room to visit with Resident #3 (roommate of R#1) and denied doing anything wrong. The documentation further identified that R#2 was instructed that he/she should not go into the room and could visit with Resident #3 in his/her room and/or a common area. A progress note dated 7/13/17 identified R#2 agreed that in the future, if he/she wanted to meet with Resident #3, they would meet outside the room or in a common area. A behavioral health progress note dated 7/14/17 identified that R #1 was seen related to the alleged incident that caused the resident anxiety. Review of R#2's care plan dated 7/14/17 identified that the resident preferred to spend time alone in his/her room but did socialize with peers however the care plan failed to address the allegation/incident of 7/13/17 and/or the intervention that the resident would not enter and/or agreed to restrict visits in R#1 and 3's room. Interview with R#1 on 9/5/17 at 3:40 PM identified that on 7/13/17 he/she reported that R#2 visited with Resident #3 regularly and often made R#1 uncomfortable but did not report anything until R#2 made an inappropriate sexual gesture that was directed at him/her. R#1 further stated that later the same night, R#2 came to the room when the lights were out, TV was off and both R#1 and R#3 were sleeping. R#1 stated that he/she saw R#2 coming into the room and although R#1 told R#2 that they were sleeping and he/she had no reason to be in the room, R#2 proceeded to enter the room. R#1 stated he/she had to yell get out before R#2 finally backed out of the room. R#1 stated that he/she became frightened of R#2's behavior and reported it the next day. R#1 stated that staff assured him/her that R#2 would no longer be allowed to come into his/her room. Interview with SW#1 on 9/5/17 at 11:55 AM and review of R#2's clinical record identified that based on the review of R#1's allegation on 7/13/17, the plan was that R#2 would not go into R#1 and 3's room however review of R#2's clinical record failed to identify that the resident's plan of care was revised to include the directive that he/she was restricted from R#1's room. Interview with the Director of Nurses on 9/5/17 at 1:00 PM identified that although the directive that R#2 was not allowed to enter R#1's room was not documented on the care plan, the directive was communicated to staff through supervisor report. The DON identified that staff were aware that R#2 was not allowed to enter R#1's room. b. Review of Resident #1's clinical record dated 8/9/17 identified that the resident stated that R#2 came into his/room and made physical contact with him/her. The record identified that the resident was visibly upset, crying and shaking. The resident was assessed with [REDACTED]. and comfort by ensuring that R#2 will be on 1:1 supervision. A Behavioral Health progress note dated 8/11/17 identified that R#1 voiced that he/she felt better knowing R#2 was going to be watched. Review of the resident's clinical record for the period of 8/11/17 through 8/15/17 identified that the resident was monitored and emotional support was provided. Review of facility documentation dated 8/9/17 identified that at 4:30 PM, R#1 reported that R#2 came into his/her room while he/she was in bed and rubbed his/her private parts' on him/her. Interview with RN #1 on 9/5/17 at 10:10 AM identified that on 8/9/17 he was the charge nurse for the 3:00 PM - 11:00 PM shift on R#1's unit. RN #1 stated that while he was passing medications, he saw R#2 walk by him and not long after that, at 4:30 PM, NA#1 called him to R#1's room. RN#1 stated that he found the resident crying and scared and told him that R#2 had come into his/her room and made inappropriate physical contact with him/her. RN #1 indicated that the nursing supervisor was informed and initiated an investigation. During the interview on 9/5/17 at 10:15 AM, RN #1 stated that prior to be called to R#1's room he did see R#2 walk by him as he passed medications. RN#1 stated that he did not see where R#2 went after he passed by him. RN#1 stated that he did not observe any usual behavior from R#2 as he/she walked the hall multiple times throughout the day however he indicated that was not aware that R#2 was not allowed in R#1's room. Interview with RN #2 on 9/5/17 at 3: 20 PM identified that on 8/9/17 she was the RN supervisor during the 3:00 PM - 11:00 PM shift. RN #2 identified that at about 4:30 PM she passed R#2 in the hall by the elevator heading toward the front entrance. RN #2 stated that she passed R#2 again on her way back up the hall and saw him/her still walking down the hall in the direction of the front entrance (in the same direction as R#1's room) but didn't watch where he/she went from there. RN #2 indicated that she was aware that R#2 was not allowed in R#1's room and didn't think he/she would go in there. Interview with R#1 on 9/5/17 at 3:40 PM identified that later in the afternoon on 8/9/17, he/she was in bed and NA#1 had just placed the phone to the resident's ear and left the room. R#1 stated that right after NA #1 left the room and while he/she was on the phone, he/she saw R#2 at the side of his/her bed. The resident stated that R#2 leaned over and placed his/her hand on R#1's stomach and asked R#1 where R#3 went. R#1 stated that he/she told R#2 not to touch him/her but R#2 leaned over more he/she could feel R#2's private part rubbing against him/her. R#1 indicated that while this was happening he/she had been on the phone and when the person he/she was speaking with yelled, R#2 must have heard and left the room quickly. R#1 stated that soon after NA#1 returned to the room, saw R#1 crying, R#1 told her what happened and NA #1 went and called the nurse. During an interview on 9/5/17 at 4:30 PM, the DON identified that although R#2's room was changed to another unit on 8/2/17, she stated RN #1 should have known that R#2 was not allowed in R#1's room. The DON further stated that R#2 was immediately placed on 1:1 supervision following this incident and remained on 1:1 supervision until he/she was discharged on [DATE]. Review of the facility's Abuse Prohibition policy identified that the resident has the right to be free from abuse. Sexual abuse included, but is not limited to, sexual harassment, sexual coercion or sexual assault and is non-consensual sexual contact of any type with a resident. The facility failed to ensure that effective interventions to prevent potential abuse of a dependent/vulnerable resident were implemented. The facility failed to ensure that Resident #1 was free from abuse.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of one sampled residents reviewed for accidents (Resident# 89), the facility failed to implement the care plan to prevent an accident with subsequent injury. The findings include: Resident # 89's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified a BIMS score of three out of fifteen indicating severe cognitive impairment and required extensive assistance of two person for transfer and toilet use. A Resident Care Plan (RCP) dated 4/06/17 identified the resident at risk for falls secondary to cognitive impairment decreased endurance/strength and history of falls. Interventions included do not leave in bathroom unattended, resident not to be left alone in back lounge and instruct in the proper use of any appliance/device to aid with balance and transfer. A physician's order [REDACTED]. A nurse's note dated 5/06/17 at 4:35 PM identified resident was observed lying on bathroom floor with head near door frame and feet pointed toward toilet. Resident alert and confused at baseline. PEARL. Nurses' notes also indicated that upon palpation of resident's scalp a large linear lump was noted to the posterior left side. MD notified and directed to transfer resident to the ER foe evaluation. Family informed. Review of the hospital Trauma History and Physical note dated 5/06/17 identified the resident was diagnosed with [REDACTED]. The resident was admitted to Trauma service for observation. Nurse's note dated 5/07/17 at 10:20 PM identified the resident was readmitted to facility with [DIAGNOSES REDACTED]. Review of facility A&I report dated 5/06/17 indicated resident was observed lying on bathroom floor with head near door and feet near toilet. Accident /Incident report also indicated resident required assistance of two with Hoyer lift and was left unattended on toilet, and resident was agitated prior to being on toilet. Interview with NA#1 on 7/25/17 at 2:39 PM identified that on the evening of 5/06/17 at the beginning of the shift he/she was instructed by LPN#1 to take R#89 to the bathroom. NA#1 indicated that he/she assisted R# 89 onto the toilet and instructed him/her to pull the call bell for assistance and then went to another room to help NA#2 with another resident. NA#1 further indicated that approximately four (4) minutes after leaving the resident he/she heard yelling and upon entering the room R#89 was observed on the floor. Interview and clinical record review with LPN#1 on 7/25/17 at 2:55 PM he/she indicated that on the evening of 5/06/17 R#89 was agitated while sitting in the TV room and LPN#1 gave R#89 a snack and then instructed NA#1 to take R#89 to his/her room and provide care. LPN#1 also indicated he/she was called to residents room a few minutes later and at that time R#89 was observed on the bathroom floor. LPN#1 indicated that R#89 had an order for [REDACTED].#89 was transferred to the toilet without the mechanical lift and with the assistance of only one nurse aide. Interview with the DNS on 7/25/17 at 3:10 PM he/she indicated that R#89 required a mechanical lift for transfer secondary to functional decline. Interview with NA#4 on 7/26/17 at 3:10 PM identified that he/she was on duty the evening of 5/06/17 however, NA#1 did not ask for assistance with transferring R#89 unto the toilet. Review of facility policy identified that electric and mechanical lifts are used to safely transfer residents who are unable to stand and pivot and/or require lifting to move from bed to chair. Transfer policy also indicated mechanical lift transfers will be done with the assist of two staff members.

Based on review of clinical records, review of facility documentation, facility policy and/or procedures and interviews for two of seven residents reviewed for accidents (Residents # 42 and 105), the facility failed to utilize an assistive device to prevent an accident and /or for for one of seven residents ( Resident # 109) reviewed for accidents , the facility failed to provide the necessary supervision when transporting a resident to prevent an accident. The findings include: 1. Resident #42 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] identified that the resident cognitively intact, required extensive assistance with activities of daily living (ADL's) including transfers, was unable to walk in the room or corridor, unsteady with surface to surface transfer and required staff assist to stabilize self, and was at risk for falls. A Resident Care Plan (RCP) dated 1/21/16 identified that the resident is at risk for falls with interventions to transfer as ordered. A physicians order dated 2/8/16 directed to transfer the resident with assist of 1 person with a rolling walker and gait belt. Review of a reportable event form dated 3/1/16 identified that R#42 fell while being weighed in the shower room and was noted with a laceration to the top of the left hand and a bump to the right side of the head. A nurse's note written by Licensed Practical Nurse (LPN# 4) on 3/1/16 at 8:59 AM identified that the resident had fallen at 8:15 AM on the scale in the shower room and sustained a cut to the left hand measuring 5.0 centimeters (cm) by 0.5 cm and 0.4 cm deep, and with bleeding present. The resident also had had a bump to the head and a blood pressure of 190/90, the Advanced Practice Registered Nurse (APRN) was notified and the resident was sent to the emergency department to be evaluated. Interview with nurse aide (NA#4) on 9/8/16 at 10:00 AM identified that he/she was caring for R#42 on 3/1/16 and had assisted R#42 onto the scale. NA#4 identified that he/she pulled the wheelchair up to the scale and assisted the resident to a standing position on the scale, he/she she stepped off of scale to the side, but was still next to the resident, when the resident was noted to fall onto her buttocks and receive a laceration to her hand and a bump on his/her head. NA#4 identified that since the resident was an assist of 1 with transfers it was appropriate to have the resident stand on the scale, but NA#4 did not have a gait belt around the resident at the time of the fall, and although he/she was aware that he/she should use a gait belt with the transfer, he/she must have left it in another residents room and, therefore did not apply the gait belt to R#42. Interview with RN#1 on 9/7/16 at 10:30 AM identified that he/she was the nursing supervisor when R#42 fell on the scale on 3/1/16, and responded to the shower room to find R#42 sitting on the scale with a laceration to the left hand and a bump to the right side of his/her head, an assessment was completed and the resident was sent to the emergency department. RN#2 further identified that he/she noted that NA#4 did not use a gait belt during the transfer, and had educated NA#4 at that time to always use a gait belt during a transfer. Additionally RN #2 identified that if a gait belt was used during the transfer NA#4 may have been able to lower R#42 onto the scale once she began to fall. Interview with the Rehabilitation Director (RD) on 9/8/16 identified that R#42 was appropriate to be weighed in the standing position on the scale, because he/she was an assist of 1 for transfers, but should have had a gait belt on during the transfer. The RD identified that a gait belt is designed to guide someone safely to the floor without injury. Interview with the Director of Nurses (DNS) on 9/8/16 at 11:30 AM identified that any resident requiring assistance with transfers and ambulation should have a gait belt applied. Review of the gait belt use policy identified that gait belts are used to prevent injury during transfers and ambulation tasks, and must be used when physically transferring and/or ambulating residents. Review of the hospital Discharge summary dated 3/1/16 identified that the resident was diagnosed with [REDACTED]. 2. Resident # 105 's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified the resident required an extensive assistance for bed mobility and transfers. The physician orders dated February 2016 identified to transfer the resident from bed to chair with assistance of one and a gait belt. The care plan dated 2/2016 identified impaired transfer ability with interventions that included to transfer the resident with assistance of one and use of a gait belt. The facility Incident and Accident report identified on 2/27/16, Resident #105 was being transferred from the bed to a chair by Nurse Aide #10, when the resident 's knees buckled causing the resident to fall forward. An assessment identified Resident # 105 sustained a lump on the left side of the head, skin tear of the right thumb, abrasion on the abdomen and a small amount of bleeding from his/her nose. Resident#105 was transferred to the Emergency Department for an evaluation and was diagnosed with [REDACTED]. Review of the facility policy identified that care plans are oriented toward preventing avoidable decline in clinical and functional levels and maintaining a specific level of functioning. Interview with the Director of Nurses on 9/7/16 identified Nurse Aide # 10 did not utilize a gait belt during the transfer on 2/27/16 in accordance with the care plan. Interview with NA # 10 on 9/7/16 identified that she/he failed to utilize a gait belt with the transfer. 3. Resident #109 [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] identified the resident as severely impaired for decision-making skills, independent for eating and drinking, requiring set up help with meals and extensive assistance from staff for activities of daily living, utilizes wheelchair and/or walker for mobility and no limitation in range of motion for upper and/or lower extremities. The RCP for assistance with ADL 5/6/16. Intervention directs to provide verbal cues, prompts, redirection and hand over-hand assistance when needed, and directed staff to give the resident sufficient time to accomplish each task. A review of the Reportable Event dated 5/25/16 at 6:30 P.M. identified in part Resident #109 had spilled hot cocoa on his/herself during dinner and indicated as NA#9 attempted to transfer the resident back to his/her room for staff to check for injuries, Resident # 109's left leg became caught underneath the resident's wheelchair. Although, the resident did not sustain a burn and/or blister from the hot cocoa, he/she did complain of lower left extremity pain. On 9/9/16 at 1:12 P.M. an interview and review of the facility documentation with the DNS indicated the facility found out about the event on the following day due to the resident expressed a complaint to staff that his/her left leg was hurting. NA#9 did not tell anyone the resident spilled hot chocolate on him /herself and /or the resident's left leg got caught in the wheelchair. The DNS further indicated the aide should have reported the incident immediately to the charge nurse and/or supervisor. On 9/9/16 at 1:20 P.M. an interview and review of the clinical record and facility documentation with LPN #3 indicated he/she had spoken to the resident around 9: 00 A.M. when Resident # 109 was noted crying and complaining about his/her left leg pain and reported to the nurse that NA#9 caught his/her left leg underneath the wheelchair when the aide was pushing him/her fast. LPN#3 further indicated he/she medicated the resident for pain and updated the APRN and the ADNS regarding the incident. A stat x-ray was ordered and following the results the resident was transferred to an acute care facility for treatment. Attempts were made to contact NA #9 for an interview on 9/9/16 at 1:45 P.M. and 2:00 P.M. but were unsuccessful. Subsequent to event on 5/25/16, the resident was diagnosed with [REDACTED].

Based on observation, clinical record review, interviews, review of facility documentation/ investigation, and review of facility policy for 1 of 4 sampled residents reviewed for accidents (Resident #131), the facility failed to ensure the plan of care was followed to prevent an accident with injury. The findings include: Resident #131's [DIAGNOSES REDACTED]. A quarterly assessment ((MDS) dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with bed mobility and transfers with two persons and assistance of one person with dressing, and had no falls since last assessment. Further assessment identified the resident's weight was 88 lbs and height of 60 inches. MDS correction was done on 10/1/14 which identified the resident had upper and lower functional range of motion limitations on both sides. Care plan dated 11/12/13 identified the problem that the resident required assistance with dressing and grooming with interventions that included to gather, provide, set-up all materials, supplies and equipment needed to provide care. Nursing note dated 12/30/14 written by RN#1 identified the patient rolled from the bed to floor. Resident #131 was found lying on the floor between the bed and the night stand on her/his left side. NA #1 stated she was doing care and she turned her back and the resident rolled from the bed. Review of facility documentation and investigation dated 12/30/13 identified that at 10:10 AM the resident rolled out of bed and fell on the floor. Review of the investigation identified that the resident was transferred back to bed with assistance of 2 persons after a shower on the day of the incident. Further documentation identified the resident was in the middle of the bed, the head of the bed flat and two half side rails were in the up position. The investigation identified that Nurse Aide (NA#1) went to get the resident's socks out of his/her dresser in the room and heard a noise, turned, and saw Resident #131 lying on the floor next to the bed. Interview and review of facility documentation with RN#1, day supervisor, on 9/30/14 at 11:30 AM identified that she was paged to the resident's room because the resident was found on the floor. Further interview identified that the resident was laying on the floor between the bed and the night stand. RN#1 identified she was unable to do a complete assessment related to the resident being cognitively impaired and with the resident being contracted. RN#1 identified that the resident did not grimace in pain, the resident was non-verbal as usual but had sustained a bruise and abrasion to the left upper extremity and left knee. RN#1 identified that the staff utilized a mechanical left to return the resident back to bed after the fall and Resident #131 did not complain of any pain during the rest of the shift until 3 PM. Review of the clinical record identified on 12/30/13 during the 3-11 shift the resident was noted to guard the left hip. The advanced practice registered nurse (APRN) was notified and an x-ray was ordered which revealed a left hip fracture. The resident was transported to the emergency room and returned that night with palliative care. Interview, review of facility documentation and demonstration and reenactment of resident in bed after transfer with NA#1 on 10/02/14 at 11:15 AM identified that she had transferred the resident from the shower chair to the bed with the assistance of another aide and gait belt. Further demonstration and conversation with NA#1 identified that she put the side rail up after she got the resident in bed and did not lower the side rail during care. NA#1 identified, while she was providing care to the Resident #131, NA#1 had forgotten the resident's socks and had to go to the dresser across from the resident bed. Interview and review of facility documentation with LPN#1 on 10/1/14 at 3:30 PM identified she found the resident on the floor next to her bed with side rails in the up position. LPN#1 further stated she asked the aide what happened and NA#1 stated she was doing care and turned around to get the resident's socks from the dresser, heard a noise and saw the resident on the floor. Based on observation of the resident's room and bed,review of the plan of care, reenactment of the event with NA#1, the facility failed to ensure that necessary personal care items were within reach while providing care.

Based on observation, record review and staff interview for one of one sampled residents reviewed for [DIAGNOSES REDACTED] protocol (R#71) the facility failed to ensure a medication was readily available and/or for one of three sampled residents reviewed for hospitalization (R#154) the facility failed to ensure hospital discharge plan/orders were transcribed and/or implemented on admission and/or for for one of two sampled residents who were reviewed for pain management (R#222) the facility failed to conduct pain and/or abdominal assessments and/or notify the physician as outlined in the plan of care. The findings include: 1. Resident #71's (R#71) [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as cognitively intact and requiring extensive assistance of one staff member for transfers, walking in corridor, dressing, toileting and personal hygiene. A care plan dated [DATE] identified a problem with diabetes with interventions that included to provide a diet as ordered, check the blood sugar if shaking, sweating, hunger, headache, etc. as the blood sugar may be low. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[DIAGNOSES REDACTED] protocol" when the resident is symptomatic of [DIAGNOSES REDACTED] and unresponsive or unable to swallow. The physician's orders [REDACTED]. On [DATE] at 11:21 AM the surveyor inquired as to what LPN#3 would do if R#71 was found unresponsive with a low blood sugar. LPN#3 stated that she/he would administer [MEDICATION NAME]. The surveyor then inquired as to where [MEDICATION NAME] was stored. LPN#3 went to the medication cart, and was unable to locate the [MEDICATION NAME]. LPN#3 then telephoned the Nursing Supervisor, left the unit, and returned 4 minutes later with [MEDICATION NAME]. Further interview with LPN#3 identified that she thought the medication was stored on the unit in the medication cart but was informed by the supervisor that [MEDICATION NAME] was kept in the Emergency box, in the first floor medication room (R#71 resides on the 2nd floor). Interview with the DNS on [DATE] at 11:25 AM identified that the [MEDICATION NAME] is not kept on the unit where the resident resides but is accessible in the Emergency Box, in the first floor medication room where the Nursing Supervisor has a key. Subsequent to surveyor inquiry, [MEDICATION NAME] would be ordered for individual resident's with a physician order [REDACTED]. 2. Resident #154 (R#154) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission form dated [DATE] noted the resident was confused at times, pulse oximeter reading was 96%, and had 2+ [MEDICAL CONDITION] in bilateral lower extremities. A resident care plan dated [DATE] identified a problem with a risk for fluid imbalance related to diuretic use. Interventions included to monitor medications as ordered, and for signs and symptoms of dehydration and fluid overload. A physician's orders [REDACTED]. A hospital W-10 Interfacility Transfer Summary dated [DATE] noted to take medication exactly as prescribed. Medications included ([MEDICATION NAME]) [MEDICATION NAME] 40 mg orally once a day. The hospital W-10 further indicated to report any new or increased swelling in feet or ankles. A rapid weight gain of 3 lbs or more in 24 hours or rapid weight gain of more than 5 lbs in 1 week. Review of a July Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the daily weights noted the following: [DATE] -109.2 lbs, [DATE]-110.4 lbs, [DATE]-111.2 lbs, [DATE]-112.8 lbs, [DATE] -112.2 lbs, [DATE]-111 lbs, [DATE]-113.4 lbs, [DATE]-114.6, [DATE]-115.8, [DATE]-116 lbs, [DATE]-115 lbs, [DATE]-118.8 lbs. A nurse's note dated [DATE] at 9:10 PM indicated R # 154's oxygen saturation was 87% on room air. The resident was placed on oxygen 2 liters. The oxygen saturation went up to 94%. Resident was noticed to have increased [MEDICAL CONDITION] in the lower bilateral extremities. Lung sounds had crackles and rhonchi throughout lung fields. Resident was lethargic and diaphoretic. Oxygen saturation went down to 80%. Oxygen increased to 5 liters. Oxygen saturation at 85%. Nonrebreather mask placed on resident and 911 called. The resident was transferred to the emergency room for evaluation. A hospital report dated [DATE] indicated the resident was treated with [MEDICATION NAME] 80 mg in the emergency room and was saturating better then when he/she came in. [MEDICAL CONDITION] most likely secondary to the [MEDICAL CONDITION] process of congested heart failure/infection. [MEDICAL CONDITION] is being treated with the [MEDICATION NAME]. A hospital discharge summary dated [DATE] noted R # 154 was admitted with shortness of breath and found to have [MEDICAL CONDITIONS], pneumonia, and fluid overload. Review of a reportable event form and investigation dated [DATE] indicated R#154 was admitted to the facility on [DATE]. A hospital discharge summary and Connecticut W-10 transfer form dated [DATE] indicated the resident was to receive [MEDICATION NAME] 40 mg by mouth every day. On [DATE] it was discovered the resident had not received the [MEDICATION NAME] from [DATE] through [DATE] as indicated on the hospital W 10 transfer form. An interview on [DATE] at 11:40 AM with RN#2 indicated when R#154 was admitted to the facility on [DATE] [MEDICATION NAME] 40 mg by mouth was ordered as indicated on the hospital W-10 transfer form. From a previous admission an order for [REDACTED]. [REDACTED]. An interview on [DATE] at 12:45 PM with the DNS indicated the hospital W-10 transfer orders are the admission orders [REDACTED]. An interview on [DATE] at 1:10 PM with APRN#1 indicated although parameters for weight gain are resident specific, he/she usually requests notification if there is a 3 lb weight gain in one day or a 5 lb weight gain in a week. Review of the daily weights at that time noted R#154 had gained 5 lbs from [DATE] to [DATE]. He/she indicated the facility is usually good about notifying him/her about weight gain when a resident has [MEDICAL CONDITION], but R#154 overall condition was poor and Hospice had been discussed which may have blurred the situation. A subsequent interview on [DATE] at 10:54 AM with APRN#1 indicated although the hospital W-10 transfer orders indicated to report a rapid weight gain of 3 lbs or more in 24 hours or weight gain of more than 5 lbs in 1 week, it is possible the covering APRN did not order those parameters on the resident's admission. APRN#1 indicated although the staff are good about reporting weight gain, because the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] on admission and weights were being done daily, there should have been weight gain parameters for physician notification. 3. Resident #222's [DIAGNOSES REDACTED]. The nursing admission form dated [DATE] identified that Resident #222 had spinal pain and the abdominal assessment identified that the resident ' s abdomen was soft, bowel sounds were present in all four quadrants and hypoactive, the routine was normal and the last bowel movement was [DATE]. The resident care plan dated [DATE] identified the resident was at risk for alteration in comfort related to the right [MEDICAL CONDITION]. Interventions directed to evaluate pain with the use of the pain scale, medicate according to physician's orders [REDACTED]. In addition, the care plan identified that Resident #222 may have [MEDICAL CONDITION] upset related to a history of gastritis, [MEDICAL CONDITION] and irritable bowel syndrome. Interventions directed to evaluate for complaints of heartburn, nausea and vomiting, poor appetite, [MEDICAL CONDITION] pain, evaluate for signs and symptoms of gastro intestinal bleeding as evidenced by weakness, lethargy, confusion, pale skin, nausea, abdominal distention and notify the physician as needed. The admission Minimum Data Set assessment dated [DATE] identified that Resident #222 had no cognitive impairments, was totally dependent on two staff person for most activities of daily living and had occasional pain rated at six on the scale of one to ten. A physician's orders [REDACTED]. The nurse ' s note dated [DATE] at 3:00 AM identified that Resident #222 had complained of a stomach ache with nausea. [MEDICATION NAME] 650 mg was given at 11:30 AM with no effect, ginger-ale was encouraged, Milk of Magnesia 30 cubic centimeters (cc) was administered per the resident ' s request with fair effect and there were no further complaints of a stomach ache. At 5:00 AM the nausea persisted, there was no vomiting and a message was left in the Advanced Practice Registered Nurse (APRN) book. The nurse ' s noted dated [DATE] at 2:20 PM identified that Resident #222 had refused breakfast, ate chicken soup for lunch, Milk of Magnesia and a suppository were given with moderate results. The [DATE] at 3:00 AM nurse ' s note identified that Resident #222 verbalized heartburn at 2:30 AM, got out of bed to the chair, and ginger-ale was given with fair effect. At 3:45 PM Resident #222 continued to complain of nausea, question if the resident had small vomited or coughed up sputum, the abdomen was slightly firm to touch, very hypoactive bowel sounds were noted and the APRN was made aware. Subsequent to the notification at 11:33 AM a medication for the nausea, blood work and an abdominal x-ray were ordered to be obtained immediately. On [DATE] at 4:25 PM Resident #222 was found without a pulse, Cardiopulmonary Resuscitation (CPR) was initiated and 911 called. The resident's mouth was suctioned during the resuscitation of brown liquid. When the paramedics arrived at 4:35 PM and assumed chest compressions, 300 to 400 cubic centimeters (cc) of brown liquid was in the suction canister, in addition to large amounts expelled prior to suctioning. At 4:55 PM the paramedics were give a verbal order from the acute care hospital physician (MD #2) to discontinue the CPR. The death certificate indicated that the cause of death was cardiopulmonary arrest and small bowel obstruction. Results of the abdominal flat plate were received in the facility by facsimile at 4:30 PM concluding dilating small bowel loops compatible with a small bowel obstruction and recommending a CT scan of the abdomen for further evaluation. Review of the physician ' s progress notes from [DATE] through [DATE] identified that Resident #222 was seen by the attending physician on [DATE] and the note did not indicate that Resident #222 had complained of nausea, vomiting, and/or pain. Further review of the progress notes failed to reflect that Resident #222 was seen after the attending physician ' s visit on [DATE]. Interview with the Corporate Nurse on [DATE] at 10:30 AM identified the facility did not have a specific policy regarding abdominal assessments. The Corporate Nurse further noted that a nurse would conduct an abdominal assessment according to nursing standards of practice when a resident had a change in condition. Interview with the APRN on [DATE] at 1:30 PM identified an abdominal assessment would include listening for bowel sounds, determine if there was distention and/or note the date and time of the last bowel movement. Interview and review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR failed to reflect the intensity of the pain before and/or after utilizing the pain scale of one to ten. The facility policy for Pain Management directed, in part, that was the assessment process, the resident's perception of pain is always considered reality and the resident goals for pain management will be honored. The resident's acceptable level of pain would be determined via resident interview. Additionally the policy directs that pain will be assessment using a standardized pain scale of ,[DATE] and /or verbal pain scale. Interview with the Director of Nursing on [DATE] at 3:10 PM identified the clinical record failed to reflect that pain assessments had been conducted and the record failed to reflect that subsequent to the resident's complaint of a stomach ache and/or nausea on [DATE] on the 11 PM to 7 AM shift abdominal assessment had not been conducted until [DATE] on the 7 AM to 3 PM shift.

Based on review of the clinical records and review of facility documentation for 2 of 14 sampled residents reviewed for medication monitoring review (R#13 and R#68) and/or for one of one sampled residents identified with a medication error, (R#104) the facility failed to follow the physician's orders [REDACTED]. The findings include: 1. Resident # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Person #1 on 8/14/12 at 9:41 AM identified that bloodwork/laboratory work had not been completed on Resident #13. A physician's orders [REDACTED]. Review of the resident's laboratory values on 8/14/12 at 12:00 PM identified that physician ordered blood work was drawn on 6/14/11 and 7/31/12 but failed to identify that a urinalysis had been obtained and/or collected. Interview with the facilities contracted laboratory on 8/14/12 at 12:02 PM identified that a urinalysis had not been completed since admission. Interview with LPN#1 on 8/14/12 at 12:00 PM identified that the Unit Secretary was responsible for identifying blood work due to be drawn, placing the requisition in the laboratory notebook, and the night nurse was responsible to place the requisition slip for the phlebotomist to view. LPN#1 further noted she was unsure of current practice because the Unit Secretary is no longer employed. 2. Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with Person #1 on 8/14/12 at 9:41 AM identified that bloodwork/laboratory work had not been completed on Resident #68. Physician orders [REDACTED]. Review of the resident's laboratory values on 8/14/12 at 12:00 PM identified that physician ordered blood work was drawn on 1/05/12, however it failed to identify a urinalysis had been obtained and/or collected. Interview with the facilities contracted laboratory on 8/14/12 at 12:02 PM identified that a urinalysis had not been completed since the resident's admission. Interview with LPN#1 on 8/14/12 at 12:00 PM identified that the Unit Secretary was responsible for identifying blood work due to be drawn, placing the requisition in the laboratory notebook, and the night nurse was responsible to place the requisition slip for the phlebotomist to view. LPN#1 further noted she was not sure of the current practice because the Unit Secretary is no longer employed. 3. Resident #104's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as cognitively impaired and was totally dependent on one staff person for ADL's, including eating. A RCP dated 3/7/12 identified the resident as status [REDACTED]. A physician's orders [REDACTED]. Review of the nurse's note and facility documentation dated 3/07/12 identified Resident #104 received [MEDICATION NAME] 400 mg po (by mouth), Senna two tablets, [MEDICATION NAME] 25 mg po, [MEDICATION NAME] 6 mg po, Acidophillus po, Tylenol 650 mg po, and [MEDICATION NAME] 100 mg po, medications prescribed for R#36, the roommate. Nurse's notes at 10:00 PM identified the resident's heart rate as 38 bpm and blood pressure as 80/45 mg/hg. Review of the Inter-Agency Patient Referral Report (W-10) dated 3/7/12 indicated Resident #104 was transferred to the acute care Emergency Department and administered [MEDICATION NAME] related to [DIAGNOSES REDACTED]. Interview with the DNS on 8/16/12 at 2:30 PM identified that on 3/07/12, RN#2 was mentored by LPN#4. The DNS indicated that the facility investigation identified that LPN #4 had discontinued the medication pass for a brief period of time and during her absence, RN #2 did not properly identify the resident prior to administering medications. Review of RN#2's statement dated 3/7/12 identified that the medication error could have been prevented if the Medication Kardex was compared to the resident's name bracelet, if the mentor had been with RN#2 and if RN #2 had been wearing reading glasses.