Every finding on record at Bel-Air Manor Nursing & Rehabilitation Center

Based on review of the clinical record, facility documentation, facility policy, camera footage, and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for pain management, the facility failed to ensure the resident remained free of significant medication errors. This included failure to administer and replace fentanyl patches every 72 hours as ordered, maintain accountability of fentanyl patches as controlled substances, accurately transcribe and implement physician's medication orders, administer oxycodone every four (4) hours as ordered, recognize and correct medication administration errors, and adequately assess and manage Resident #2's pain. These failures resulted in repeated missed, delayed, inaccurately documented, and unaccounted-for opioid doses resulting in uncontrolled pain and restlessness. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required supervision with bed mobility, required partial assistance with transfers, received scheduled and as-needed pain medications, experienced frequent moderate pain, and received hospice services.The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 required assistance with activities of daily living (ADLs) and had altered comfort related to small cell lung cancer with metastasis to the intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease, lumbar spinal stenosis, chronic bilateral low back pain with sciatica (pain caused by irritation or compression of the sciatic nerve), and claudication (pain or cramping caused by decreased blood flow). Interventions included providing one-person assistance with bathing, dressing, toileting, hygiene, and transfers using a rolling walker, monitoring for pain, administering medications as ordered, documenting the effectiveness of pain medications, and monitoring and documenting verbal and nonverbal signs and symptoms of pain.A. Delay in fentanyl patch administrationA physician's order dated 5/13/26 at 6:08 AM directed a fentanyl transdermal patch 12 micrograms (mcg) per hour, apply one (1) patch every three (3) days for pain, rotate application sites, and remove the patch according to the schedule.The May 2026 Medication Administration Record (MAR) identified RN #4 applied the 12 mcg fentanyl patch at 8:30 AM on 5/13/26. The order was discontinued later that day at 6:07 PM.A physician's order dated 5/13/26 at 6:05 PM, entered by Advanced Practice Registered Nurse (APRN) #2, directed a fentanyl transdermal patch 12 mcg per hour, apply one (1) patch every three (3) days for pain, rotate application sites, and remove the patch according to schedule.The May 2026 MAR identified the replacement order scheduled the next fentanyl patch application for 8:30 AM on 5/14/26, although the initial patch had already been applied on 5/13/26. RN #4 documented the 5/14/26 dose as not administered because the previously applied patch remained in place. The next documented fentanyl patch change did not occur until 5/17/26. Although the physician's order directed the patch be changed every 72 hours, the patch remained in place for approximately 96 hours.The Controlled Substance Disposition Record identified ten (10) fentanyl 12 mcg patches were received. One (1) patch was removed from inventory on 5/13/26, leaving nine (9) patches remaining. The next patch was not removed from inventory until 5/17/26, leaving eight (8) patches remaining, consistent with the delayed replacement documented in the MAR.Interview with the Director of Nursing (DON) on 7/16/26 at 10:05 AM identified she was unaware of the medication error until surveyor notification. The DON identified the order re-entered by APRN #2 was transcribed incorrectly, causing the administration schedule to populate inaccurately. The DON identified APRN #2 should have verified when the initial fentanyl patch had been administered before re-entering the order, and RN #4 should have questioned why the order repopulated the following day rather than document the medication as not administered.Interview with APRN #2 on 7/16/26 at 10:56 AM identified she did not recall why the original order was discontinued but believed it was related to pharmacy processing requirements for controlled substances. APRN #2 identified she re-entered the order without verifying the generated administration schedule and was unaware the electronic medical record scheduled the next application for 5/14/26 instead of 5/16/26. APRN #2 identified she should have adjusted the order time to reflect the initial application on 5/13/26 so the subsequent 72-hour administration schedule populated correctly.Interview with RN #4 on 7/16/26 at 11:22 AM identified he applied the fentanyl patch on 5/13/26. When prompted to administer another patch on 5/14/26, he observed the previous patch remained intact and documented the medication as not administered because he believed the electronic medical record generated the order in error. RN #4 identified he did not review the physician's order to determine why the medication repopulated and acknowledged he should have. On 5/17/26, he removed the patch dated 5/13/26 and applied a new patch but did not recognize the original patch had remained in place longer than the ordered 72-hour interval.B. Missing fentanyl patches on 5/18/26A Nurse's note by RN #2 dated 5/18/26 at 3:18 PM identified she notified the provider after both fentanyl patches were removed by Resident #2. RN #2 searched Resident #2's room but was unable to locate either fentanyl patch. The MAR was updated with a new order to reapply the fentanyl patches. RN #2 documented she educated Resident #2 and a family member regarding the importance of leaving the fentanyl patches in place.The May 2026 MAR identified a physician's order dated 5/12/26 directing one (1) fentanyl transdermal patch 25 micrograms (mcg) per hour every three (3) days for pain. The MAR identified the last documented application occurred on 5/16/26 at 8:30 AM. A physician's order dated 5/13/26 directed staff to administer one (1) fentanyl transdermal patch 12 mcg per hour every three (3) days. The last documented application occurred on 5/17/26 at 8:30 AM. The MAR further identified licensed nurses documented both fentanyl patches were present during every shift check on 5/17/26, including RN #4 during the 7:00 AM to 3:00 PM shift, LPN #5 during the 3:00 PM to 11:00 PM shift, and LPN #3 during the 11:00 PM to 7:00 AM shift. Both fentanyl patches were documented as reapplied on 5/18/26 at 12:30 PM by LPN #4.Interview with LPN #4 on 7/16/26 at 11:36 AM identified he was assigned to Resident #2 during the 7:00 AM to 3:00 PM shift on 5/18/26. During the scheduled fentanyl patch check, he was unable to locate either the 12 mcg or 25 mcg fentanyl patch. Resident #2 was unable to identify what happened to the patches.Interview with RN #2 on 7/16/26 at 12:00 PM identified LPN #4 notified her both fentanyl patches were missing. RN #2 completed a body check, searched Resident #2's bed linens, trash receptacles, and room, but was unable to locate either fentanyl patch. RN #2 identified Resident #2 reported attempting to remove the nicotine patch because he/she wanted to smoke; however, the nicotine patch remained intact. RN #2 notified the DON, who instructed her to notify the provider for replacement orders. Although the fentanyl patches could not be located, RN #2 did not obtain statements from staff members who had contact with Resident #2.Interview with the DON on 7/16/26 at 12:12 PM identified RN #2 did not report the missing fentanyl patches on 5/18/26. The DON identified when she later reviewed documentation she determined placement of both fentanyl patches had been verified by LPN #3 during the overnight shift before they were discovered missing. Although RN #2 documented Resident #2 reported removing the patches, the missing fentanyl patches represented unaccounted-for controlled substances. The DON identified the incident should have been reported to the State Agency, staff and visitor statements should have been obtained, and an investigation should have been initiated immediately.Interview with LPN #3 on 7/20/26 at 11:11 AM identified if she documented verifying placement of the fentanyl patches during the 11:00 PM to 7:00 AM shift, the fentanyl patches were present. LPN #3 identified if either fentanyl patch had been missing, she would have notified the nursing supervisor immediately. LPN #3 further identified she was never contacted by the facility to provide a statement after the incident.Although attempted, an interview with LPN #5 was not obtained.C. Missing fentanyl patches on 5/24/26The Reportable Event (RE) form dated 5/24/26 identified RN #4 was unable to locate Resident #2's fentanyl patches during the scheduled morning placement check. The provider, hospice agency, and police department were notified. Resident #2 was monitored for changes in pain, and an investigation was initiated regarding the missing fentanyl patches and individuals who had visited Resident #2 after the patches were last documented as present.A Nurse's note by RN #4 dated 5/24/26 at 10:48 AM identified he was unable to locate the fentanyl patches applied on 5/23/26 at 12:30 PM. RN #4 completed a body check, searched Resident #2's room, bed linens, and trash receptacles, but was unable to locate either fentanyl patch. Resident #2 denied removing the patches.The May 2026 MAR identified licensed nurses documented both fentanyl patches were present on 5/23/26 during the 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts before they were later discovered missing.A Nurse's note by RN #5 dated 5/24/26 at 4:51 PM identified RN #4 notified her the fentanyl patches applied to Resident #2's right posterior scapular area could not be located. RN #5 initially checked the application site but delayed completing a full body check until Resident #2 finished breakfast. During the subsequent body check, completed with RN #4 and NA #1, Resident #2 reported a family member had placed one (1) fentanyl patch on his/her leg. No fentanyl patches were identified until NA #1 observed a fentanyl patch dated 5/17/26 on Resident #2's left upper inner arm while providing personal care. The DON, hospice agency, and provider were notified. Hospice requested the fentanyl patches be discontinued, and the provider ordered scheduled oral oxycodone in place of the fentanyl patches.D. Oxycodone order transcribed incorrectly resulting in missed overnight dosesFacility documentation dated 6/17/26 identified the administration times for Resident #2's oxycodone did not match the physician's orders from 5/24/26 through 6/17/26.Physician's orders dated 5/24/26, 5/29/26, 6/4/26, and 6/15/26 directed staff to administer oxycodone 10 milligrams (mg) by mouth every four (4) hours for terminal pain.The May 2026 Medication Administration Record (MAR) identified the 5/24/26 and 5/29/26 oxycodone orders contained administration times of 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM, but failed to include the required 2:00 AM administration, resulting in one missed scheduled dose every day.The June 2026 MAR identified the 6/4/26 and 6/15/26 oxycodone orders continued to omit the required overnight administration. The administration schedule was not corrected until 6/17/26, when the MAR was revised to include every four (4) hour administration times of 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM.The Order Audit Report identified RN #5 entered the original oxycodone order on 5/24/26 and RN #2 confirmed the order as accurate.Interview with Person #2 on 7/17/26 at 9:05 AM identified Resident #2 frequently complained of not receiving pain medication during the overnight shift and repeatedly reported uncontrolled pain. Interview with Resident #2 on 7/17/26 at 10:42 AM identified he/she experienced chronic pain requiring scheduled pain medication but was unable to recall specific dates doses were missed.Interview with RN #2 on 7/20/26 at 1:07 PM identified she confirmed the 5/24/26 oxycodone order without recognizing the administration schedule omitted the overnight dose. RN #2 identified she should have thoroughly reviewed the administration times before confirming the order and acknowledged the medication error could have been identified sooner.Interview with RN #5 on 7/20/26 at 1:18 PM identified she entered the original oxycodone order and mistakenly selected prepopulated administration times that excluded the overnight dose. RN #5 identified she should have fully reviewed the physician's order before completing the transcription.Interview with APRN #2 on 7/20/26 at 2:07 PM identified licensed nurses were responsible for ensuring physician's orders were accurately entered and followed. APRN #2 identified staff should compare physician's orders with the Medication Administration Record (MAR), medication card, and Controlled Substance Disposition Record to identify transcription errors. APRN #2 further identified Resident #2's chronic pain could have worsened overnight when the scheduled oxycodone doses were omitted.The May and June 2026 MARs identified the only as-needed (PRN) pain medication available after the scheduled oxycodone order was acetaminophen 325 mg, two (2) tablets by mouth every six (6) hours as needed for discomfort or a temperature greater than 101 degrees. The MAR failed to identify administration of the PRN acetaminophen from 5/24/26 through 6/17/26.Interview with the Director of Nursing (DON) on 7/20/26 at 3:46 PM identified RN #5 should have accurately transcribed the oxycodone order and RN #2 should have thoroughly reviewed the order before confirming it. The DON identified comparison of the MAR, medication card, and Controlled Substance Disposition Record should have identified the error sooner and prevented the continued omission of scheduled overnight oxycodone doses.E. Failure to administer oxycodone every four hours as ordered on 6/13/26 into 6/14/26A physician's order dated 6/4/26 directed staff to administer oxycodone 10 mg by mouth every four (4) hours for terminal pain.Continuous camera footage dated 6/13/26 identified LPN #5 administered medications at approximately 9:15 PM and informed Resident #2 pain medication was being administered. Nursing staff did not re-enter the room until 12:09 AM, when RN #9 administered Ativan. At 3:29 AM Resident #2 was observed thrashing about in bed and grimacing. At 3:51 AM Resident #2 appeared restless and attempted to place both legs over the side of the bed. At 3:52 AM RN #9 entered the room, briefly assessed Resident #2, identified Resident #2 was incontinent, turned off the call bell, and exited without administering pain medication. At 4:00 AM an NA changed Resident #2's brief and exited the room. At 4:23 AM Resident #2 was observed thrashing about in bed and restless. Resident #2 continued to appear restless until 5:37 AM, when RN #9 returned and administered oxycodone, more than eight (8) hours after the previous scheduled dose.The Controlled Substance Disposition Record identified oxycodone 10 mg was administered on 6/13/26 at 10:00 PM and was not administered again until 5:30 AM on 6/14/26, approximately seven and one-half (7.5) hours later.The June 2026 Medication Administration Record (MAR) identified the only PRN pain medication available remained acetaminophen 325 mg. The MAR failed to identify administration of PRN acetaminophen during the overnight shift. RN #9 documented Resident #2's pain level as zero (0) despite the camera footage capturing restlessness, grimacing, thrashing about in bed, and attempting to get out of bed.Interview with RN #9 on 7/20/26 at 2:24 PM identified Resident #2 routinely complained of pain. RN #9 identified she documented pain assessments based on her observations and believed Resident #2 was not exhibiting signs of pain. RN #9 acknowledged if Resident #2 had reported pain or demonstrated signs of discomfort she should have administered pain medication.F. Failure to administer oxycodone every four (4) hours as ordered on 6/22/26 into 6/23/26Continuous camera footage dated 6/22/26 identified LPN #6 administered medications to Resident #2 in applesauce at approximately 9:17 PM but did not identify what the medications administered were. No licensed nurse entered Resident #2's room again until 3:03 AM on 6/23/26. At 3:01 AM, Resident #2 was observed thrashing about in bed and repeatedly kicking his/her legs over the side of the bed, appearing uncomfortable. At 3:03 AM, RN #9 entered the room and administered pain medication in applesauce more than three (3) hours after the scheduled administration time, although the Medication Administration Record (MAR) documented the oxycodone 10 milligrams (mg) dose as administered at 12:00 AM with a pain level of zero (0). At 5:07 AM, RN #9 returned and administered another oxycodone dose approximately two (2) hours after the previous administration. At 7:50 AM, LPN #9 asked Resident #2 if he/she was in pain. Resident #2 reported a little bit of pain, and LPN #9 administered haloperidol (Haldol), morphine, oxycodone, and gabapentin. The camera footage identified Resident #2 received three (3) oxycodone doses within four (4) hours and forty-seven (47) minutes.The Controlled Substance Disposition Record identified Resident #2 received oxycodone 10 mg on 6/22/26 at 9:00 PM, the next dose was not administered until 2:40 AM on 6/23/26, five (5) hours and forty (40) minutes later, followed by another dose at 5:15 AM and again at 8:00 AM, approximately every two (2) to three (3) hours rather than every four (4) hours as ordered.Interview with RN #9 on 7/20/26 at 2:24 PM identified she could not recall the events of 6/22/26 into 6/23/26. RN #9 identified physician's orders should be followed, medications should be administered within one (1) hour of the scheduled administration time, and documentation should occur at the time medications were administered. RN #9 acknowledged she should not have administered the scheduled oxycodone dose more than three (3) hours late, followed by another scheduled dose approximately two (2) hours later. RN #9 further identified she should have notified the provider and communicated the late medication administration to the oncoming shift.Interview with LPN #9 on 7/20/26 at 2:59 PM identified RN #9 did not notify her the previous scheduled oxycodone dose had been administered late. LPN #9 identified had she known, she would have adjusted the next administration time to comply with the physician's order.G. Failure to administer oxycodone every four (4) hours as ordered on 6/26/26 into 6/27/26Continuous camera footage dated 6/26/26 identified LPN #7 administered medications to Resident #2 at approximately 7:58 PM. Camera footage identified Resident #2 was awake throughout the night and appeared distressed. No licensed nurse entered Resident #2's room again until 5:29 AM on 6/27/26, when RN #8 informed Resident #2 she was administering clonazepam (Klonopin) and pain medication. Although RN #8 was not observed entering Resident #2's room until 5:29 AM, the MAR documented oxycodone administrations at 12:00 AM and 4:00 AM with pain assessments of zero (0). At 6:03 AM, two (2) Nursing Assistants (NA #2 and NA #3) provided personal care, during which Resident #2 reported not feeling well and requested the hospice nurse.The Progress Notes dated 6/27/26 failed to identify missed or late pain medication administration, Resident #2's request for the hospice nurse, or notification of the provider regarding the change in condition.The Controlled Substance Disposition Record identified oxycodone 10 mg was removed from inventory for the documented 12:00 AM and 4:00 AM administrations; however, the camera footage did not identify RN #8 entering Resident #2's room until 5:29 AM.Interview with Person #2 on 7/17/26 at 9:05 AM identified he/she reviewed the camera footage and notified RN #6 on 6/27/26 that Resident #2 had not received pain medication for approximately ten (10) hours even though the medications had been documented as administered. Person #2 further identified Resident #2 repeatedly reported not feeling well and requested hospice be contacted.Interview with the Director of Nursing (DON) on 7/20/26 at 3:30 PM identified licensed nurses were responsible for assessing Resident #2 for pain each shift, implementing interventions when pain was identified, administering medications according to physician's orders, and notifying the provider whenever medications could not be administered within the required timeframe.Although attempted, interviews with RN #6, RN #8, NA #2, and NA #3 were not obtained.The Medication Errors policy dated 11/2025 directed, in part, medications were to be administered according to physician's orders and accepted standards of professional practice. The policy further directed licensed nurses to verify the right resident, medication, dose, route, time, and administration to prevent medication errors and ensure residents remained free from significant medication errors.The Pain Management policy dated 10/16/25 directed, in part, the facility would utilize a systematic approach to recognizing, assessing, treating, monitoring, and reassessing pain. The policy directed staff to identify verbal and nonverbal indicators of pain, administer pain management interventions consistent with the resident's assessment and physician's orders, evaluate the effectiveness of interventions, reassess pain, revise interventions when pain was not adequately controlled, and notify the practitioner when pain management was ineffective.The Medication Orders policy (undated) directed, in part, medication orders were to be documented promptly and accurately, entered correctly into the electronic health record, transcribed onto the Medication Administration Record (MAR), clarified when necessary, and verified to ensure safe implementation. Staff were responsible for ensuring medication orders accurately reflected the physician's directions before implementation.

Based on clinical record review, facility documentation, facility policies, interviews, and observations, for one (1) of three (3) sampled residents (Resident #2) reviewed for pain management, the facility failed to ensure pain medications were administered according to physician's orders. This included failure to administer and replace fentanyl patches every 72 hours as ordered, maintain accountability of fentanyl patches as controlled substances, accurately transcribe and implement physician's medication orders, administer oxycodone every four (4) hours as ordered, recognize and correct medication administration errors, and adequately assess and manage Resident #2's pain. These failures resulted in missed and delayed doses of prescribed pain medication, prolonged intervals between medication administrations, unaccounted-for controlled substances and unmanaged pain. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required supervision with bed mobility, required partial assistance with transfers, received scheduled and as-needed pain medications, experienced frequent moderate pain, and received hospice services.The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 required assistance with activities of daily living (ADLs) and had altered comfort related to small cell lung cancer with metastasis to the intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease, lumbar spinal stenosis, chronic bilateral low back pain with sciatica (pain caused by irritation or compression of the sciatic nerve), and claudication (pain or cramping caused by decreased blood flow). Interventions included providing one-person assistance with bathing, dressing, toileting, hygiene, and transfers using a rolling walker, monitoring for pain, administering medications as ordered, documenting the effectiveness of pain medications, and monitoring and documenting verbal and nonverbal signs and symptoms of pain.A. Delay in fentanyl patch administrationA physician's order dated 5/13/26 at 6:08 AM directed a fentanyl transdermal patch 12 micrograms (mcg) per hour, apply one (1) patch every three (3) days for pain, rotate application sites, and remove the patch according to the schedule.The May 2026 Medication Administration Record (MAR) identified RN #4 applied the 12 mcg fentanyl patch at 8:30 AM on 5/13/26. The order was discontinued later that day at 6:07 PM.A physician's order dated 5/13/26 at 6:05 PM, entered by Advanced Practice Registered Nurse (APRN) #2, directed a fentanyl transdermal patch 12 mcg per hour, apply one (1) patch every three (3) days for pain, rotate application sites, and remove the patch according to schedule.The May 2026 MAR identified the replacement order scheduled the next fentanyl patch application for 8:30 AM on 5/14/26, although the initial patch had already been applied on 5/13/26. RN #4 documented the 5/14/26 dose as not administered because the previously applied patch remained in place. The next documented fentanyl patch change did not occur until 5/17/26. Although the physician's order directed the patch be changed every 72 hours, the patch remained in place for approximately 96 hours.The Controlled Substance Disposition Record identified ten (10) fentanyl 12 mcg patches were received. One (1) patch was removed from inventory on 5/13/26, leaving nine (9) patches remaining. The next patch was not removed from inventory until 5/17/26, leaving eight (8) patches remaining, consistent with the delayed replacement documented in the MAR.Interview with the Director of Nursing (DON) on 7/16/26 at 10:05 AM identified she was unaware of the medication error until surveyor notification. The DON identified the order re-entered by APRN #2 was transcribed incorrectly, causing the administration schedule to populate inaccurately. The DON identified APRN #2 should have verified when the initial fentanyl patch had been administered before re-entering the order, and RN #4 should have questioned why the order repopulated the following day rather than document the medication as not administered.Interview with APRN #2 on 7/16/26 at 10:56 AM identified she did not recall why the original order was discontinued but believed it was related to pharmacy processing requirements for controlled substances. APRN #2 identified she re-entered the order without verifying the generated administration schedule and was unaware the electronic medical record scheduled the next application for 5/14/26 instead of 5/16/26. APRN #2 identified she should have adjusted the order time to reflect the initial application on 5/13/26 so the subsequent 72-hour administration schedule populated correctly.Interview with RN #4 on 7/16/26 at 11:22 AM identified he applied the fentanyl patch on 5/13/26. When prompted to administer another patch on 5/14/26, he observed the previous patch remained intact and documented the medication as not administered because he believed the electronic medical record generated the order in error. RN #4 identified he did not review the physician's order to determine why the medication repopulated and acknowledged he should have done so. On 5/17/26, he removed the patch dated 5/13/26 and applied a new patch but did not recognize the original patch had remained in place longer than the ordered 72-hour interval.B. Missing fentanyl patches on 5/18/26A Nurse's note by RN #2 dated 5/18/26 at 3:18 PM identified she notified the provider after both fentanyl patches were removed by Resident #2. RN #2 searched Resident #2's room but was unable to locate either fentanyl patch. The MAR was updated with a new order to reapply the fentanyl patches. RN #2 documented she educated Resident #2 and a family member regarding the importance of leaving the fentanyl patches in place.The May 2026 MAR identified a physician's order dated 5/12/26 directing one (1) fentanyl transdermal patch 25 micrograms (mcg) per hour every three (3) days for pain. The MAR identified the last documented application occurred on 5/16/26 at 8:30 AM. A physician's order dated 5/13/26 directed staff to administer one (1) fentanyl transdermal patch 12 mcg per hour every three (3) days. The last documented application occurred on 5/17/26 at 8:30 AM. The MAR further identified licensed nurses documented both fentanyl patches were present during every shift check on 5/17/26, including RN #4 during the 7:00 AM to 3:00 PM shift, LPN #5 during the 3:00 PM to 11:00 PM shift, and LPN #3 during the 11:00 PM to 7:00 AM shift. Both fentanyl patches were documented as reapplied on 5/18/26 at 12:30 PM by LPN #4.Interview with LPN #4 on 7/16/26 at 11:36 AM identified he was assigned to Resident #2 during the 7:00 AM to 3:00 PM shift on 5/18/26. During the scheduled fentanyl patch check, he was unable to locate either the 12 mcg or 25 mcg fentanyl patch. Resident #2 was unable to identify what happened to the patches.Interview with RN #2 on 7/16/26 at 12:00 PM identified LPN #4 notified her both fentanyl patches were missing. RN #2 completed a body check, searched Resident #2's bed linens, trash receptacles, and room, but was unable to locate either fentanyl patch. RN #2 identified Resident #2 reported attempting to remove the nicotine patch because he/she wanted to smoke; however, the nicotine patch remained intact. RN #2 notified the DON, who instructed her to notify the provider for replacement orders. Although the fentanyl patches could not be located, RN #2 did not obtain statements from staff members who had contact with Resident #2.Interview with the DON on 7/16/26 at 12:12 PM identified RN #2 did not report the missing fentanyl patches on 5/18/26. The DON identified when she later reviewed documentation she determined placement of both fentanyl patches had been verified by LPN #3 during the overnight shift before they were discovered missing. Although RN #2 documented Resident #2 reported removing the patches, the missing fentanyl patches represented unaccounted-for controlled substances. The DON identified the incident should have been reported to the State Agency, staff and visitor statements should have been obtained, and an investigation should have been initiated immediately.Interview with LPN #3 on 7/20/26 at 11:11 AM identified if she documented verifying placement of the fentanyl patches during the 11:00 PM to 7:00 AM shift, the fentanyl patches were present. LPN #3 identified if either fentanyl patch had been missing, she would have notified the nursing supervisor immediately. LPN #3 further identified she was never contacted by the facility to provide a statement after the incident.Although attempted, an interview with LPN #5 was not obtained.C. Missing fentanyl patches on 5/24/26 The Reportable Event (RE) form dated 5/24/26 identified RN #4 was unable to locate Resident #2's fentanyl patches during the scheduled morning placement check. The provider, hospice agency, and police department were notified. Resident #2 was monitored for changes in pain, and an investigation was initiated regarding the missing fentanyl patches and individuals who had visited Resident #2 after the patches were last documented as present.A Nurse's note by RN #4 dated 5/24/26 at 10:48 AM identified he was unable to locate the fentanyl patches applied on 5/23/26 at 12:30 PM. RN #4 completed a body check, searched Resident #2's room, bed linens, and trash receptacles, but was unable to locate either fentanyl patch. Resident #2 denied removing the patches.The May 2026 MAR identified licensed nurses documented both fentanyl patches were present on 5/23/26 during the 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts before they were later discovered missing.A Nurse's note by RN #5 dated 5/24/26 at 4:51 PM identified RN #4 notified her the fentanyl patches applied to Resident #2's right posterior scapular area could not be located. RN #5 initially checked the application site but delayed completing a full body check until Resident #2 finished breakfast. During the subsequent body check, completed with RN #4 and NA #1, Resident #2 reported a family member had placed one (1) fentanyl patch on his/her leg. No fentanyl patches were identified until NA #1 observed a fentanyl patch dated 5/17/26 on Resident #2's left upper inner arm while providing personal care. The DON, hospice agency, and provider were notified. Hospice requested the fentanyl patches be discontinued, and the provider ordered scheduled oral oxycodone in place of the fentanyl patches.D. Oxycodone order transcribed incorrectly resulting in missed overnight dosesFacility documentation dated 6/17/26 identified the administration times for Resident #2's oxycodone did not match the physician's orders from 5/24/26 through 6/17/26.Physician's orders dated 5/24/26, 5/29/26, 6/4/26, and 6/15/26 directed staff to administer oxycodone 10 milligrams (mg) by mouth every four (4) hours for terminal pain.The May 2026 Medication Administration Record (MAR) identified the 5/24/26 and 5/29/26 oxycodone orders contained administration times of 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM, but failed to include the required 2:00 AM administration, resulting in one missed scheduled dose every day.The June 2026 MAR identified the 6/4/26 and 6/15/26 oxycodone orders continued to omit the required overnight administration. The administration schedule was not corrected until 6/17/26, when the MAR was revised to include every four (4) hour administration times of 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM.The Order Audit Report identified RN #5 entered the original oxycodone order on 5/24/26 and RN #2 confirmed the order as accurate.Interview with Person #2 on 7/17/26 at 9:05 AM identified Resident #2 frequently complained of not receiving pain medication during the overnight shift and repeatedly reported uncontrolled pain.Interview with Resident #2 on 7/17/26 at 10:42 AM identified he/she experienced chronic pain requiring scheduled pain medication but was unable to recall specific dates doses were missed.Interview with RN #2 on 7/20/26 at 1:07 PM identified she confirmed the 5/24/26 oxycodone order without recognizing the administration schedule omitted the overnight dose. RN #2 identified she should have thoroughly reviewed the administration times before confirming the order and acknowledged the medication error could have been identified much sooner.Interview with RN #5 on 7/20/26 at 1:18 PM identified she entered the original oxycodone order and mistakenly selected prepopulated administration times that excluded the overnight dose. RN #5 identified she should have fully reviewed the physician's order before completing the transcription.Interview with APRN #2 on 7/20/26 at 2:07 PM identified licensed nurses were responsible for ensuring physician's orders were accurately entered and followed. APRN #2 identified staff should compare physician's orders with the Medication Administration Record (MAR), medication card, and Controlled Substance Disposition Record to identify transcription errors. APRN #2 further identified Resident #2's chronic pain could have worsened overnight when the scheduled oxycodone doses were omitted.The May and June 2026 MARs identified the only as-needed (PRN) pain medication available after the scheduled oxycodone order was acetaminophen 325 mg, two (2) tablets by mouth every six (6) hours as needed for discomfort or a temperature greater than 101 degrees. The MAR failed to identify administration of the PRN acetaminophen from 5/24/26 through 6/17/26.Interview with the Director of Nursing (DON) on 7/20/26 at 3:46 PM identified RN #5 should have accurately transcribed the oxycodone order and RN #2 should have thoroughly reviewed the order before confirming it. The DON identified comparison of the MAR, medication card, and Controlled Substance Disposition Record should have identified the error sooner and prevented the continued omission of scheduled overnight oxycodone doses.E. Failure to administer oxycodone every four hours as ordered on 6/13/26 into 6/14/26A physician's order dated 6/4/26 directed staff to administer oxycodone 10 mg by mouth every four (4) hours for terminal pain.Continuous camera footage dated 6/13/26 identified LPN #5 administered medications at approximately 9:15 PM and informed Resident #2 pain medication was being administered. Nursing staff did not re-enter the room until 12:09 AM, when RN #9 administered Ativan. At 3:29 AM Resident #2 was observed thrashing about in bed and grimacing. At 3:51 AM Resident #2 appeared restless and attempted to place both legs over the side of the bed. At 3:52 AM RN #9 entered the room, briefly assessed Resident #2, identified Resident #2 was incontinent, turned off the call bell, and exited without administering pain medication. At 4:00 AM an NA changed Resident #2's brief and exited the room. At 4:23 AM Resident #2 was observed thrashing about in bed and restless. Resident #2 continued to appear restless until 5:37 AM, when RN #9 returned and administered oxycodone, more than eight (8) hours after the previous scheduled dose.The Controlled Substance Disposition Record identified oxycodone 10 mg was administered on 6/13/26 at 10:00 PM and was not administered again until 5:30 AM on 6/14/26, approximately seven and one-half (7.5) hours later.The June 2026 Medication Administration Record (MAR) identified the only PRN pain medication available remained acetaminophen 325 mg. The MAR failed to identify administration of PRN acetaminophen during the overnight shift. RN #9 documented Resident #2's pain level as zero (0) despite the camera footage capturing restlessness, grimacing, thrashing about in bed, and attempting to get out of bed.Interview with RN #9 on 7/20/26 at 2:24 PM identified Resident #2 routinely complained of pain. RN #9 identified she documented pain assessments based on her observations and believed Resident #2 was not exhibiting signs of pain. RN #9 acknowledged if Resident #2 had reported pain or demonstrated signs of discomfort she should have administered pain medication.F. Failure to administer oxycodone every four (4) hours as ordered on 6/22/26 into 6/23/26Continuous camera footage dated 6/22/26 identified LPN #6 administered medications to Resident #2 in applesauce at approximately 9:17 PM but did not identify what the medications administered were. No licensed nurse entered Resident #2's room again until 3:03 AM on 6/23/26. At 3:01 AM, Resident #2 was observed thrashing about in bed and repeatedly kicking his/her legs over the side of the bed, appearing uncomfortable. At 3:03 AM, RN #9 entered the room and administered pain medication in applesauce more than three (3) hours after the scheduled administration time, although the Medication Administration Record (MAR) documented the oxycodone 10 milligrams (mg) dose as administered at 12:00 AM with a pain level of zero (0). At 5:07 AM, RN #9 returned and administered another oxycodone dose approximately two (2) hours after the previous administration. At 7:50 AM, LPN #9 asked Resident #2 if he/she was in pain. Resident #2 reported a little bit of pain, and LPN #9 administered haloperidol (Haldol), morphine, oxycodone, and gabapentin. The camera footage identified Resident #2 received three (3) oxycodone doses within four (4) hours and forty-seven (47) minutes.The Controlled Substance Disposition Record identified Resident #2 received oxycodone 10 mg on 6/22/26 at 9:00 PM, the next dose was not administered until 2:40 AM on 6/23/26, five (5) hours and forty (40) minutes later, followed by another dose at 5:15 AM and again at 8:00 AM, approximately every two (2) to three (3) hours rather than every four (4) hours as ordered.Interview with RN #9 on 7/20/26 at 2:24 PM identified she could not recall the events of 6/22/26 into 6/23/26. RN #9 identified physician's orders should be followed, medications should be administered within one (1) hour of the scheduled administration time, and documentation should occur at the time medications were administered. RN #9 acknowledged she should not have administered the scheduled oxycodone dose more than three (3) hours late, followed by another scheduled dose approximately two (2) hours later. RN #9 further identified she should have notified the provider and communicated the late medication administration to the oncoming shift.Interview with LPN #9 on 7/20/26 at 2:59 PM identified RN #9 did not notify her the previous scheduled oxycodone dose had been administered late. LPN #9 identified had she known, she would have adjusted the next administration time to comply with the physician's order.G. Failure to administer oxycodone every four (4) hours as ordered on 6/26/26 into 6/27/26Continuous camera footage dated 6/26/26 identified LPN #7 administered medications to Resident #2 at approximately 7:58 PM. Camera footage identified Resident #2 was awake throughout the night and appeared distressed. No licensed nurse entered Resident #2's room again until 5:29 AM on 6/27/26, when RN #8 informed Resident #2 she was administering clonazepam (Klonopin) and pain medication. Although RN #8 was not observed entering Resident #2's room until 5:29 AM, the MAR documented oxycodone administrations at 12:00 AM and 4:00 AM with pain assessments of zero (0). At 6:03 AM, two (2) Nursing Assistants (NA #2 and NA #3) provided personal care, during which Resident #2 reported not feeling well and requested the hospice nurse.The Progress Notes dated 6/27/26 failed to identify missed or late pain medication administration, Resident #2's request for the hospice nurse, or notification of the provider regarding the change in condition.The Controlled Substance Disposition Record identified oxycodone 10 mg was removed from inventory for the documented 12:00 AM and 4:00 AM administrations; however, the camera footage did not identify RN #8 entering Resident #2's room until 5:29 AM.Interview with Person #2 on 7/17/26 at 9:05 AM identified he/she reviewed the camera footage and notified RN #6 on 6/27/26 that Resident #2 had not received pain medication for approximately ten (10) hours even though the medications had been documented as administered. Person #2 further identified Resident #2 repeatedly reported not feeling well and requested hospice be contacted.Interview with the Director of Nursing (DON) on 7/20/26 at 3:30 PM identified licensed nurses were responsible for assessing Resident #2 for pain each shift, implementing interventions when pain was identified, administering medications according to physician's orders, and notifying the provider whenever medications could not be administered within the required timeframe.Although attempted, interviews with RN #6, RN #8, NA #2, and NA #3 were not obtained.The Pain Management policy dated 10/16/25 directed, in part, the facility would utilize a systematic approach to recognizing, assessing, treating, monitoring, and reassessing pain. The policy directed staff to identify verbal and nonverbal indicators of pain, administer pain management interventions consistent with the resident's assessment and physician's orders, evaluate the effectiveness of interventions, reassess pain, revise interventions when pain was not adequately controlled, and notify the practitioner when pain management was ineffective.The Medication Orders policy (undated) directed, in part, medication orders were to be documented promptly and accurately, entered correctly into the electronic health record, transcribed onto the Medication Administration Record (MAR), clarified when necessary, and verified to ensure safe implementation. Staff were responsible for ensuring medication orders accurately reflected the physician's directions before implementation.The Medication Errors policy dated 11/2025 directed, in part, medications were to be administered according to physician's orders and accepted standards of professional practice. The policy further directed licensed nurses to verify the right resident, medication, dose, route, time, and administration to prevent medication errors and ensure residents remained free from significant medication errors.

Based on clinical record review, facility documentation, facility policy, camera footage, and interviews, for one (1) of three (3) sampled residents (Resident #2) reviewed for medication administration, the facility failed to thoroughly investigate an allegation of medication misappropriation and an allegation of neglect related to medication administration. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required supervision with bed mobility and partial assistance with transfers, received scheduled and as-needed pain medication, had frequent moderate pain, and was receiving hospice services.The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 required assistance with activities of daily living (ADLs) and had an alteration in comfort/pain related to small cell lung cancer metastasized to intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease/spinal stenosis of the lumbar region, chronic bilateral low back pain with sciatica (nerve pain caused by compression or irritation of the sciatic nerve), and claudication (muscle pain, cramping or weakness of the legs or buttocks). Interventions included providing an assist of one (1) for bathing, dressing, toileting, hygiene, and transfers with a rolling walker as ordered; monitoring for pain; administering medications as ordered; documenting the effects of pain medication; and monitoring and documenting verbal and nonverbal signs and symptoms of pain.A. A Nurse's note by RN #2 dated 5/18/26 at 3:18 PM identified she notified the APRN that both fentanyl patches had been removed by Resident #2. RN #2 searched Resident #2's room but was unable to locate the patches. RN #2 documented educating Resident #2 and a family member regarding the importance of the patches and instructing Resident #2 to give any removed patches to nursing staff.The May 2026 Medication Administration Record (MAR) identified an order dated 5/12/26 directing administration of fentanyl transdermal patch 25 micrograms (mcg) per hour, one (1) patch transdermally every three (3) days for pain. The last administration was documented on 5/16/26 at 8:30 AM. An order dated 5/13/26 directed administration of fentanyl transdermal patch 12 mcg per hour, one (1) patch transdermally every three (3) days. The last administration was documented on 5/17/26 at 8:30 AM. The MAR also directed staff to check placement of the fentanyl patches every shift. Placement was documented as verified on 5/17/26 by RN #4 on the 7:00 AM to 3:00 PM shift, LPN #5 on the 3:00 PM to 11:00 PM shift, and LPN #3 on the 11:00 PM to 7:00 AM shift. Both fentanyl patches were documented as reapplied on 5/18/26 at 12:30 PM by LPN #4.Interview with LPN #4 on 7/16/26 at 11:36 AM identified he was the charge nurse assigned to Resident #2 on the 7:00 AM to 3:00 PM shift on 5/18/26. When he checked Resident #2 to verify the fentanyl patches were intact, he was unable to locate either the 12 mcg or 25 mcg fentanyl patch, and Resident #2 was unable to identify their whereabouts. LPN #4 immediately notified RN #2. LPN #4 identified consistent staff had been working with Resident #2, with the exception of LPN #3, an agency nurse who worked the 11:00 PM to 7:00 AM shift from 5/17/26 into 5/18/26.Interview with RN #2 on 7/16/26 at 12:00 PM identified LPN #4 notified her on 5/18/26 that Resident #2's fentanyl patches could not be located. RN #2 performed a body check for Resident #2 and checked Resident #2's sheets and garbage but was unable to locate the patches. RN #2 reported Resident #2 indicated he/she attempted to remove the nicotine patch because he/she wanted to smoke; however, the nicotine patch remained intact. RN #2 reported she assumed Resident #2 removed the fentanyl patches and notified the DON, who directed her to notify the provider for new orders. RN #2 acknowledged she did not initiate an investigation or obtain statements from staff who had contact with Resident #2 and was unable to explain why.Interview with the DON on 7/16/26 at 12:12 PM identified RN #2 did not report the missing fentanyl patches to her on 5/18/26. The DON identified she routinely reviewed nurses' notes for the off hours but did not recall seeing RN #2's note dated 5/18/26. The DON identified she was notified of the incident on 5/24/26 and subsequently reviewed the documentation. The DON identified LPN #3 had documented verification of the fentanyl patches during the 11:00 PM to 7:00 AM shift prior to the patches being unable to be located. The DON further identified that when fentanyl patches could not be located, staff and visitor statements should have been obtained and an investigation should have been initiated.B. Camera footage dated 6/26/26 through 6/27/26 identified Resident #2 received medications from LPN #7 at 7:58 PM on 6/26/26. No nursing staff were observed entering Resident #2's room to administer medications again until RN #8 entered at 5:29 AM on 6/27/26. At 5:29 AM, RN #8 was heard identifying she was administering Klonopin and pain medication. However, RN #8 had documented administration of oxycodone 10 mg at 12:00 AM and 4:00 AM on 6/27/26, with pain levels of zero (0).The Controlled Substance Disposition Record (CSDR) for Resident #2's oxycodone 10 mg every four (4) hours identified a dose administered on 6/26/26 at 9:00 PM. The 12:00 AM and 4:00 AM doses on 6/27/26 were documented as removed from stock; however, camera footage did not identify RN #8 entering Resident #2's room until 5:29 AM.Camera footage dated 6/27/26 at 6:03 AM, identified NA #2 and NA #3 were observed in Resident #2's room providing personal care. Resident #2 reported not feeling well and requested the hospice nurse.The 6/27/26 progress notes failed to identify documentation of missed or late medications or notification that Resident #2 reported not feeling well or requested the hospice nurse.Interview with Person #2 on 7/17/26 at 9:05 AM identified Person #2 reviewed camera footage from 6/26/26 into 6/27/26 and notified RN #6 on 6/27/26 that Resident #2 had not received pain medication in approximately ten (10) hours and the medications were being documented as administered. Person #2 further identified Resident #2 subsequently reported not feeling well and requested that hospice be contacted.Interview with the DON on 7/20/26 at 3:30 PM identified she was not shown the camera footage related to the overnight medication administration concerns. The DON identified Person #2 also notified her that Resident #2 had not received medications during the overnight shift from 6/26/26 into 6/27/26. The DON reviewed the MAR and CSDR, identified the medications were documented as administered, and determined the allegation was unsubstantiated. The DON did not initiate a further investigation, including obtaining statements from staff assigned to the overnight shift from 6/26/26 into 6/27/26.Although attempted, an interview with RN #6 was not obtained.The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy (undated) directed, in part, that allegations or suspicions of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be investigated, residents be protected during the investigation, actions taken be documented, and investigation results and corrective actions be reported as required.The Abuse, Neglect and Exploitation policy (undated) identified misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The policy directed the facility to immediately investigate allegations of misappropriation, protect residents during and after investigations, and implement corrective actions when indicated.

Based on clinical record review, facility documentation, facility policy, camera footage, and interviews, for one (1) of three (3) sampled residents (Resident #2) reviewed for medication administration, the facility failed to ensure an incident involving missing fentanyl patches and an allegation of neglect related to medication administration were reported to the State Agency within the required timeframe (within 2 hours). The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required supervision with bed mobility and partial assistance with transfers, received scheduled and as-needed pain medication, had frequent moderate pain, and was receiving hospice services.The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 required assistance with activities of daily living (ADLs) and had an alteration in comfort/pain related to small cell lung cancer metastasized to intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease/spinal stenosis of the lumbar region, chronic bilateral low back pain with sciatica (nerve pain caused by compression or irritation of the sciatic nerve), and claudication (muscle pain, cramping or weakness of the legs or buttocks). Interventions included providing an assist of one (1) for bathing, dressing, toileting, hygiene, and transfers with a rolling walker as ordered; monitoring for pain; administering medications as ordered; documenting the effects of pain medication; and monitoring and documenting verbal and nonverbal signs and symptoms of pain.A. The May 2026 Medication Administration Record (MAR) identified an order dated 5/12/26 directing administration of fentanyl transdermal patch 25 micrograms (mcg) per hour, one (1) patch transdermally every three (3) days for pain. The last administration was documented on 5/16/26 at 8:30 AM. An order dated 5/13/26 directed administration of fentanyl transdermal patch 12 mcg per hour, one (1) patch transdermally every three (3) days. The last administration was documented on 5/17/26 at 8:30 AM. The MAR also directed staff to check placement of the fentanyl patches every shift. Placement was documented as verified on 5/17/26 by RN #4 on the 7:00 AM to 3:00 PM shift, LPN #5 on the 3:00 PM to 11:00 PM shift, and LPN #3 on the 11:00 PM to 7:00 AM shift. Both fentanyl patches were documented as reapplied on 5/18/26 at 12:30 PM by LPN #4.A Nurse's note by RN #2 dated 5/18/26 at 3:18 PM identified she notified the APRN that both fentanyl patches had been removed by Resident #2. RN #2 searched Resident #2's room but was unable to locate the patches. RN #2 documented educating Resident #2 and a family member regarding the importance of the patches and instructing Resident #2 to give any removed patches to nursing staff.Interview with LPN #4 on 7/16/26 at 11:36 AM identified he was the charge nurse assigned to Resident #2 on the 7:00 AM to 3:00 PM shift on 5/18/26. When he checked Resident #2 to verify the fentanyl patches were intact, he was unable to locate either the 12 mcg or 25 mcg fentanyl patch, and Resident #2 was unable to identify their whereabouts. LPN #4 immediately notified RN #2. LPN #4 identified consistent staff had been working with Resident #2, with the exception of LPN #3, an agency nurse who worked the 11:00 PM to 7:00 AM shift from 5/17/26 into 5/18/26.Interview with RN #2 on 7/16/26 at 12:00 PM identified LPN #4 notified her on 5/18/26 that Resident #2's fentanyl patches could not be located. RN #2 performed a body check for Resident #2 and checked Resident #2's sheets and garbage but was unable to locate the patches. RN #2 reported Resident #2 indicated he/she attempted to remove the nicotine patch because he/she wanted to smoke; however, the nicotine patch remained intact. RN #2 reported she assumed Resident #2 had removed the fentanyl patches, notified the Director of Nursing (DON), and was directed to notify the provider for new orders. RN #2 acknowledged she did not recognize the missing fentanyl patches as an incident of medication misappropriation, did not report the incident to the State Agency, did not initiate an investigation, and did not obtain statements from staff who had contact with Resident #2.Interview with the DON on 7/16/26 at 12:12 PM identified RN #2 did not report the missing fentanyl patches to her on 5/18/26. The DON identified she routinely reviewed nurses' notes for the off hours but did not recall seeing RN #2's note dated 5/18/26. The DON identified she was notified of the incident on 5/24/26 and subsequently reviewed the documentation. The DON identified LPN #3 had documented verification of the fentanyl patches during the 11:00 PM to 7:00 AM shift prior to the patches being unable to be located. The DON further identified that when fentanyl patches could not be located, the incident should have been reported to the State Agency, statements should have been obtained from staff and visitors who had contact with Resident #2, and an investigation should have been initiated.B. Camera footage dated 6/26/26 through 6/27/26 identified Resident #2 received medications from LPN #7 at 7:58 PM on 6/26/26. No nursing staff were observed entering Resident #2's room to administer medications again until RN #8 entered at 5:29 AM on 6/27/26. At 5:29 AM, RN #8 was heard identifying she was administering Klonopin and pain medication. However, RN #8 had documented administration of oxycodone 10 mg at 12:00 AM and 4:00 AM on 6/27/26, with pain levels of zero (0).The Controlled Substance Disposition Record (CSDR) for Resident #2's oxycodone 10 mg every four (4) hours identified a dose administered on 6/26/26 at 9:00 PM. The 12:00 AM and 4:00 AM doses on 6/27/26 were documented as removed from stock; however, camera footage did not identify RN #8 entering Resident #2's room until 5:29 AM.Camera footage dated 6/27/26 at 6:03 AM identified NA #2 and NA #3 were observed in Resident #2's room providing personal care. Resident #2 reported not feeling well and requested the hospice nurse.Review of the 6/27/26 progress notes failed to identify documentation of missed or late medications or notification that Resident #2 reported not feeling well or requested the hospice nurse.Interview with Person #2 on 7/17/26 at 9:05 AM identified Person #2 reviewed camera footage from 6/26/26 into 6/27/26 and notified RN #6 on 6/27/26 that Resident #2 had not received pain medication in approximately ten (10) hours and the medications were being documented as administered. Person #2 further identified Resident #2 subsequently reported not feeling well and requested that hospice be contacted.Interview with the DON on 7/20/26 at 3:30 PM identified she was not shown the camera footage related to the overnight medication administration concerns. The DON identified Person #2 also notified her that Resident #2 had not received medications during the overnight shift from 6/26/26 into 6/27/26. The DON reviewed the MAR and CSDR, identified the medications were documented as administered, and determined the allegation was unsubstantiated. The DON did not report the allegation to the State Agency within the required timeframe and did not initiate a further investigation, including obtaining statements from staff assigned to the overnight shift from 6/26/26 into 6/27/26.Although attempted, an interview with RN #6 was not obtained.The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy (undated) directed all allegations or suspicions of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately to the Administrator and appropriate State and Federal agencies within required timeframes. The policy further directed the facility to investigate allegations, protect residents during the investigation, document actions taken, and report investigation results and corrective actions as required.The Abuse, Neglect and Exploitation policy (undated) identified misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The policy directed the facility to immediately investigate allegations of misappropriation, protect residents during and after investigations, and implement corrective actions when indicated.

Based on review of the clinical record, facility policy, camera footage and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for personal care, the facility failed to ensure Resident #2 was treated with dignity and respect during the provision of care. Specifically, review of continuous camera footage revealed multiple instances in which staff failed to communicate appropriately, did not address the resident by name, did not obtain permission before providing care, and did not maintain the resident's dignity. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome and palliative care. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and required supervision with bed mobility and partial assistance with transfers. Additionally, it identified Resident #1 received scheduled pain medication and as needed pain medication, had frequent moderate pain and was on hospice services. The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 required assistance with Activities of Daily Living (ADLs) and had an alteration in comfort/pain related to small cell lung cancer metastasized to intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease/spinal stenosis of the lumbar region, chronic bilateral low back pain with sciatica (nerve pain caused by compression or irritation of the sciatic nerve) and claudication (muscle pain, cramping or weakness of the legs or buttocks). Interventions included providing an assist of one (1) for bathing, dressing, toileting, hygiene and transfers with a rolling walker as ordered, monitoring for pain, administering medications as ordered, documenting the effects of pain medication and monitoring for verbal/nonverbal signs and symptoms of pain and documenting the pain. A. Review of continuous camera footage dated 6/17/26 at 10:07 PM identified NA #4 and NA #6 entered Resident #2's room. NA #6 approached the left side of the bed, pulled the sheet off of Resident #2 and opened Resident #2's brief without speaking to Resident #2. NA #4 was talking to NA #6 in a language which Resident #2 did not speak or understand and stopped care multiple times to talk to NA #6. NA #4 wiped Resident #2's front side with a towel and started to turn Resident #2 to the side when Resident #2 appeared to wake up. At 10:10 PM NA #6 spoke to Resident #2 for the first time stating, We're going to turn you. NA #6 cannot be heard talking throughout the footage due to her back facing the camera. B. Review of continuous camera footage dated 6/19/26 at 8:24 PM identified NA #4 walked into Resident #2's room and stated, They are going to complain. NA #5 was on the right side of Resident #2's bed, Resident #2 had eyes closed and NA #5 removed the oxygen nasal cannula without speaking to Resident #2. Resident #2 woke up, appeared frightened and started to grab NA #5. NA #4 placed her hand between Resident #2's legs to touch the brief and stated, he/she's not wet, we'll leave him/her alone. NA #5 covered Resident #2 and at 8:25 PM NA #4 was heard saying, I'm not going to jail. They exit the room at 8:26 PM with Resident #2 visibly awake. Interview with the DON on 7/20/26 at 3:30 PM identified she was not aware of the video footage but reported Resident #2 should have been treated with dignity and respect. The DON identified staff should always knock before entering a resident's room and explain what they will be doing prior to touching a resident or performing care. Staff should not speak in a language which the resident cannot understand or make inappropriate comments in a resident's room. Interview with NA #5 on 7/20/26 at 4:02 PM identified she was aware there was a camera recording in Resident #2's room and she should have addressed Resident #2 by name, woken him/her up and explained what they were going to do prior to taking off the oxygen. NA #5 identified Resident #2 should have been treated with dignity and respect. Although attempted, an interview with NA #4 was not obtained. Review of the Quality of Life- Dignity policy dated 11/10/25 directed, in part, residents must always be treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff will knock and request permission before entering residents' rooms. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or care needs. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed.

Based on clinical record review, camera footage, facility documentation/policy, and interviews, for one (1) of three (3) sampled residents (Resident #2) reviewed for medication administration and care, the facility failed to ensure staff followed the individualized plan of care. Specifically, across multiple shifts and involving multiple staff members, the facility failed to ensure two (2) staff members were present for all care, including medication administration, as directed by the Resident Care Plan (RCP) and physician's order. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and required supervision with bed mobility and partial assistance with transfers.The RCP dated 3/19/26 identified Resident #2 was at risk for falls and serious injuries related to a history of falls. Interventions included providing Resident #2 with verbal reminders of individual limitations and observing for alterations in gait.The RCPs dated 3/22/26 identified Resident #2 required assistance with activities of daily living (ADLs) and had an alteration in comfort/pain related to small cell lung cancer metastasized to intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease/spinal stenosis of the lumbar region, chronic bilateral low back pain with sciatica (nerve pain caused by compression or irritation of the sciatic nerve), and claudication (muscle pain, cramping or weakness of the legs or buttocks). Interventions included providing an assist of one (1) for bathing, dressing, toileting, hygiene, and transfers with a rolling walker as ordered; monitoring for pain; administering medications as ordered; providing two (2) staff members for care; documenting the effects of pain medication; and monitoring and documenting verbal and nonverbal signs and symptoms of pain.A physician's order dated 5/27/26 directed staff to provide two (2) staff for all care, including medication administration, and observation every shift for behaviors and allegations.A. Continuous camera footage dated 6/13/26 identified Resident #2 was administered medications in applesauce by LPN #5 at 9:15 PM, and LPN #5 was heard identifying she was administering pain medication. A second staff member was not present during the medication administration.Continuous camera footage dated 6/14/26 at 12:09 AM identified RN #9 entered Resident #2's room and was heard identifying she was administering Ativan before administering a syringe to Resident #2. A second staff member was not present during the medication administration.Continuous camera footage dated 6/14/26 at 3:51 AM identified Resident #2 was observed with his/her legs over the side of the bed and appeared to be attempting to get out of bed. At 3:52 AM, RN #9 entered Resident #2's room, checked Resident #2, identified Resident #2 was wet, turned off the call bell, and exited the room. At 4:00 AM, NA #7 entered Resident #2's room, provided personal care, and exited without a second staff member present. At 5:37 AM, RN #9 entered Resident #2's room and was heard identifying she was administering oxycodone to Resident #2. A second staff member was not present during the medication administration.The June 2026 Treatment Administration Record (TAR) identified LPN #5 and RN #9 signed off on 6/13/26 that two staff members were present for all care, including medication administration.Although attempted, interviews with LPN #5 and NA #7 were not obtained.B. Continuous camera footage dated 6/16/26 identified NA #5 entered Resident #2's room at 8:57 PM and provided personal care. NA #5 completed care and exited the room at 9:03 PM. A second staff member was not present during the care.Interview with NA #5 on 7/20/26 at 4:02 PM identified she was aware Resident #2 required two (2) staff for care. NA #5 was unable to explain why a second staff member was not present and could not recall specific details of 6/16/26.C. Continuous camera footage dated 6/17/26 at 9:35 AM identified NA #1 informed Resident #2 she was going to transfer Resident #2 to the shower chair for a shower. NA #1 assisted Resident #2 to sit on the left side of the bed. Without applying a gait belt or using a rolling walker as ordered, NA #1 instructed Resident #2 to give her a big hug and performed a bear-hug transfer. At 9:50 AM, following the shower, NA #1 again instructed Resident #2 to sit up and give her a big hug and performed another bear-hug transfer. NA #1 was the only staff member present during both transfers to and from the shower chair.Interview with NA #1 on 7/20/26 at 1:28 PM identified that before preparing to shower Resident #2, other staff informed her Resident #2 required an assist of one (1) for care and transfers. NA #1 identified she did not review Resident #2's care card (a quick-reference summary sheet that outlines essential daily care needs), although she should have. NA #1 identified she transferred Resident #2 to and from the shower chair alone without a second staff member present.D. Continuous camera footage dated 6/22/26 identified Resident #2 was administered medications in applesauce by LPN #6 at 9:17 PM. A second staff member was not present during the medication administration.Continuous camera footage dated 6/23/26 at 3:03 AM identified RN #9 entered Resident #2's room and was heard identifying she was administering pain medication in applesauce. A second staff member was not present during the medication administration. At 5:07 AM, RN #9 entered Resident #2's room and was heard identifying she was administering oxycodone. A second staff member was not present during the medication administration. At 7:50 AM, LPN #9 entered Resident #2's room and was heard identifying she was administering Haldol, morphine, oxycodone, and gabapentin and administered the medications in applesauce. A second staff member was not present during the medication administration.The June 2026 TAR identified LPN #6 and RN #9 signed off on 6/22/26 and LPN #9 signed off on 6/23/26, that two staff members were present for all care, including medication administration.Interview with RN #9 on 7/20/26 at 2:24 PM identified that although she signed the TAR indicating a second staff member was present when she administered medications to Resident #2 during her 11:00 PM to 7:00 AM shift from 6/13/26 into 6/14/26 and from 6/22/26 into 6/23/26, she was unaware Resident #2 required two (2) staff for care. RN #9 identified that if she signed the TAR indicating two staff members were present, she should have ensured the documentation was accurate.Interview with LPN #9 on 7/20/26 at 2:59 PM identified she was unable to recall whether a second staff member was present when she administered medications to Resident #2 on 6/23/26 but identified that if she signed the TAR indicating a second staff member was present, she should have ensured the documentation was accurate.Interview with LPN #6 on 7/20/26 at 3:22 PM identified he was unable to recall whether a second staff member was present when he administered medications to Resident #2 on 6/22/26 but identified that if he signed the TAR indicating a second staff member was present, he should have ensured the documentation was accurate.E. Continuous camera footage dated 6/26/26 identified Resident #2 was administered medications in applesauce by LPN #7 at 7:58 PM. A second staff member was not present during the medication administration. On 6/27/26 at 5:29 AM, RN #8 entered Resident #2's room and was heard identifying she was administering Klonopin and pain medication. A second staff member was not present during the medication administration.The June 2026 TAR identified LPN #7 and RN #8 signed off on 6/26/26 that two staff members were present for all care, including medication administration.Interview with the DON on 7/20/26 at 3:30 PM identified staff were responsible for reviewing each resident's plan of care through the RCP and/or care card every shift before providing care. The DON identified staff should have followed Resident #2's plan of care at all times and ensured two (2) staff members were present for all care, including medication administration. The DON identified the two-staff requirement was implemented following an alleged medication misappropriation on 5/24/26 and was intended to protect both Resident #2 and staff. The DON identified she was unaware of the camera footage concerning the medication administration and reported Resident #2's family had only shown her the footage of the shower provided by NA #1 on 6/17/26. The DON further identified licensed staff should not have signed the TAR indicating two staff members were present when they were not and that documentation should have been accurate.Although attempted, interviews with LPN #7 and RN #8 were not obtained.The Care Planning policy dated 11/2025 directed, in part, that a comprehensive and individualized plan of care be developed for each resident and guide caregivers in assisting residents to achieve or maintain their highest practical level of well-being. The policy further directed Resident Care Cards be updated as needed to reflect changes made to the resident's plan of care.Although requested, policies regarding following physician's orders and NA care cards were not available.

Based on clinical record review, facility documentation, camera footage, facility policy, and interviews, for one (1) of three (3) sampled residents (Resident #2) reviewed for safe transfers, the facility failed to ensure Resident #2 was transferred in accordance with the physician's order and individualized plan of care. Specifically, staff failed to use the required gait belt and rolling walker and performed transfers using an unsafe, unapproved bear hug technique despite Resident #2 exhibiting anxiety, grabbing the shower chair, and verbally indicating an inability to assist. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, palliative care, and a history of falling.A physician's order dated 3/10/26 directed staff to provide an assist of one (1) for transfers with a rolling walker.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and required supervision with bed mobility and partial assistance with transfers.The Resident Care Plan (RCP) dated 3/19/26 identified Resident #2 was at risk for falls and serious injuries related to a history of falls. Interventions included providing Resident #2 with verbal reminders of individual limitations and observing for alterations in gait.The RCP dated 3/22/26 identified Resident #2 required assistance with activities of daily living (ADLs) and had an alteration in comfort/pain related to small cell lung cancer metastasized to intrathoracic lymph nodes, restless leg syndrome, degenerative disc disease/spinal stenosis of the lumbar region, chronic bilateral low back pain with sciatica (nerve pain caused by compression or irritation of the sciatic nerve), and claudication (muscle pain, cramping or weakness of the legs or buttocks). Interventions included providing an assist of one (1) for bathing, dressing, toileting, hygiene, and transfers with a rolling walker as ordered, monitoring for pain, administering medications as ordered, providing two (2) staff members for care, documenting the effects of pain medication, and monitoring and documenting verbal and nonverbal signs and symptoms of pain.A physician's order dated 5/27/26 directed staff to provide two (2) staff for all care, including medication administration, and observation every shift for behaviors and allegations.Continuous camera footage dated 6/17/26 at 9:35 AM showed NA #1 informing Resident #2 she was going to transfer Resident #2 to the shower chair for a shower. NA #1 assisted Resident #2 to sit on the left side of the bed. Without applying a gait belt or using the ordered rolling walker, NA #1 instructed Resident #2 to give her a big hug and performed a bear-hug transfer. Resident #2 repeatedly grabbed the shower-chair arm and appeared anxious. NA #1 told Resident #2 to Let go twice, removed Resident #2's hand, and pivoted Resident #2 into the shower chair positioned at the left side of the bed.At 9:50 AM, following the shower, NA #1 again directed Resident #2 to sit up and give her a big hug and performed another bear-hug transfer. Resident #2 stated, I can't, and made grunting noises; however, NA #1 continued the transfer and pivoted Resident #2 back to bed. NA #1 was the only staff member present during both transfers.Interview with the Rehab Director on 7/20/26 at 12:42 PM identified NA #1 should have used a gait belt and rolling walker for Resident #2's transfers in accordance with the established plan of care. The Rehab Director identified the bear-hug transfer performed by NA #1 was not an approved transfer technique and placed Resident #2 at risk for injury. The Rehab Director further identified that when Resident #2 appeared anxious and grabbed the shower chair, NA #1 should have stopped the transfer and requested assistance. When Resident #2 indicated an inability to assist as directed, NA #1 should not have continued the transfer and instead should have stopped to ensure Resident #2's safety.Interview with NA #1 on 7/20/26 at 1:28 PM identified that before preparing to shower Resident #2, other staff informed her Resident #2 was an assist of one (1) for care and transfers. NA #1 acknowledged she did not review Resident #2's care card (a quick-reference summary sheet that outlines essential daily care needs), although she should have. NA #1 identified she transferred Resident #2 to and from the shower chair alone, without using the rolling walker or gait belt. NA #1 further identified that when Resident #2 became anxious and grabbed the shower chair, she should have stopped and requested assistance but instead performed the bear-hug transfer. NA #1 acknowledged that after the shower she should have requested staff assistance to safely transfer Resident #2 back to bed and should have stopped when Resident #2 stated, I can't, rather than continue the transfer.Interview with the DON on 7/20/26 at 1:49 PM identified NA #1 did not follow Resident #2's established transfer and care instructions on 6/17/26. The DON identified NA #1 should have reviewed Resident #2's care card before assisting with the shower and should not have attempted the transfers without the required gait belt and rolling walker. The DON identified the bear-hug transfer was unsafe, was not an approved technique, and placed Resident #2 at risk for injury. The DON further identified that when Resident #2 became anxious, grabbed the shower chair, or stated, I can't, NA #1 should have stopped the transfer, reassessed the situation, and requested additional staff assistance.Review of the Safe Resident Handling/Transfers policy (undated) directed, in part, that all residents require safe handling when transferred to prevent or minimize the risk of injury to residents and employees. The policy directed that the interdisciplinary team or designee evaluate each resident's individual mobility needs and identified handling aids may include gait belts, transfer boards, or other devices. The policy further directed that resident lifting and transferring be performed according to the resident's individual plan of care.Although requested, a policy regarding gait belts was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for medication order transcription and controlled substances, the facility failed to ensure physician orders were accurately entered and transcribed into the electronic medical record and failed to ensure proper accountability and disposition of controlled substances.Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome, and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and required supervision or limited assistance with activities of daily living.The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 had altered comfort related to small cell lung cancer with metastasis and chronic pain. Interventions included monitoring for pain, administering medications as ordered, and documenting the effectiveness of pain medications.A. Incorrect transcription of fentanyl patch ordersA physician's order dated 5/13/26 directed staff to apply one (1) fentanyl transdermal patch 12 micrograms (mcg) per hour every three (3) days and rotate application sites. The order was discontinued and re entered later that day by Advanced Practice Registered Nurse (APRN) #2.The May 2026 Medication Administration Record (MAR) identified the electronic medical record scheduled the next fentanyl patch application for 5/14/26, despite the patch being applied on 5/13/26.The Controlled Substance Disposition Record identified ten (10) fentanyl patches were received and only one (1) patch was removed from inventory on 5/13/26, with the next patch removed on 5/17/26. This reflected a delay in patch replacement consistent with an incorrectly generated administration schedule.Interview with the DON on 7/16/26 at 10:05 AM identified the order re entered by APRN #2 was transcribed incorrectly, causing the administration schedule to populate inaccurately. The DON identified APRN #2 should have verified the initial administration time when re entering the order so the correct 72 hour schedule would populate.Interview with APRN #2 on 7/16/26 at 10:56 AM identified she re entered the fentanyl order without reviewing the automatically generated administration times and acknowledged she should have adjusted the order to reflect the patch applied on 5/13/26.B. Failure to maintain accountability for controlled substances (missing fentanyl patches on 5/18/26)A nurse's note by RN #2 dated 5/18/26 at 3:18 PM identified she notified the provider after both fentanyl patches were removed by Resident #2. RN #2 searched Resident #2's room but was unable to locate either fentanyl patch. The MAR was updated with a new order to reapply the fentanyl patches. The May 2026 MAR identified a physician's order dated 5/12/26 directing one (1) fentanyl transdermal patch 25 micrograms (mcg) per hour every three (3) days for pain. The MAR identified the last documented application occurred on 5/16/26 at 8:30 AM. A physician's order dated 5/13/26 directed staff to administer one (1) fentanyl transdermal patch 12 mcg per hour every three (3) days. The last documented application occurred on 5/17/26 at 8:30 AM. The MAR further identified licensed nurses documented both fentanyl patches were present during every shift check on 5/17/26, including RN #4 during the 7:00 AM to 3:00 PM shift, LPN #5 during the 3:00 PM to 11:00 PM shift, and LPN #3 during the 11:00 PM to 7:00 AM shift. Both fentanyl patches were documented as reapplied on 5/18/26 at 12:30 PM by LPN #4.Interview with LPN #4 on 7/16/26 at 11:36 AM identified he was assigned to Resident #2 during the 7:00 AM to 3:00 PM shift on 5/18/26 and was unable to locate either fentanyl patch during the scheduled patch check.Interview with RN #2 on 7/16/26 at 12:00 PM identified she conducted a search of Resident #2's room and belongings, but the patches were not located. RN #2 identified she did not obtain statements from staff or visitors who had contact with Resident #2.Interview with the DON on 7/16/26 at 12:12 PM identified the missing fentanyl patches represented unaccounted for controlled substances. The DON identified the incident should have been immediately reported to the State Agency, staff and visitor statements should have been obtained, and an investigation should have been initiated. The DON further identified staff were not interviewed regarding the missing patches.Although attempted, an interview with LPN #5 was not obtainedC. Failure to maintain accountability for controlled substances (missing fentanyl patches on 5/24/26)A Reportable Event (RE) form dated 5/24/26 identified RN #4 was unable to locate Resident #2's fentanyl patches during the scheduled morning placement check. The provider, hospice agency, and police department were notified. An investigation was initiated regarding individuals who had visited Resident #2 after the patches were last documented as present.A nurse's note by RN #4 dated 5/24/26 at 10:48 AM identified he completed a body check and searched Resident #2's room and belongings but was unable to locate either fentanyl patch applied on 5/23/26.The May 2026 MAR identified licensed nurses documented both fentanyl patches were present on 5/23/26 during the 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts before they were later discovered missing.A nurse's note by RN #5 dated 5/24/26 at 4:51 PM identified she initially checked the application site and later completed a full body assessment with RN #4 and NA #1. NA #1 identified an old fentanyl patch dated 5/17/26 on Resident #2's left upper inner arm. The DON, hospice agency, and provider were notified. The hospice agency requested discontinuation of fentanyl patches, and the provider ordered scheduled oral oxycodone in place of the fentanyl patches.D. Incorrect transcription of oxycodone orders resulting in omitted overnight dosingFacility documentation dated 6/17/26 identified the administration times for Resident #2's oxycodone did not match the physician's orders from 5/24/26 through 6/17/26.Physician's orders dated 5/24/26, 5/29/26, 6/4/26, and 6/15/26 directed staff to administer oxycodone 10 milligrams (mg) by mouth every four (4) hours for terminal pain. The May 2026 MAR identified the 5/24/26 and 5/29/26 oxycodone orders populated administration times of 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM, but did not include the required overnight dose scheduled every four hours.The June 2026 MAR identified the 6/4/26 and 6/15/26 orders continued to omit the overnight dosing until the MAR was corrected on 6/17/26.The Order Audit Report identified RN #5 entered the original oxycodone order on 5/24/26 and RN #2 confirmed the order as accurate.Interview with RN #2 on 7/20/26 at 1:07 PM identified she confirmed the oxycodone order without recognizing the administration schedule omitted the overnight dose. RN #2 identified she should have thoroughly reviewed the generated schedule before confirming the order.Interview with RN #5 on 7/20/26 at 1:18 PM identified she mistakenly selected prepopulated administration times that excluded the overnight dose and acknowledged she should have fully reviewed the physician's order before completing the transcription.Interview with APRN #2 on 7/20/26 at 2:07 PM identified licensed nurses were responsible for ensuring physician's orders were accurately entered, transcribed, and followed. APRN #2 identified staff should compare orders with the MAR and medication card to identify transcription errors.Interview with the DON on 7/20/26 at 3:46 PM identified RN #5 should have accurately transcribed the oxycodone order and RN #2 should have thoroughly reviewed it before confirming. The DON identified comparison of the MAR, medication card, and Controlled Substance Disposition Record should have identified the error sooner.Review of the facility's Medication Orders policy (undated) directed, in part, medication orders were to be entered accurately into the electronic health record, transcribed correctly onto the MAR, clarified when necessary, and verified before implementation.

Based on clinical record review, observations, camera footage, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for incontinence care, the facility failed to ensure infection control practices were implemented during incontinence care, specifically failing to ensure that soiled incontinence briefs and soiled linens were not placed on the floor or on clean surfaces. The findings include:Resident #2's diagnoses included malignant neoplasm of the bronchus/lung, secondary malignant neoplasm of the intrathoracic lymph nodes, chronic pain syndrome and palliative care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required supervision with bed mobility and partial assistance with transfers. The MDS identified Resident #2 was frequently incontinent of urine and occasionally incontinent of bowel.The Resident Care Plan (RCP) dated 3/22/26 identified Resident #2 required assistance with ADLs. Interventions included providing an assist of one (1) for bathing, dressing, toileting, hygiene and transfers with a rolling walker as ordered.A. Review of continuous camera footage dated 6/15/26 at 8:02 PM identified NA #4 and NA #5 entered Resident #2's room to provide incontinence care. At 8:03 PM, NA #4 threw a soiled brief directly onto the bedside floor mat to the right side of the bed. The soiled linens that were used to wash Resident #2 were placed directly on the bed sheets and the sheets were not changed prior to NA #4 and NA #5 leaving the room.Although attempted, an interview with NA #4 was not obtained.B. Review of continuous camera footage dated 6/16/26 at 8:57 PM identified NA #5 entered Resident #2's room to provide incontinence care. At 8:58 PM, NA #5 threw a soiled brief directly onto the bedside floor mat to the right side of the bed. The soiled linens that were used to wash Resident #2 were placed directly on the bed sheets and the sheets were not changed prior to NA #5 leaving the room.Interview with the DON on 7/20/26 at 3:30 PM identified infection control is a standard of care and staff should never place dirty linens or incontinent briefs on clean linens or floor surfaces, rather, they should be bagged separately and discarded.Interview with NA #5 on 7/20/26 at 4:02 PM identified dirty briefs and linens should be placed in separate bags and not placed directly on clean linens or the floor. She was unable to explain why the surfaces were not cleaned, and the sheets were not changed prior to leaving Resident #2's room.Although requested, a policy on infection control practices related to disposing of soiled linens and incontinence supplies was not obtained.

Based on review of clinical records, interviews, and facility documentation for three (3) of three (3) residents (Resident #1, #2, and #3) for medication administration, the facility failed to ensure residents blood glucose levels were obtained before meals and failed to ensure insulin was administered before meals according to provider order. The findings included: 1a. Resident #1 was admitted to the facility in April of 2025 and had diagnoses that included Type 2 diabetes mellitus, dementia, and chronic obstructive pulmonary disease. A physician's order dated 4/23/25 directed Lispro (a short-acting insulin) administration per sliding scale (two (2) units for a blood glucose level of 151-200, four (4) units for a blood glucose level of 201-250, six (6) units for a blood glucose level of 251-300, eight (8) units for a blood glucose level of 301-350, ten (10) units for a blood glucose level of 351-400, and to notify the provider of blood glucose levels greater than 400) before meals and at bedtime for diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of 6), was dependent with toileting, lower body dressing, and toileting transfers. The Resident Care Plan (RCP) dated 5/6/25 identified Resident #1 had diabetes. Interventions directed to monitor blood glucose levels and administer medications as ordered. Review of the mealtime schedule identified Resident #1 had breakfast scheduled for 8:00 AM, lunch scheduled for 11:30 AM, and dinner scheduled for 4:30 PM. The Medication Administration Report dated April 2025 identified Lispro was administered as follows: - 4/26/25 at 10:00 AM (scheduled to be administered before breakfast) - 4/26/25 at 5:53 PM (scheduled to be administered before dinner) - 4/29/25 at 9:27 AM (was scheduled to be administered before breakfast) Review of the Medication Administration Report dated May 2025 identified Lispro was administered as follows: - 5/1/25 at 12:05 PM (scheduled to be administered before breakfast) - 5/1/25 at 2:14 PM (scheduled to be administered before lunch) - 5/4/25 at 8:47 AM (scheduled to be administered before breakfast) - 5/4/25 at 5:31 PM (scheduled to be administered before dinner) - 5/5/25 at 9:07 AM (scheduled to be administered before breakfast) - 5/6/25 at 12:37 PM (scheduled to be administered before lunch) - 5/8/25 at 9:04 AM (scheduled to be administered before breakfast) - 5/9/25 at 8:59 AM (scheduled to be administered before breakfast) - 5/16/25 at 6:14 PM (scheduled to be administered before dinner) - 5/19/25 at 6:08 PM (scheduled to be administered before dinner) - 5/15/25, at 8:51 AM (scheduled to be administered before breakfast) - 5/16/25 at 9:07 AM (scheduled to be administered before breakfast) 1b. Resident #2 was admitted to the facility in April of 2025 with diagnoses that included Type 2 diabetes mellitus, chronic kidney disease, and major depressive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was dependent with toileting, bathing, and mobility. The RCP dated 4/29/25 identified diabetes. Interventions directed to monitor blood glucose levels and administer medications as ordered. A physician's order dated 4/11/25 directed to administer Lispro, five (5) units, with meals for diabetes. Review of the mealtime schedule identified Resident #2 had breakfast scheduled for 8:00 AM, lunch scheduled for 11:30 AM, and dinner scheduled for 4:30 PM. Review of the April Medication Administration Report identified Lispro was to be given at 8:00 AM, 12:00 PM, and 5:00 PM with meals, however, was administered as follows: - 5/1/25: 5 units were administered at 10:36 AM - 5/6/25: 5 units were administered at 9:27 AM - 5/7/25: 5 units were administered at 6:04 PM - 5/8/25: 5 units were administered at 9:16 AM - 5/15/25: 5 units were administered at 9:24 AM - 5/20/25: 5 units were administered at 9:15 AM - 5/21/25: 5 units were administered at 7:11 PM - 5/23/25: 5 units were administered at 9:17 AM - 5/28/25: 5 units were administered at 6:06 PM - 5/30/25: 5 units were administered at 6:33 PM - 5/31/25: 5 units were administered at 7:07 PM - 6/1/25: 5 units were administered at 6:24 PM 1c. Resident #3 was admitted to the facility in February of 2023 and had diagnoses that included Type 2 diabetes mellitus, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of 7) and required substantial assistance with toileting, bathing, and personal hygiene. The RCP dated 5/6/25 identified risk for hyper/hypoglycemia related to diabetes mellitus, type 2. Interventions directed to monitor blood glucose levels per physician's order and administration of insulin per order. A physician's order directed to administer Insulin Lispro Injection Solution 100 units per milliliter as per sliding scale: (two (2) units for a blood glucose level of 200-249, three (3) units for a blood glucose level of 250-299, four (4) units for a blood glucose level of 300-349, five (5) units for a blood glucose level of 350-399, six (6) units for a blood glucose level of greater than 400 and provider notification) with meals related to Type 2 diabetes mellitus with diabetic neuropathy. Review of the mealtime schedule identified Resident #3 had breakfast scheduled for 8:30 AM to 8:45 AM, lunch scheduled for 12:00 PM to 12:15 PM, and dinner scheduled for 4:30 PM to 4:45 PM. Review of the April Medication Administration Report identified Lispro was to be given at 8:00 AM, 12:00 PM, and 5:00 PM with meals, however, was administered as follows: - 5/7/25: at 5:56 PM (scheduled to be administered with dinner) - 5/12/25: at 6:06 PM (scheduled to be administered with dinner) - 5/14/25: at 11:01 AM (scheduled to be administered with lunch) - 5/14/25: at 5:54 PM (scheduled to be administered with dinner) - 5/15/25: at 9:09 AM (scheduled to be administered with breakfast) - 5/19/25: at 1:10 PM (scheduled to be administered with lunch) - 5/21/25: at 6:08 PM (scheduled to be administered with dinner) - 5/22/25: at 1:00 PM (scheduled to be administered with lunch) - 5/25/25: at 1:02 PM (scheduled to be administered with lunch) - 5/24/25: at 5:20 PM (scheduled to be administered with dinner) - 5/28/25: at 7:05 PM (scheduled to be administered with dinner) - 5/30/25: at 6:32 PM (scheduled to be administered with dinner) - 5/31/25: at 6:39 PM (scheduled to be administered with dinner) - 6/1/25: at 6:23 PM (scheduled to be administered with dinner) Interview with RN #1 on 6/2/25 at identified meals were served to residents anytime between their scheduled mealtime and thirty (30) minutes thereafter. Interview with the Director of Nursing Services (DNS) on 6/2/25 at 1:10 PM identified the facility's standard of practice was to check the resident's blood glucose level prior to meals. Interview with APRN #1 on 6/2/25 at 12:39 PM identified staff should obtain blood glucose levels within thirty (30) minutes of meal intake. APRN #1 later identified that a resident could be at risk for a hypoglycemic episode if blood glucose levels were taken during or following meals, depending on how much food was eaten prior to the blood glucose level being checked and treated. Interview with the DNS on 6/3/25 at 1:41 PM identified residents prescribed a set dose of insulin with meals should be administered their dose either thirty (30) minutes prior to their meal or with their meal. Review of the Medication Administration and General Guidelines policy directed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy further identified that medications were administered in accordance with written orders of the prescriber.

Based on the tour of the Dietary Department, interview and facility documentation, the facility failed to identify expiration dates for dry stock and frozen items. The findings included: Tour of the Dietary Department on 5/9/25 at 12:05 PM with the Dietary Manager identified the following: a. The basement dry stock contained 16 individual bags of sliced white breads with no expiration date, 2 (1-gallon) coleslaw dressing jars with no expiration date and 4 (1-pound) cans of chicken base that lacked an expiration date. b. The walk-in basement freezer contained 12 packages of hot dog buns with no expiration date, 12 packages of hamburger buns with no expiration date, 2 plastic wrapped 5-pound beef chucks with no expiration dates, a 1 5-pound bag of chicken tenders with no expiration date and a 10-pound bag of chicken breast with no expiration date. Interview with the Dietary Director on 5/9/25 at 12:56 PM failed to identify the policy on expiration dates, and stated they were most likely on the boxes they were delivered in, but due to lack of room in the facility, items were removed from the boxes. She was unable to identify how the items with no expiration dates would be identified as expired without being labeled. Review of the Food policy directed in part that all food will be labeled and dated to allow for rotation of supplies. Review of the Shelf Life and Use of Frozen Foods policy directed in part that all foods should be covered, labeled and dated when it was freezed.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 2 of 2 residents (Resident #23 and Resident #44) who transferred to the hospital and were reviewed for Multi-Drug Resistant Organisms (MDROs), the facility failed ensure at the time of transfer to an acute care hospital the MDRO colonization status, special instructions or precautions for ongoing care related to the MDRO were communicated to the receiving hospital. The findings include: 1. Resident #23 was admitted with diagnoses that included Parkinson's disease and chronic obstructive pulmonary disease (COPD). A lab result dated 6/24/24 identified Resident #23's sputum was positive for Extended- spectrum beta lactamase (ESBL-enzymes that identify antibiotic resistance) bacteria (Klebsiella) and Methicillin (antibiotic) resistance bacteria (staphylococcus) or MRSA. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was alert and oriented and was independent for personal hygiene, ambulation with a walker and transfer. Resident #23 was occasionally incontinent of urine. The MDS did not identify Resident #23 had a MDRO (despite the lab result of 6/24/24 identifying MRSA and ESBL in the sputum). The Resident Care Plan (RCP) dated 10/22/24 identified Resident #23 had emphysema (lung disease) and was an active smoker. Interventions included aerosol treatments as ordered and elevate head of the bed. A nursing note dated 11/10/24 at 8:37 AM identified that Resident #23 was in respiratory distress and was transferred to the hospital emergency department (ED) via 911. Interview and review of the Multi Drug Resistant Organism (MDRO) log with RN #3, the Infection Preventionist on 5/9/25 at 11:00 AM identified Resident #23 was on the facility MDRO list and had facility acquired MRSA and ESBL in both the urine and nose as of 6/28/24 and again on 10/9/24. Nursing notes failed to identify that Resident #23's MDRO status was communicated on transfer to the hospital on [DATE]. 2. Resident #44 was admitted with diagnoses that included dementia and end stage renal disease. A lab result dated 11/26/24 identified Resident #44 had ESBL klebsiella (bacteria) in urine cultures. The Resident Care Plan (RCP) dated 11/7/24 identified Resident #44 was frequently incontinent of bladder with interventions that included incontinent care every 2 hours and as needed. A hospital Discharge summary dated [DATE] identified Resident #44 had history of ESBL klebsiella (bacteria) in urine cultures. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and needed substantial assistance for personal/toilet hygiene, and transfer. Resident #44 was occasionally incontinent of urine. A nursing note dated 4/8/25 at 12:23 PM identified that Resident #44 was in respiratory distress and was transferred to the hospital emergency department (ED) via 911. Interview and review of the Multi Drug Resistant Organism (MDRO) log with RN #3, the Infection Preventionist on 5/9/25 at 11:00 AM identified Resident #44 was on the facility MDRO list and had community acquired ESBL in the urine. Nursing notes failed to identify that Resident #44's MDRO status was communicated on transfer to the hospital on 4/8/25. Interview with RN #3 on 5/12/25 at 12:30 PM identified that Resident #23 was transferred to the hospital on [DATE] and Resident #44 had been transferred to the hospital on 4/8/25. Both medical records lacked documentation that at the time of transfer to the hospital that the MDRO colonization status, any special instructions or precautions for ongoing care were identified and communicated to the hospital. He was aware that the facility needed to notify at the time of transfer to another facility of the MDRO status. RN #3 continued that it was the facility's process to inform the hospital verbally. He could not locate any documentation regarding information that was provided upon transfer to another facility (nursing notes, Inter-Agency Referral form/W10) for Resident #23 or Resident #44 and noted he did not monitor that aspect of the MDRO requirements. Interview with the DNS on 5/13/25 at 9:30 AM identified she was aware that the facility needed to notify on transfer a resident's MDRO status and this was completed when the transferring nurse provided verbal report. The documentation that was provided at transfer included the resident's face sheet that included diagnoses and the resident's medication profile. A copy was not retained, and the nurses were not completing the electronic transfer/discharge document that was a part of the electronic medical record, so she was unable to provide any documentation of communication of MDRO status and any precautions necessary upon transfer. Interview with RN #6, (Regional Nurse) on 5/13/25 at 11:30 AM identified that the face sheet would include the MDRO diagnoses but that the facility did not retain any copies of paperwork completed on transfer to the hospital and the electronic discharge form was not utilized. Resident #23's and #44's face sheet failed to include the MDRO diagnoses. The facility policy Control of MDRO colonization failed to identify the requirement to notify the hospital upon transfer of the MDRO status. The facility policy Guidelines for Methicillin- Resistant Staphylococcus Organism (MDRO) colonization identified in part, to notify other institutions as soon as possible of the resident's history of MRSA when planning inter-agency transfer to help ensure optimal infection control measures are instituted.

Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for nutrition, the facility failed to ensure that meal percentages were consistently being documented for a resident with significant weight loss. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, dysphagia, severe protein-calorie malnutrition and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required substantial assistance for bed mobility. Additionally, the MDS identified that Resident #1 had a weight loss of 5 percent (%) or more in the last month or a loss of 10 % or more in the last 6 months. The Resident Care Plan (RCP) dated 4/28/25 identified Resident #1 had severe protein calorie malnutrition related to severe weight loss, dysphagia, loss of muscle and fat, low Body Mass Index (BMI) and blood work indicating inflammation despite intake being above the estimated needs. Interventions included to monitor the dietary intake as ordered. A nutrition note dated 4/23/25 at 3:08 PM identified that Resident #1's weight was down 4 pounds from the weight of the previous week. The nutritional note reported that blood work was obtained and indicated inflammation or chronic disease state was a factor affecting the resident's weight loss. The note identified that by mouth intakes averaged 50 %. An Advanced Practice Registered Nurse (APRN) progress note dated 4/25/25 at 10:00 AM identified that Resident #1 was evaluated for ongoing weight loss with poor meal intake of approximately 50 %. The note reported that nursing will monitor and report changes in oral intake. Review of April 2025 Documentation Survey Report (Nurse Aide documentation) identified that the meal intake percent (%) eaten for breakfast was not documented for Resident #1 on 4/1/25, 4/2/25, 4/7/25, 4/17/25, 4/22/25, 4/24/25 and 4/29/25. The meal intake percent (%) eaten for lunch was not documented on 4/1/25, 4/2/25, 4/3/25, 4/6/25, 4/7/25, 4/11/25, 4/14/25 through 4/17/25, 4/19/25, 4/21/25, 4/22/25, 4/24/25 through 4/26/25, 4/28/25 and 4/29/25. An APRN progress note dated 5/2/25 at 10:00 AM identified that Resident #1 continued to decline overall with continued weight loss and poor appetite with a meal intake of approximately 50 % and the resident was recently started on Mirtazapine 15 mg at bedtime as an appetite enhancer. Review of May 2025 Documentation Survey Report (Nurse Aide documentation) identified that the meal intake percent (%) eaten for breakfast was not documented for Resident #1 on 5/2/25, and 5/4/25. The meal intake percent (%) eaten for lunch was not documented on 5/1/25 through 5/9/25. The meal intake percent (%) eaten for dinner was not documented on 5/5/25. Interview and clinical record review with the Dietician on 5/12/25 at 12:28 PM identified that she averaged the resident's meal intakes within a certain timeframe to calculate intake trends to treat the resident appropriately, so she relied on the Nurse Aide's (NA's) to document accurately and consistently every meal so that the calculation was correct. She reported that for Resident #1, who has had a significant weight loss, the NA's were not documenting on each meal and although she doesn't believe it would affect her treatment plan, she expected that the NA's document the meal percentages eaten accurately and consistently and report any changes to nursing so that she can then be notified. Interview with the DNS on 5/12/25 at 1:04 PM identified that she expects that the NAs document completely and accurately for all tasks for each resident, reporting that she was not aware that they were not documenting on the meal percentages each meal for Resident #1 stating they should have been. She identified that the accuracy and completeness of the NA documentation is important for the care of each resident and that she will start reviewing the NA documentation more closely for omissions. Review of Charting and Documentation policy (undated) directed, in part, that Certified Nursing Assistants may only make entries in the resident's medical chart as permitted by facility policy. Interview with RN #4 (Regional) on 5/12/25 at 2:35 PM identified that she could not locate a policy pertaining to NA documentation but reported that all NAs receive training on electronic documentation on hire and that all NAs are expected to document complete and accurate information for all populated tasks for all residents on their assignments. Although requested, a facility policy for Nurse Aide documentation was not provided.

Based on observations, facility policy and interviews, the facility failed to ensure the medication carts and medication storage room were free from unlabeled and expired medications and non-medication items and that medications were stored properly. The findings include: 1. Observation and interview on 5/9/25 at 11:38 AM in the South Wing Medication room with the DNS, identified house stock medications including a box of 100 capsules of Diphenhydramine (an antihistamine and/or sedative medication) 25 milligram (mg) expired 11/2024, and a box of Beneprotein 0.25 ounce packets expired 7/2023. Opened, unlabeled and undated medications were identified as Miconazole Nitrate 2 percent (%) cream and Lactulose (a medication used as a laxative or to treat liver disease) 10 grams (g) in 15 milliliters (mL) solution. Food items were observed to be stored in the medication room cabinets alongside house stock medications included a basket of coffee creamers and sugar/sugar substitute packets, and a foam take out container with plastic utensils inside. Drawers of the medication room were contained of unlabeled curling irons, electric razors, charging cords, headphones, air pumps, glasses and hearing aids. The DNS identified that expired medications, opened and unlabeled medications, food items, electronics and residents' personal items should not be stored in the medication room, and she was unsure of the reason the above medications were present and not discarded. She identified that expired and discontinued medications should be stored in the applicable bin to be returned to the pharmacy and not in the cabinets, drawers or the countertops of the medication room. The DNS identified that all food items should be stored in the nourishment room only. She reported that the South Wing medication room was recently cleaned out approximately one (1) week ago and was completed every week on the day shift and was unsure of the reason staff were storing the above items in the medication room. 2. Observation of the nursing supervisor's office and interview with RN #1 (the 7:00 AM to 3:00 PM nursing supervisor) on 5/9/25 at 12:42 PM identified a box of Juven packets (a powder that is mixed with water and ingested to support wound healing) and a box of fourteen (14) bottles of Kayexalate (a medication to treat elevated potassium levels) 15 grams on the top shelf above the desk. RN #1 reported that she was unsure of the reason the Juven packets were in the nursing supervisor's office, stating they should have been in the medication room but identified that the bottles of Kayexalate 15 grams were stock for the Pyxis (automatic medication dispensing team). She reported that the bottles do not fit in the drawers of the Pyxis and she hadn't had time to call the pharmacy and decide how to get a larger drawer added but identified that they shouldn't have been stored in the nursing supervisor's office. 3. Observation and interview on 5/9/25 at 12:55 PM with LPN #1 of the Annex medication cart, identified an opened, unlabeled and undated container of Xarelto (a medication to prevent blood clots) 15 mg tablets with an expiration date of 4/2025 and nine (9) house stock Diphenhydramine capsules in a blister pack with an expiration date of 3/2024. Multiple loose pills totaling at least ten (10) were noted in and around the blister packs of the medication cart. The bottom drawer of the medication cart was noted with a roller hairbrush, unlabeled black glasses, nine (9) loose green lancets, an open package of Calcium Alginate (wound treatment product) and multiple packets of Peri- Guard ointment (skin protectant). LPN #1 identified that expired medications should not be stored in the medication cart, reported that non medication items such as treatment items, hairbrushes and unlabeled personal items should not be stored in the medication cart, and he was not sure of the reason the items were stored in the cart. Interview with RN #3 (the Infection Preventionist) on 5/9/25 at 1:25 PM identified that he personally cleans the medication carts weekly on Mondays during environmental rounds and reported that he had just cleaned the carts on 5/5/25 and was unsure why expired medications and non-medication items were stored in the medication carts, reporting that they should not have been. He reported that he expected staff to keep the carts clean and free of expired medications and non medication items. 4. Observation and interview on 5/9/25 at 1:48 PM with LPN #2 at the South medication cart, identified house stock medications including Zinc Sulfate 220 mg tablets expired 1/2025, Hydrocortisone Acetate 25 mg suppositories expired 5/2/25 and Vitamin B-6 100 mg tablets expired 4/2025. The cart was noted to be overly sticky and at least one dozen loose pills were located on the floor of one of the drawers of the medication cart. LPN #2 identified that she was agency staff and hadn't worked at the facility in a long time but reported that the medication cart was unorganized and dirty and reported that expired medications should not be stored in the medication cart. Review of the Medication Storage in the Facility policy directed, in part, that all medications dispensed by the pharmacy are stored in the container with the pharmacy label. Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. Although requested, a policy on medication cart cleaning was not provided.

Based on interviews, record and policy review for 1 of 3 residents (Resident #40) sampled for nutrition, the facility failed to follow a physician's order to obtain weekly weights and a reweight on a resident with a significant weight loss. The findings included: Resident #40 was admitted to the facility in April 2025 with diagnoses that included dysphagia, aphasia, and type 2 diabetes mellitus. A physician's order dated 4/21/25 directed to weigh Resident #40 weekly on his/her shower day. The Resident Care Plan dated 4/23/25 identified Resident #40 had impaired utilization of nutrients related to diabetes mellitus, stroke, no teeth, puree diet, and elevated blood pressure with risk for weight loss and unplanned weight loss, muscle loss related to diet texture dislike and refusing to eat puree meats. Interventions included diet and fluids as ordered, magic cup supplement with lunch, weights as ordered per facility protocol, registered dietician evaluation as needed, speech therapy as needed, monitor dietary intake as ordered, and administer supplements as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired and required substantial/maximal assistance with eating, and oral hygiene. Additionally, the MDS identified Resident #40's weight on admission was 144 pounds, without loss of liquids/solids from mouth when eating/drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing/choking during meals or when swallowing medications, or complaints of difficulty/pain when swallowing. Although physician's orders directed to weigh Resident #40 weekly on shower day, a review of the weights and vitals sheet identified weekly weights were only taken on 4/19/25 (144.2 pounds), and on 5/5/25, (123.4 pounds). (A severe weight loss of 20.8 pounds/14.4 % in 2 weeks). A physician's order dated 5/7/25 directed for a re-weight on 5/7/25 to verify the weight loss from 5/5/25 of 20.8 pounds in 2 weeks. Although physician's orders directed to reweigh Resident #40 on 5/7/25, a review of the weights and vitals sheet identified Resident #40 was not reweighed. Interview with Nurse Aide (NA) #1 on 5/9/25 at 8:58 AM identified the NA's were notified by the nurse to weight and resident and the NAs were responsible for obtaining resident weights , and the weights were documented on the vital sign clipboard. Interview and record review with Registered Nurse (RN) #1 on 5/9/25 at 9:55 AM identified it was facility policy to obtain weights on residents per physician or dietician order, that the NAs were responsible for obtaining the weight and the nurse checks for completion/discrepancies and then transcribes the weight from the vital sign sheet into the electronic health record. Review of the weights with RN #1 failed to identify that weights were obtained weekly per physician's order or that a reweight was obtained on 5/7/25, with the only weights documented were on 4/19/25 (admission) and 5/5/25. Subsequent to surveyor inquiry, RN #1 obtained a re-weight for Resident #40, which was documented as 132.6 pounds. Review of the Weight Assessment and Intervention Policy directed in part for nursing staff to obtain resident weight on admission, the next day and weekly for 4 weeks. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month-5% weight loss is significant; great than 5% is severe. Interventions for undesirable weight loss shall be based on careful consideration of the following: resident choices, nutrition and hydration needs, functional factors, environmental factors, chewing or swallowing abnormalities, medications, use of supplementation or feeding tubes and end of life decisions.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #23) reviewed for medication administration, the facility failed to ensure that the expiration date was checked on a narcotic medication prior to administration. The findings include: Resident #23's diagnoses included Parkinson's disease, chronic pain and type 2 diabetes mellitus with polyneuropathy. A physician's order dated 3/20/25 directed to administer Morphine Sulfate Extended Release (ER) 15 milligram (mg) oral tablet by mouth every eight (8) hours for chronic pain, as part of a 45 mg dose (received in combination with a 30 mg tablet) and to hold for sedation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had intact cognition and was independent with eating, personal care and bed mobility. The Resident Care Plan (RCP) dated 4/10/25 identified Resident #23 had pain related to cancer, a history of chronic pain and was receiving Morphine and Dilaudid (narcotic pain medications) for break-through pain. Interventions included assessing the characteristic of the pain, reassessing interventions with any changes in response to pain or pain medications and with every assessment and administering pain medications as ordered. Review and observation of the Annex medication cart narcotic box on 5/9/25 at 12:55 PM with LPN #1 identified one (1) blister pack of Morphine Sulfate Extended Release (ER) 15 mg oral tablets with prescription number 2910659/001. The blister pack was noted to have seven (7) tablets remaining and had a lot number A71434 and an expiration date of 3/19/25. Review of the Controlled Substance Disposition Record for the Morphine Sulfate Extended Release (ER) 15 mg oral tablet with prescription number 2910659/001 identified that it was sent by the pharmacy and received on 4/4/25 (16-days after expiration) with sixty (60) tablets. The disposition record identified that fifty-three (53) tablets had been signed out as administered between 4/15/25 and 5/2/25 (after the medication's expiration date). Interview with LPN #1 on 5/9/25 at 12:55 PM identified that he had signed out the Morphine on 4/21/25 at 5:52 PM and on 4/25/25 at 9:40 AM from that blister pack (prescription number 2910659/001), reporting he didn't check the expiration date and never noticed the medication had expired but identified that he should always check for expiration dates prior to medication administration. The DNS was subsequently notified. Interview with the DNS on 5/9/25 at 1:50 PM identified that she contacted the pharmacy and they stated that the expiration date on the blister pack of Morphine Sulfate Extended Release (ER) 15 mg oral tablet with prescription number 2910659/001 was incorrect and that the correct expiration date was 10/26, reporting that the pharmacy stated they would fax a confirmation letter and pick up the medication from the facility. The DNS identified that it was her expectation that all staff check the expiration date on all medications prior to administering the medication to a resident and reported that she was unsure why this hadn't happened for Resident #23's Morphine Sulfate Extended Release (ER) 15 mg oral tablet with prescription number 2910659/001. Review of a pharmacy fax dated 5/9/25 regarding Resident #23 identified that they had spoken with the facility DNS about the Morphine Sulfate 15 mg ER tablets with an expiration of 2025 reporting that they checked the lot number and stock bottle, and the foil had been misprinted and the actual expiration was 10/2026. It identified that they would pick up the medication from the facility and fix the foil. Review of the Medication Storage in the Facility policy (undated) directed, in part, that the nurse will check the expiration date of each medication prior to administering it. No expired medications will be administered to a resident.

Based on staff interview, observations, review of the clinical record and facility policy for 1 of 5 sampled resident (Resident #5) reviewed for side rails and for 1 of 3 sampled residents (Resident #53) reviewed for pressure ulcers, the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include side rail padding (Resident #5) and refusals for positioning (Resident #53). The findings include: 1. Resident #5's diagnoses included vascular dementia without behavioral disturbances, generalized muscle weakness and cachexia (irreversible weight and muscle loss). A physician's order dated 11/9/20 and currently in effect directed for quarter (¼) side-rails to be in place to both sides of the bed for mobility and transfer ability. A side rail evaluation dated 3/2/23 identified that a side-rail was indicated for enhancement of mobility and that the resident expressed a desire for a side-rail. It reported that side-rails were not indicated to provide safety for Resident #5 and that the resident does not have a history of seizures. The evaluation did not identify how many side-rails were indicated or the length of the side-rails that were to be put in place. A side rail evaluation dated 8/18/23 was incomplete with no information filled out. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was severely cognitively impaired and required substantial assistance for bed mobility. The Resident Care Plan (RCP) dated 2/18/25 identified that Resident #5 was at risk for falls related to decreased strength, decreased coordination, impaired sense of balance and unsteady gait (walking or moving on foot). Interventions included providing assistance with all Activities of Daily Living (ADLs). Observation of Resident #5 on 5/8/25 at 10:58 AM identified Resident #5 in bed with double-sided Velcro pads intact to both side-rails. Observation of Resident #5 on 5/9/25 at 12:51 PM identified Resident #5 in bed with double-sided Velcro pads intact to both side-rails. Review of active physician's orders and/or the RCP failed to identify the use of side-rail padding. Review of the Nurse Aide Care Card (undated) failed to identify the use of ¼ side rails or side rail padding. Observation of Resident #5 and interview with the DNS on 5/9/25 at 2:35 PM identified the resident in bed with double-sided Velcro pads intact to both side-rails, reporting that she was unsure of the reason the padding was in place, that the use of side-rail padding should be identified in the RCP and she was unsure of the reason it was not. She reported that she was unaware that side-rail padding was not identified on the facility paper care cards for the Nurse Aides (NA's) to also follow. The DNS identified that she was unable to provide documentation as to the reason the padding was in place. 2. Resident #53's diagnoses included type 2 diabetes mellitus with hyperglycemia, chronic pain and edema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #53 was moderately cognitively impaired, required substantial assistance for bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 4/8/25 identified that Resident #53 was at risk for skin breakdown due to immobility and deconditioning and had recurrent skin breakdown on the sacrum/coccyx. Interventions included turning and repositioning the resident every 2 hours while in bed and as it meets the resident's needs, pressure redistribution devices as ordered, following the facility skin protocol and reporting any new areas to the nurse and provider. Review of wound care physician's note dated 5/2/25 identified that Resident #53 was seen for evaluation of a Moisture Associated Skin Damage (MASD) wound which measured 2.0 centimeters (cm) by 1.5 cm by 0.2 cm reporting that the wound base was 100 percent (%) granulation (newly formed connective tissue indicating the start of the healing process) and a moderate amount of serous drainage (clear, thin, watery fluid seen in the early stages of wound healing) was noted. The note identified that the wound had been first evaluated on 3/28/25 and that a pressure redistributing mattress was in place, staff was repositioning the resident every 2 hours and that staff was encouraging an out of bed schedule. Observation of Resident #53 with Registered Nurse #3 (wound nurse) and MD #2 (wound physician) on 5/9/25 at 11:00 AM identified Resident #53 lying on his/her back without offloading with the head of the bed elevated approximately 45 degrees, an air mattress was in place to the bed, and the resident's spouse was at the bedside. The coccyx wound was assessed by MD #2 and was measured at 3 cm by 1.5 cm, Medi honey (wound treatment) was applied to the wound bed and a foam dressing was applied. All infection control measures were noted to be followed. A pillow was then placed under the resident's left buttocks for offloading purposes. Interview with MD #2 on 5/9/25 following the wound evaluation identified that although the resident was receiving a protein supplement and staff was attempting to offload and reposition Resident #53 off of his/her coccyx area frequently, he reported that the coccyx wound had worsened to a Stage 3 pressure ulcer (full-thickness skin loss where the wound extends through the skin and into the subcutaneous tissue revealing the fatty layer). MD #2 stated that the worsened wound was due to the resident's non-compliance with repositioning, not allowing the head of the bed to be lowered to offload pressure to his/her lower back and buttocks and refusing a consistent out of bed schedule. Review of wound care physician's note dated 5/9/25 identified that Resident #53 was seen for evaluation of a coccyx wound which measured 3.0 centimeters (cm) by 1.5 cm by 0.2 cm reporting that the wound base was 100 percent (%) granulation and a moderate amount of serous drainage was noted. The note identified that the wound was now a Stage 3 pressure ulcer and that despite the facility treating the wound correctly, the resident's co-morbidities (multiple diagnoses) and his/her unwillingness to offload the area is contributing to the outcome/decline. Interview and review of Resident #53's Care Plan (RCP) with RN #3 on 5/9/25 at 11:32 AM identified that although he was aware that Resident #53 doesn't allow staff to consistently turn and reposition him/her. Additionally, RN #3 stated Resident #53 would only allow repositioning onto the left side, would often complain of the pillow on one side of his/her buttocks and request that it be pulled out, he was unsure of the reason the RCP did not include Resident #53's refusals, stating Resident #53 should have been, as the refusals have been taking place for a few months. RN #3 reported that although he made rounds with the wound physician and received updates prior to other staff related to skin integrity, it was the responsibility of the charge nurse, MDS or Nursing Supervisor to update the plan of care to include refusals. Interview with NA #1 on 5/9/25 at 12:12 PM identified that when Resident #53 was in bed, he/she often refused to allow the head of the bed to be lowered and to be repositioned and when he/she does allow it, the resident often requested for the pillow to be removed shortly after. NA #1 reported that when Resident #53 doesn't allow repositioning, she sometimes reports it to the charge nurse if they were in the area. Subsequent to surveyor inquiry, Resident #53's RCP related to skin breakdown was updated on both 5/9/25 and 5/11/25 to identify that he/she refused repositioning, offloading and an out of bed schedule. Interview with RN #5 (MDS Coordinator) on 5/12/25 at 10:10 AM identified that although she only began employment at the facility 1 week ago, refusal care plans were an interdisciplinary responsibility, stating that staff that observed a behavior consistently should be the ones to update the plan of care, identifying that she updated the RCP's when she was reviewing resident documentation for quarterly evaluations but that initiation of behavior care plans to include resident refusals were not her sole responsibility. Review of the Care Planning- Interdisciplinary Team policy (undated) directed, in part, that ongoing changes in residents' status shall be updated by Nursing and/or Interdisciplinary Team (IDT) as needed. As care plans are updated, staff shall follow the updated plan of care and as updated on the Care card as applicable. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #25) reviewed for grievances, the facility failed to notify state and local authorities of an allegation of neglect. The findings include: Resident #25 was admitted with diagnoses that included cancer that spread to the bone, major depression and post-traumatic stress syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was alert and oriented and was independent for personal hygiene, ambulation with a walker and transfer. The Resident Care Plan (RCP) dated 3/25/25 identified Resident #25 had a history of anxiety and depression. Interventions included observing for periods of anxiety or sadness, provide a calm, quiet environment and encourage Resident #25 to verbalize thoughts and feelings related to anxiety. A facility grievance/concern form dated 4/15/25, noted Resident #25 reported that a call bell was ringing in another resident's room at 1:00 AM. Resident #25 went to the nurse's station and observed the Licensed Practical Nurse (LPN) #5 to be sleeping. She/he called out to LPN #5, but LPN #5 did not wake up. Resident #25 took a picture of LPN #5 and sent it to the Director of Nurses (DNS) later in the shift at 4:27 AM, the concern form continued that Resident #25 noticed the same call light was on reporting that the staff did not answer the call light. Resident #25 continued that it was not answered until her/his nurse, after finishing medication administration at 5:14 AM, answered it. Resident #25 expressed that the facility was lucky as the other resident could have fallen or had a medical emergency. At 7:15 AM, Resident #25 reported that she/he had overheard the day shift NAs saying that 2 residents on the unit had not been changed overnight due to the call bell not answered for 3 hours. A facility statement dated 4/15/25 and written by Nurse Aide (NA) #3 identified she had found Resident #32 with a saturated brief and pad. Resident #32 reported that staff did not provide her/him with any care overnight. A Grievance response letter dated 4/22/25 addressed to Resident #25 written by the Director of Social Work identified that the findings of the investigation into staff sleeping was confirmed. The findings regarding Resident #25's report of incontinent care not being completed was not confirmed. Interview and review of the facility investigation of Resident #25's 4/15/25 allegation with the Director of Nursing (DNS) on 5/12/2025 at 8:40 AM identified if there was a report of a resident who did not get care for overnight or for 3 hours, she would consider it an allegation of neglect. She continued that she completed the investigation into Resident #25's grievance and addressed both reported concerns as documented on the grievance form: sleeping staff, unanswered call bell, and staff not checking or changing residents. She confirmed that the LPN was asleep and as part of Resident #25's grievance investigation, she completed a call bell and incontinence care audit. Reviewing NA #3's statement, she identified that it could be interpreted as an allegation of neglect. The DNS was aware of the reporting requirements for allegations of neglect and identified that she did not report the allegation of the staff not providing incontinence care as she only followed the facility's grievance process when completing the investigation. Interview and review of a facility statement dated 4/15/25 with NA #3 on 5/12/25 at 11:55 AM identified she was working on 4/15/25 on Resident #25's unit. Resident #32 had the call light on when she came on shift at 7:00 AM and she went to the room to see what was needed. Resident #32's pad and incontinent brief were saturated, and Resident # 32 had reported that she/he had not been changed all night. She immediately went to get RN #1, the supervisor to evaluate the resident. Interview with RN #1 on 5/12/25 at 1:14 PM identified that on 4/15/25, NA #3 came to her early in the shift to report that Resident #32 reported that she/he did not get changed overnight and NA #3 asked her to come to the resident's room. Resident #32 identified that she/he had not been changed all night. RN #1 assisted NA #3 to change the resident. RN #1 recalled Resident #32's pad and incontinent brief were saturated with urine. She immediately reported it to the Director of Nurses as she felt it was an allegation of neglect. The Director of Social Work was unavailable for interview during the survey. The facility policy Recognizing Signs and Symptoms of Abuse/Neglect/Exploitation or Mistreatment dated 11/25/2016 identified in part, that signs of possible physical neglect included caregivers' intentional indifference to resident's personal care or needs or residents left alone who needed supervision. The facility policy Reporting Abuse to Facility Management dated 11/25/2016 directed in part, when an alleged abuse is reported, the administrator or designee notified the following persons or agencies: the state DPH, attending physician, responsible party and the local police. Abuse was defined as deprivation by an individual including the caretaker, of services necessary to attain or maintain physical, mental and psychosocial well-being. Neglect was defined as the failure to provide goods and or services to the resident to avoid physical harm, pain, mental anguish or emotional distress. Any individual observing or suspecting resident abuse must promptly report the incident and a reportable event form is completed.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for one of four residents (Resident #24) reviewed for pressure ulcers and one out of three residents (Resident #40) reviewed for nutrition, the facility failed to notify the Advanced Practice Registered Nurse (APRN) and family/responsible party of a significant weight loss. The findings include: 1. Resident #24 had diagnoses that included dysphagia, the presence of a cardiac pacemaker and dementia. The Resident Care Plan (RCP) dated 1/16/25 identified Resident #24 had a history of pressure wounds and was at risk for oral/nutritional problems with a goal to not have a weight loss. Interventions included weight as ordered and per facility protocol, and Registered Dietician (RD) evaluation as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was severely cognitively impaired, required substantial/maximal assistance with for eating and was dependent for personal hygiene and transfer. Review of Resident #24's weights in the clinical record identified weights were as follows: on 3/22/25 Resident #24 weighed 118 pounds (lbs.), on 3/29/25 weighed 116.3 lbs., on 4/5/25 weighed 115.8 lbs., and on 4/19/25 weighed 106.1 lbs. (a 11.9 lb./10.08% loss in 28 days). The next recorded weight on 4/24/25 was a re-weight of 104.1 lbs (a continued weight loss of 13.9 lbs./11.77% in 33 days). A Dietician note dated 4/28/25 (9 days after the significant weight loss was documented and 4 days after the re-weight) at 1:19 PM identified Resident #25 weight monitoring identified weight of 118 lbs. to 106/104 lbs. this morning. Severe weight loss of 10.5%. Intake had declined to 50-75% of meals. Resident #24 received assistance with meals and was consuming supplements every day 75- 100%. Plan was to increase supplements to address unplanned weight loss. Nursing notes failed to identify documentation that the APRN or family had been updated about the loss of 11.9 lbs. or 10.08 percent (%) of body weight in less than 1 month. As well as after a reweight that was completed on 4/24/25 of 104.1 that confirmed the weight loss. Interview with RN #1, (the 7:00 AM to 3:00 PM Nursing Supervisor) on 5/9/25 at 8:20 AM identified that if a resident had a confirmed significant weight loss identified by nursing, they would contact the nursing supervisor who would then contact the APRN and family. The weight loss would be confirmed by a reweight. The nursing staff would also contact the dietician either face to face when she was here, place information in her communication book or email her. Although she was not on 4/19/25, she was the Nursing Supervisor on 4/24/25 and could not recall that she was contacted with Resident #24's confirmation re-weight. Interview and review of Resident #24's medical record with APRN #2 on 5/9/25 at 10:52 AM identified she was unaware of Resident #24's significant weight loss initially recorded on 4/19/25 or when the reweight was completed on 4/23/25. She would have expected the nurses to contact her or at least place the information in the APRN communication book located on the unit. She just reviewed the book and noted that there was no documentation of Resident #24's weight loss. Had she been contacted on 4/19/25 or 4/23/2025 she would have evaluated the resident, documented her evaluation and would have likely started the additional supplements that were ordered upon notification of the significant weight loss on 4/28/25. Interview and review of Resident #24's medical record with the Director of Nursing (DNS) on 5/12/25 at 8:40 AM identified that she would expect the nursing staff to contact the APRN for a significant weight loss of 5%. She continued that it would also be placed in the APRN follow up book. She did not know the reason this was not done when Resident #24 had the documented 10.08% weight loss in 1 month on 4/19/25 and after the next weight, recorded on 4/24/25. The nursing staff should also contact the family to notify them of the weight loss at the time it was identified. Interview and review of Resident #24's medical record with the Dietician on 5/12/24 at 9:40 AM identified she had reviewed Resident #24's record on 4/16/25 and had added a supplement due to Resident #24's reported decreased meal intake. Upon her review the next time she was at the facility on 4/23/25, she identified the 4/19/25 recorded weight of 106.1 lbs. She noted that the electronic medical record had flagged the weight as a 10.5% weight loss for Resident #24 from the previous month's recorded weight on 3/22/25 of 118 lbs. She continued that she did not evaluate Resident 24's flagged unplanned significant weight loss on 4/23/25 as she needed to have a confirmed weight with a reweight before completing an evaluation. She placed a request into Resident #24's electronic record (PCC) for a reweight but did not talk to nursing to get a reweight that day. She continued that it was the end of day and that was the most efficient way for her to communicate the need for a reweight as it would populate a report that the facility would review and assure the request was completed. When she returned to the facility on 4/28/25, she noted that the reweight documented for Resident #24 was completed on 4/24/28 as 104 lbs. With the reweigh completed, she determined the weight to be accurate and she completed her evaluation with recommendations for increased supplements. She then triggered in PCC that the information be placed on the MD report that the APRN would review. She had not contacted the APRN prior to notifying through PCC on 4/28/25. Interview with LPN #3 and review of Resident #24's weight documentation on 5/13/25 at 11:00 AM identified she recorded Resident #24's weight on 4/19/25 of 106 lbs. and did not know the reason she did not reweigh the resident at that time and she did not know why she did not contact the supervisor or the APRN. She continued that she 'had dropped the ball. Had she contacted the supervisor, either she or the supervisor would have contacted the family. She identified she also should have sent an email or written in the dietician's communication book to notify the dietician as well. She did not do that either. Subsequent to the surveyor inquiry, APRN #2 evaluated Resident #24's weight loss on 5/9/25 and agreed with the current treatment plan as recommended by the Dietician and to monitor. 2. Resident #40 was admitted to the facility in April 2025 with diagnoses that included dysphagia, aphasia, and Type 2 diabetes mellitus. A physician's order dated 4/21/25 directed to weigh Resident #40 weekly on shower days. The Resident Care Plan dated 4/23/25 identified Resident #40 had impaired utilization of nutrients related to diabetes mellitus, stroke, no teeth, and being on a puree diet. Other impaired utilization of nutrients listed were elevated blood pressure with the risk for weight loss and unplanned weight loss, muscle loss related to diet texture dislike and refusing to eat puree meats. Interventions included to provide diet and fluids as ordered, magic cup supplement with lunch, weights as ordered per facility protocol, Registered Dietician evaluation as needed, speech therapy as needed, monitor dietary intake as ordered, and administer supplements as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired and required substantial/maximal assistance with eating, oral hygiene, and dressing. Additionally, the MDS identified Resident #40's weight on admission was 144 pounds, without loss of liquids/solids from mouth when eating/drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing/choking during meals or when swallowing medications, or complaints of difficulty/pain when swallowing. Although physician's orders directed to weigh Resident #40 weekly on shower days, a review of the weights and vitals sheet identified weekly weights were only taken on 4/19/25 (144.2 pounds), and on 5/5/25, (123.4 pounds). (Identifying a significant weight loss of 20.8 pounds/14.4 % in 2 weeks). A physician's order dated 5/7/25 that was entered by the Dietician and not from MD/APRN being notified per interview with the Dietician on 5/9/25 at 11:36 AM directed for a re-weight on 5/7/25 to verify the weight loss of 20.8 pounds in 2 weeks. A review of Resident #40's electronic health record failed to identify the APRN/physician was notified of the significant weight loss. Interview and record review with Registered Nurse (RN) #1 on 5/9/25 at 9:55 AM identified it was facility policy to obtain a reweight for a significant/severe weight loss, update the family, provider and Dietician. The record review failed to identify that the provider was notified of the weight loss. Interview with APRN #2 on 5/9/25 at 10:02 AM failed to identify that she was notified of Resident #40's severe weight loss, but stated the facility had another APRN that also oversees Resident #40. Interview with APRN #1 on 5/9/25 at 10:22 AM identified she was not aware of the severe weight loss for Resident #40, only speech therapy and family concerns of poor meal intake for which she started him/her on an appetite stimulant. If she had been notified of the severe weight loss, she would have collaborated with speech therapy and the Dietician to find out the underlying cause, order blood work, and make sure it's not due to any medications he/she was on. Review of the Resident Nutrition Services Policy directed in part that nursing personnel will evaluate food and fluid intake in residents with, or at risk for, significant nutritional problems. Significant variants from usual eating or intake patterns must be recorded in the resident's medical record. The nurse supervisor shall evaluate the significance of such information and report it to the attending Physician and Dietician. The facility policy Weight Assessment and Intervention, directed in part that any weight change of 5 % or more since the last weight assessment will be retaken the next day for confirmation with nursing communicating the weight in writing to the dietician once verified. The dietician will respond within 48 hours of the written receipt. The threshold for significant unplanned weight loss was a 5% weight loss in 1 month with a loss greater than 5% was considered severe.

Based on interviews, record and policy review for 1 of 3 residents (Resident #40) sampled for nutrition, the facility failed to include a resident in the participation of the development and implementation of his or her person-centered plan of care. The findings include: Resident #40 was admitted to the facility in April 2025 with diagnoses that included dysphagia, aphasia, and Type 2 diabetes mellitus. The baseline Resident Care Plan (RCP) dated 4/19/25 identified Resident#40 had a decline in intellectual functioning characterized by a deficit in memory, judgement, decision making and thought process related to altered mental status. The facility admission Record Face Sheet dated 4/19/25 identified Resident #40 was the guarantor and care conference person and Person #1 was an alternate care conference contact. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired and required substantial/maximal assistance with eating, oral hygiene, and dressing. Additionally, the MDS identified Resident #40 was an active participant in the assessment process and goal setting, with an overall goal to return to the community. Although multiple requests were made, the facility failed to identify if any person (Resident #40 or Person #1) was invited and/or attended the RCC, and could not identify who from the interdisciplinary team attended the RCC, either through a RCC attendance sheet or social service notes, etc. Interview with the Regional Registered Nurse (RN) #6 on 5/13/25 at 12:30 PM identified the facility did not have a RCC sign in sheet for Resident #40 because a conference was not held. Additionally, he identified that a conference should have been held, and it was the responsibility of the MDS Coordinator and Social Services to ensure the meeting took place. Interview and record review with the MDS Coordinator Registered Nurse (RN) #5 on 5/13/25 at 12:42 PM identified it was facility policy to hold a RCC with the resident or responsible party 48-72 hours after admission, and then quarterly. The record review failed to identify social worker or MDS documentation that the meeting was held, or that Resident #40 was invited to attend. Additionally, she identified it was the social workers responsibility to schedule the conference and invite the resident. The social worker was not available for interview. Review of the Care Planning Policy identified the care plan is developed by the interdisciplinary team in collaboration with the resident and/or the responsible party and the resident's physician. The resident or responsible party will be invited to attend all care plan conferences.

Based on a review of the clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for diet consistency, the facility failed to ensure the resident was served the physician ordered diet consistency with a subsequent choking episode resulting in a finding of Immediate Jeopardy. Please cross reference F 684 Resident #1 was admitted with diagnoses that include dysphagia, hemiplegia affecting right side dominant side, aphasia, and cerebral infarction. The annual Minimum Data Set, dated dated dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required extensive assistance with Activities of daily living. The care plan dated 10/26/2023 identified Resident #1 had dysphagia related to a cerebral vascular accident with interventions that directed to provide a mechanical soft diet with thin liquids and set up and assist as needed. A physician's order dated 1/1/2024 directed to provide Resident #1 with a mechanical soft diet with thin liquids. A review of Resident #1's meal ticket dated 1/24/2024 for the dinner meal identified Resident #1's diet order on the meal ticket was a mechanical soft diet with thin liquids. Review of the SBAR (change in condition) Communication Form dated 1/24/2024 at 5:30 P.M. written by RN #4 identified Resident #1 was observed sitting in his/her wheelchair, unresponsive to verbal and tactile stimulation (sternal rub) and was clammy. Resident #1 had a carotid pulse present, Resident #1's vital signs were checked with a blood pressure reading of 119/62 (normal blood pressure is under 140/90), pulse of 102 beats per minute (bpm) with an irregular rhythm (pulse is 60-100 bpm), respirations were 10 per minute (normal 12-18), and an oxygen saturation level of 88 % (normal 90-100%) on room air, 911 was called. Prior to calling 911, RN #4 placed Resident #1 on oxygen, performed a mouth check and finger sweep of Resident #1's mouth and nothing was found. A review of the facility's reportable event form and investigation summary dated 1/24/2024 at 5:25 P.M. identified Resident #1 was observed sitting in his/her wheelchair unresponsive, difficult to arouse, clammy, with a positive carotid pulse, 911 was called, and oxygen was applied. Resident #1's mouth was opened and checked with a finger sweep and nothing was found. Resident #1 was sent to the hospital for further evaluation. The resident was readmitted to the facility on [DATE] and was at baseline. Review of the Emergency Medical Service run sheet dated 1/24/2024 at 5:07 P.M. identified Resident #1 was found lying supine on his/her bed. The facility stated Resident #1 was sitting in his/her wheelchair eating dinner when he/she went unresponsive at or about 5:00 P.M. Staff reported that they placed Resident #1 back into bed with oxygen via nasal cannula for low oxygen saturation level. The oxygen saturation level at 5:31 P.M. was 77% on 2 liters per minute of oxygen. Resident #1 presents shallow breathing, unresponsive to verbal or painful stimulation skin is warm and dry. Resident #1 has no sign of injury or trauma. Resident #1 was suctioned, two whole grapes were found in the airway, Resident #1 transferred to the emergency room for evaluation. Review of the hospital emergency room (ED) history and physical dated 1/24/2024 at 6:04 P.M. identified Resident #1 was brought to the ED from the skilled nursing facility with a chief complaint of being unresponsive. Resident #1 with known dysphagia, apparently was eating grapes and EMS reports that they pulled grapes out of his/her airway. It is unclear why Resident #1 with his/her deficient history was given whole grapes, but this appears to be the genesis of the choking episode. Resident #1's discharge diagnoses were choking episode, hypoxia (low oxygen levels in the blood), hypotension (low blood pressure), and vasovagal syncope (passing out due to a stressful trigger). The record identified that Resident #1 required a follow up regarding the vasovagal event secondary to choking and to provide a dysphagia diet with supervised meals. Interview with Dietary Aide #1 on 2/15/2024 at 10:30 A.M. identified he was new to the facility with a hire date of 12/27/2023. Dietary Aide #1 identified that he had not received any formal education on the different diet consistencies nor what his specific responsibilities were on the tray line. Dietary Aide #1 identified on 1/24/2024 he did not know the differences were between a regular diet and a mechanical soft diet. Dietary Aide #1 stated he thinks on 1/24/2024 he told the cook he needed the alternate dinner meal for Resident #1 which was a fruit platter containing cottage cheese, whole grapes, and an orange. Dietary Aide #1 identified on or about 1/27/2024 after the choking incident with Resident #1 he was provided education on diet consistencies and his responsibilities on the tray line. Dietary Aide #1 identified his responsibilities on the tray line are to ensure he reads the resident's meal tickets to the cook by calling out the resident name and ordered diet consistency. Interview with [NAME] #1 on 2/15/2024 at 10:45 A.M. identified that prior to Resident #1's choking episode on 1/24/2024 the tray line process was for the dietary aide to read off the resident's meal tickets by calling out the diet consistencies without the stating the resident name. [NAME] #1 identified she plated the food based on what diet consistency was called out to her by the dietary aide. [NAME] #1 identified on 1/24/2024 it was very busy, and she only had one dietary aide on duty (instead of 2) during the dinner meal. [NAME] #1 identified prior to Resident #1's choking incident on 1/24/2024 she was aware that if a resident was on a mechanical soft diet no raw fruits could be served. [NAME] #1 identified after Resident #1's choking episode on 1/24/2024 SLP #1 provided her with education on the different diet consistencies and including what foods are allowed and which foods are not allowed. [NAME] #1 identified after Resident #1's choking episode on 1/24/2024 the tray line process has been revised, dietary aides now call out the resident name, the diet consistency prior to her plating the food to prevent mixing up resident meals resulting in a resident receiving the wrong ordered diet consistency. Interview with the Food Service Director (FSD) on 2/15/2024 at 10:10 A.M. identified the dietary aides are responsible for ensuring that residents receive the correct meal per the ordered diet consistency as the facility policies dictate. The FSD identified the resident meal tickets are generated using the physician orders for diet consistency. The FSD identified the cook plates the resident's meal based on what is called out by the dietary aide. The FSD identified that upon hire Dietary Aide #1 did not have any formal education on the different diet consistencies or on the tray line process which includes reading the resident's meal tickets to the cook with the resident name and diet consistency order. The FSD identified she did not have a process in place to ensure dietary aides were competent prior to working on the tray line and reading meal tickets to the cook. The FSD identified on 1/24/2024 during the dinner meal there was one cook and one dietary aide on duty, but there should have been 2 dietary aides on duty. The FSD stated during her investigation regarding the incident on 1/24/2024, Resident #1 was served the fruit platter which was the incorrect diet consistency dinner due to Dietary Aide #1 mixing up Resident #1's meal ticket with his/her roommate who was on a regular diet. Interview with NA #1 on 2/15/2024 at 12:05 P.M. identified that on 1/24/2024 while she was passing the dinner trays out, and Resident #1 was not in his/her room, so she left Resident #1's dinner meal consisting of grapes, cottage cheese, and a peeled orange on his/her bed side table. NA#1 identified that she failed to verify that the food served was the right consistency because she was unaware that was her responsibility, and that she did not know the difference between a regular and mechanical soft consistency. Interview with Speech Language Pathologist (SLP) #1 on 2/15/2024 at 1:15 P.M. identified that Resident #1 was on a mechanical soft diet with thin liquids and was independent with eating. SLP #1 identified a mechanical soft diet consistency is one in which no fresh fruits, no raw fruits, or vegetables are permitted. SLP #1 identified on 1/24/2024 Resident #1 was served a fruit platter that consisted of cottage cheese, whole grapes, and oranges, and whole grapes and oranges are not permitted on a mechanical soft diet. SLP #1 identified nurse aides are responsible for checking the resident's meal tickets and observing what meal is on the tray prior to passing the meals out to ensure the meal matches the ordered diet consistency. Interview with the DNS on 2/15/2024 at 1:55 P.M. identified on 1/24/2024 Resident #1's dinner meal was the wrong diet consistency and Resident #1 should not have been provided with a fruit platter that included fresh fruit. The DNS identified that nurse aides are responsible for checking the meal tickets for diet consistency then looking at the food on the tray prior to serving the meal to the residents to ensure it matches the ordered diet consistency, however, NA#1 failed to do so. Review of the undated facility passing trays during meals process identified prior to passing the tray identify the patient via name and room number, uncover plate and make sure the tray ticket is read and food plated matches with the diet order. Review of the undated facility tray line set up and calling training process identified dietary aides read tickets to the cook, identify resident's name, diet order, and allergies if any.

Based on a review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for change in condition, the facility failed to ensure a resident, who was found unresponsive during the dinner meal, was promptly identified as a choking victim. The facility staff failed to administer the Heimlich maneuver. Upon Emergency Medical Service arrival, two whole grapes were suctioned from Resident #1's airway by EMS staff, the resident was subsequently hospitalized for a choking episode resulting in a finding of Immediate Jeopardy. Please cross reference F 805 The finding included: Resident #1 was admitted with diagnoses that included dysphagia, hemiplegia affecting right side dominant side, aphasia, and a cerebral infarction. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required extensive assistance with Activities of Daily Living. The care plan dated [DATE] identified Resident #1 had dysphagia related to a cerebral vascular accident with interventions that directed to provide a mechanical soft diet with thin liquids with set up and assist as needed. A physician's order dated [DATE] directed to provide Resident #1 with a mechanical soft diet with thin liquids. Review of Resident #1's meal ticket dated [DATE] for the dinner meal identified Resident #1's diet order was a Mechanical Soft with thin liquids. Review of the SBAR (change in condition) Communication Form dated [DATE] at 5:30 P.M., written by RN #4, identified Resident #1 was observed sitting in his/her wheelchair, unresponsive to verbal and tactile stimulation (sternal rub) and was clammy. Resident #1 had a carotid pulse present, and vital signs included a blood pressure reading of ,d+[DATE] (normal blood pressure is below ,d+[DATE]), pulse of 102 beats per minute (bpm) with an irregular rhythm (normal pulse is ,d+[DATE] bpm), respirations were 10 per minute (normal ,d+[DATE]), with an oxygen saturation level of 88 % (normal ,d+[DATE]%) on room air, 911 was then called. Prior to calling 911, RN #4 placed Resident #1 on oxygen, performed a mouth check and finger sweep of Resident #1's mouth and nothing was found. A review of the facility's reportable event form and investigation summary dated [DATE] at 5:25 P.M. identified Resident #1 was observed by the Nurse Aide (NA) to be unresponsive. The NA called for help, the nurse responded to find the resident sitting in his/her wheelchair unresponsive, difficult to arouse, clammy, with a positive carotid pulse, 911 was called, and oxygen was applied. Resident #1's mouth was opened, checked with a finger sweep and nothing was found. Resident #1 was sent to the hospital for further evaluation. The resident was readmitted to that facility on [DATE] at baseline. Review of the EMS run sheet dated [DATE] at 5:07 P.M. identified Resident #1 was found lying supine on his/her bed. The facility stated Resident #1 was sitting in his/her wheelchair eating dinner when he/she went unresponsive at or about 5:00 P.M. Staff reported that they placed Resident #1 back into bed with oxygen via nasal cannula for low oxygen saturation level. The oxygen saturation level at 5:31 P.M. was 77% on 2 liters per minute of oxygen. Resident #1 presented with shallow breathing, was unresponsive to verbal or painful stimulation, and skin was warm and dry. Resident #1 has no signs of injury or trauma. Resident #1 was suctioned, and two (2) whole grapes were removed from the resident's airway, Resident #1 was transferred to the emergency room for evaluation. Review of the hospital emergency room (ED) history and physical dated [DATE] at 6:04 P.M. identified Resident #1 was brought to the ED from the skilled nursing facility with a chief complaint of being unresponsive. Resident #1 with known dysphagia, apparently was eating grapes and EMS reports that they pulled grapes out of his/her airway. It is unclear why Resident #1 with his/her deficient history was given whole grapes, but this appears to be the genesis of the choking episode. Resident #1's discharge diagnoses were choking episode, hypoxia (low oxygen levels in the blood), hypotension (low blood pressure), and vasovagal syncope (passing out due to a stressful trigger). The record identified that Resident #1 required a follow up regarding the vasovagal event secondary to choking and to provide a dysphagia diet with supervised meals. Interview with Speech Language Pathologist #1 on [DATE] at 1:15 P.M. identified that Resident #1 was on a mechanical soft diet with thin liquids, and was independent with eating. SLP #1 identified on [DATE] she was called into the room by NA #1 between 5:00 and 5:30 P.M. and observed that Resident #1 was unresponsive and slumped over in the wheelchair. SLP #1 identified that she stood in front of Resident #1 who did not appear to be breathing initially, called out Resident #1's name with no response, and indicated that she saw Resident #1 breathing. The resident's dinner tray was in front of him/her and consisted of cottage cheese, whole grapes, and oranges. Although she suspected the resident could be choking and identified she was trained in the Heimlich maneuver, she stated she performed tactile stimulation by lifting Resident #1's head and rubbing Resident #1's chest area. SLP #1 further identified that raw fruits are not permitted on a mechanical soft diet. Interview with the Director of Food Services on [DATE] at 10:10 A.M. identified that based on her investigation from the [DATE] incident, Resident #1 was served the fruit platter which was the wrong diet consistency for Resident #1. Dietary Aide #1 mixed up Resident #1's meal ticket with his/her roommate who was on a regular diet. The FSD further identified that residents on a mechanical soft diet should not be served grapes. Interview with NA #1 on [DATE] at 12:05 P.M. indicated on [DATE] between 5:,d+[DATE]:30 P.M. while she was passing the dinner meal trays out, Resident #1 was not in his/her room, so she left Resident #1's dinner meal consisting of grapes, cottage cheese, and a peeled orange on his/her bed side table, without verifying that the food served was the right consistency. NA #1 identified she went across the hall to feed another resident and a few minutes later she saw Resident #1 return to his/her room. NA #1 identified she said hello to Resident #1 from across the hall and Resident #1 did not respond. NA #1 identified she went into Resident #1's room who was sitting in the wheelchair, with h/her head hunched over, and was noted to be unresponsive, so NA #1 called for help. Interview with RN #1 on [DATE] at 11:32 A.M. RN #1 stated that on [DATE] between 5:00 and 5:30 P.M. during the dinner meal, NA #1 informed her Resident #1 was unresponsive. RN #1 indicated that when she arrived at Resident #1's room RN #4 and SLP #1 were present trying to arouse Resident #1 who was sitting in his/her wheelchair. RN #1 identified that Resident #1 remained unresponsive, however, was breathing on his/her own. RN #1 identified Resident #1 had a fruit platter in front of him/her with some grapes, and she did a finger sweep with nothing found. RN #1 identified RN #4 administered oxygen because Resident #1's oxygen saturation was a little low (she could not recall how low). RN #1 identified she did not initiate the Heimlich because Resident #1 was breathing and had a pulse. Interview with RN #4 on [DATE] at 12:25 P.M. RN #4 stated that on [DATE] she was alerted by SLP #1 that Resident #1 needed assistance. RN #4 indicated she went to Resident #1's room and found Resident #1 unresponsive with his/head down sitting in his/her wheelchair with a meal of cottage cheese, grapes and oranges in front of h/her, she did a finger sweep of Resident #1's mouth and nothing was found. RN #1 indicated she performed a sternal rub on Resident #1 with no response. RN #4 identified Resident #1 was breathing with shallow respirations and a positive carotid pulse. RN #4 identified Resident #1's oxygen saturation level was 88% on room air and she placed Resident #1 on 2 liters of oxygen via nasal cannula. RN #4 indicated Resident #1 was Hoyer lifted back to bed and 911 was called. RN #4 identified she did not initiate the Heimlich on Resident #1 because he/she had no signs or symptoms of choking. Interview with the DNS on [DATE] at 1:55 P.M. identified on [DATE], Resident #1 received the wrong diet consistency for the dinner meal which included a fruit platter. The DNS identified that Resident #1's choking episode was caused by 2 whole grapes that were suctioned from Resident #1's airway by EMS. The DNS further identified she would not have expected the nursing staff to perform the Heimlich maneuver when Resident #1 was found unresponsive because Resident #1 was not exhibiting any signs or symptoms of choking. Interview and review of CPR cards with RN #3 on [DATE] at 3:00 P.M. identified both RN #1 and RN #4 were CPR certified, which included proficiency in the Heimlich maneuver. Review of the facility Heimlich Maneuver policy identified the Heimlich Maneuver is performed on victims whose airway is obstructed by a foreign object.

Based on clinical record reviews, review of facility documentation, policy review, and interviews for one of three sampled residents (Resident #1) who was dependent on staff for transfers in and out of the bed via a mechanical lift, the facility failed to ensure the staff were positioned correctly prior to moving the lift to provide the appropriate support of the lower extremities to prevent the resident from falling out of the lift sling that resulted in an injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was unable to make decision regarding tasks of daily living, had required extensive two (2) person assistance with turning and repositioning while in bed, was totally dependent on two (2) person assistance with transfers in and out of the bed and had no history of falls. The Resident Care Plan dated 10/16/19 identified the resident had a self -care performance deficit related to fatigue and the inability to ambulate. Interventions directed to provide assistance with activities of daily living as ordered. A physician's orders [REDACTED]. Review of the nurse aide care card identified Resident #1 was an assist of two (2) via a Hoyer lift for transfers. The change in condition nurse's note dated 12/9/19 at 7:48 AM identified Resident #1 fell from the Hoyer lift sling during a transfer, complained of neck and back pain and was transferred to the hospital for an evaluation. A physician's orders [REDACTED].#1 to the hospital for an evaluation. The Reportable Event Form dated 12/9/19 at 7:48 AM identified Resident #1 sustained a fall from the Hoyer lift on 12/9/19 and the cause of the fall was one (1) nurse aide, Nurse Aide (NA) #1 pulled the Hoyer lift to start the transfer too soon and she did not allow a second nurse aide, NA #2, to properly position herself to assist with holding the lower extremities and to coordinate a safety check of the sling straps before the transfer. The facility's final summary report indicated NA #1 had felt resistance with the Hoyer lift when she was pulling the lift and tugged on the lift causing the strap to become dislodged and Resident #1 slid from the sling to the floor. The summary identified the mechanical lift was taken out of service, along with an additional lift that required clips for the straps as a precaution and the maintenance department inspected all the mechanical lifts and found no issues. The summary indicated the Director of Nursing reenacted the event with both nurse aides to determine the process that was utilized and subsequently NA #1, who was operating the mechanical lift, was suspended pending the investigation and all nursing staff, including NA #1,were re-educated on the mechanical lift policy and procedure and skilled competencies were conducted. The hospital discharge summary dated 12/13/19 identified Resident #1 presented to the Emergency Department after the resident fell approximately two (2) to three (3) feet from a Hoyer lift sling. The hospital summary indicated a CT scan of the [MEDICATION NAME] lumber spine completed on 12/9/19 identified Resident #1 sustained acute non displaced fractures of the Cervical Spine 6 (C6) through the [MEDICATION NAME] 3 (T3). The Magnetic Resonance Imaging (MRI) completed on 12/10/19 showed acute T1, T3 through T5 and Lumbar L1 vertebral body compression fracture deformities. On 12/11/19 Resident #1 was seen by the hospital's neurosurgery who recommended non-surgical management of the fractures, to wear a [MEDICATION NAME] Lumbar Sacral Orthosis (TLSO) for comfort. Interview with NA #2 on 1/22/20 at 10:20 AM identified on 12/9/19 she assisted NA #1 with transferring Resident #1 from the bed to the wheelchair using the Hoyer lift. NA #2 stated she was on the opposite side of the bed from where the lift and NA #1 were. NA #2 identified NA #1 started moving the lift before she could get around the bed to check the straps to the Hoyer lift and hold Resident #1's legs while the resident was being transferred. NA #2 indicated Resident #1 slid from the lift to the floor and after to the fall she noticed that one (1) of the Hoyer straps was not in place. NA #2 stated it was the practice for a second staff member to be present during a transfer with a Hoyer lift and that second staff member would hold the resident's legs. NA #2 identified she did not notice whether the Hoyer straps on the side where NA #1 stood were securely in place prior to the transfer. In an interview with 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 1/22/20 at 10:30 AM identified she was called to Resident #1's room on 12/9/19 at approximately 8:00 AM and saw the Hoyer lift was in a raised up position, the sling was attached, one strap was disconnected from the lift and Resident #1 was lying on the floor. RN #1 stated the she completed an assessment and called the Advanced Practice Registered nurse (APRN) who directed Resident #1 be transferred to the hospital. An interview and review of the educational in-services with RN #2 (Staff Development and the Infection Control Nurse) on 1/22/20 at 11:00 AM identified that on hire all staff including NA #1 and NA #2 completed education and competencies on Hoyer lifts in areas of: How to use the lift, hooking up the resident, emergency stop button, where batteries are charged and each resident fitted with their personal slings which are kept at the resident's bedside. RN #2 stated that use of the Hoyer lift was demonstrated to the staff and the staff are required to perform a return demonstration with emphasis on the each person checking for safety. Interview with the Director of Nursing (DON) on 1/22/20 at 1:10 PM she identified that in a reenactment with NA #1 and NA #2 of the transfer the two (2) performed on 12/9/19, it would be impossible to disconnect the straps from the Hoyer lift if the straps were properly applied. The DON stated there were no loose hinges when she inspected the lift and the accident was human error and staff did not follow the policy. The DON indicated that NA #1 and NA #2 failed to communicate between themselves, the nurse aides failed to double check the Hoyer straps prior to the lift being moved with the resident in the sling and before the second nurse aide took hold of Resident #1's legs as outlined by the policy. Review of the Hoyer Lift policy directed two care givers must perform the transfer and to support residents lower extremities to ensure safety.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #2) who was reviewed for accidents, the facility failed to ensure the appropriate size mechanical lift sling was utilized during a transfer to prevent an accident in which the resident sustained [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. An admission physician's orders [REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had consistent reasonable decisions regarding tasks of daily life, required total two (2) person assistance with transfers in and/or out of the bed and chair, was non-ambulatory, and had a history of [REDACTED]. Interventions directed to transfer with the assistance of two (2) via a mechanical lift. The nurse's note dated 10/5/17 at 7:51 PM identified Resident #2 slipped off from the bottom of the mechanical lift pad when staff tried to transfer the resident from the wheelchair and the resident was observed lying on his/her back on the floor. The physician's progress note dated 10/6/17 identified Resident #2 was seen due to a fall from the Hoyer lift for a protrusion of the left shoulder and the resident's pain level was a five (5) on a scale of 1 to 10 when previously Resident #2 did not have pain to the left shoulder. The progress note indicated the left shoulder appeared to be dislocated on physical exam and Resident #2 was transferred to the hospital for a work-up. The hospital x-ray report dated 10/6/17 identified the left shoulder humeral head was dislocated and rotated laterally. The Reportable Event Form dated 10/5/17 identified Resident #2 was observed lying on the ground with his/her back on the floor and the resident sustained [REDACTED].#1, on 6/12/18 at 3:00 PM identified although she assisted another nurse aide, NA #2, with a mechanical lift transfer for Resident #2, she did not assist with putting the sling under the resident. NA #1 stated after NA #2 indicated the resident was secured in the sling, she operated the lift from behind the lift and as the resident was being lifted, NA #2 stated to her the resident was slipping out of the sling and as NA #2 pulled the wheelchair away Resident #2 fell through the hole in sling and landed on his/her bottom. NA #1 stated she did not know what size sling was used for Resident #2 and after fall it appeared that the sling was too big for the resident. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #3, on 6/13/18 at 12:30 PM identified that upon entering Resident #2's room, the resident was observed on the floor with a pillow under his/her head and after assessment the resident was assisted back to bed with the assistance of four (4) staff and a mechanical lift. RN #3 stated he did not identify any injury to Resident #2 after the fall on 10/5/17, however on 10/6/17 it was identified Resident #2 had a dislocated left shoulder. In an interview with NA #2 on 6/14/18 at 3:10 PM identified during the transfer from the wheelchair to bed Resident #2 slid out of the mechanical lift sling and landed on his/her buttocks on the floor. NA #2 stated as Resident #2 was lifted up with the mechanical lift, the resident was noted to be at an angle with the head tilting forward, the legs were going up and the resident's back was slipping out of the sling. NA #2 identified he tried to brace the resident to prevent him/her from hitting his/her head on the floor, but the resident's bottom hit the floor first. NA #2 identified that he was not sure which size sling Resident #2 needed for the transfer at that time, so he borrowed a sling from another resident to aide in the transfer of Resident #2. NA #2 indicated that after Resident #2 fell he realized the sling that was utilized was too big for the resident. NA #2 indicated that prior to the incident the facility did not have a system in place and after the fall, a sling based on weight was assigned to every resident who needed one. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2, on 6/13/18 at 3:30 PM she was informed Resident #2 fell during a mechanical lift transfer and upon entering the resident's room, Resident #2 was observed on the floor. LPN #2 stated she could not recall which sling was utilized for the transfer however the sling that was used was too large for the resident causing Resident #2 to slide out. LPN #2 identified at the time of the 10/5/17 incident nursing utilized whatever sling was available and the sling was not based on weight. LPN #2 stated that procedure changed after the incident. Review of the Hoyer lift policy directed that a mechanical lift will be used to transfer residents who are unable to assist with transfer or who are too heavy to safely transfer with caregiver assistance. Although the policy identified the appropriate size sling should be used to better accommodate the resident's size and avoid injuries during transfer, the policy failed to reflect documentation regarding who would conduct an assessment and determine the appropriate size and style of sling for the resident. Subsequent to the 10/5/17 incident an action plan was developed and implemented. Nursing would determine an accurate list of residents who required a mechanical lift transfer; nursing would review the weight requirements from all brands and determine the size range to be utilized going forward and the nurses were in-serviced; nursing would confirm that all residents are utilizing the appropriate sized sling; the slings would be laundered, inspected and marked by size with indelible ink in large letters; the resident's name would be written on a yellow tag and attached to the appropriate size and type of sling; the charge nurse would identify the sling size to be used on the original care card and the copy located in the resident's closet; nursing would be in-serviced on the updated procedure and monitored for compliance, audits would be conducted and forwarded to the Quality Assurance and Performance Improvement committee for review; and all nurse aides would receive education and competencies conducted on hire and annually.

Based on clinical record reviews, review of facility documentation and interview for one of three sampled residents (Resident#132) who had alleged neglect of care and services, the facility failed to ensure that the resident received appropriate post-operative care. The findings include: Resident #132's [DIAGNOSES REDACTED]. The hospital discharge summary dated 2/14/13 directed to provide therapy on a daily basis, may ambulate with a walker, toe-touch weight bearing on the left, a postoperative boot on the leg that can be adjusted for comfort and remove daily to check the skin, change the dressing on an as need basis, remove the skin staples in two weeks postoperatively (around 2/25/13), follow up in the orthopedic clinic in four weeks, and please call to make that appointment for the resident. The admission nurse's note dated 2/15/13 identified the presence of six surgical incisions on the left lower leg and left knee area, five of the incisions had three staples and the left knee cap had twelve staples. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. The progress note dated 2/22/13 identified that the APRN was asked to see the resident regarding [DIAGNOSES REDACTED] to the incision site on the lower left extremity. The assessment identified that the lower left extremity looked good, staples were intact without [DIAGNOSES REDACTED], area of ecchymosis to mid shin and heel, no interventions needed, continue to keep leg elevated. The skin condition section of the long term care facility's discharge summary dated 3/2/13 identified that the skin was dry, clean and intact, some discoloration on the left lower leg, the staples were intact and the follow up orthopedic appointment was scheduled for 3/11/13 at 9:30 AM. Communication between the Administrator and Resident #132 dated 3/22/13 indicated that on 3/11/13 the orthopedic physician called to inform the DON and the Administrator that the resident had residual staples that required an outpatient procedure to remove secondary to skin over-growth (28 days post-operatively). Interview with Resident #132 on 6/4/13 at 9:25 AM indicated that the home health agency nurse alerted him/her to the issue of the staples and contacted the surgeon when the home care nurse attempted to remove the staples and was not successful. Resident #132 further identified that the orthopedic physician applied a cold topical spray to numb the area to decrease the discomfort during the removal of the staples. Interview with the Registered Nursing Supervisor (RN) #5 on 6/4/13 at 3:36 PM identified that the usual practice was to review the inter-agency referral report, the transfer summary and the medication list on admission. RN #5 indicated that the recommendations to remove the staples two weeks postoperatively was missed and therefore not transcribed into the admission orders [REDACTED].

Based on clinical record reviews, observations, review of facility documentation and interviews for three of seven sampled residents (Residents #164, #165 and #166) who were reviewed for accidents, the facility failed to provide the appropriate care and supervision to prevent an injury and/or for two of two sampled residents (Residents #2 and #91) who had smoking privileges, the facility failed to ensure that smoking assessments were conducted and/or an appropriate safety device was utilized properly per the facility's policy. The findings include: 1. Resident #165's [DIAGNOSES REDACTED]. The Advanced Practice Registered Nurse (APRN) note dated 6/25/12 indicated the resident complained of neck pain due to stiffness and the APRN directed to apply heat packs to the neck for twenty minutes three times a day and Ben Gay to be massaged into the neck and shoulders twice a day. The significant change MDS dated [DATE] identified Resident had severe cognitive impairment, was totally dependent on staff for transfers, personal hygiene, and dressing and required non-medication interventions for pain. The resident care plan dated 8/22/12 identified pain related to decreased mobility and neck contracture. Interventions directed to notify the physician of any changes in the level and/or frequency of pain, apply Ben Gay and hot packs to the neck and assess the characteristics of pain. The nurse's note dated 10/12/12 identified the presence of four fluid filled blisters on the left neck. The Reportable Event Form dated 10/12/12 identified that Resident #165 had sustained a thermal burn to the left posterior neck secondary to the hot pack, three small blisters were noted in the localized area, the APRN examined Resident #165 and directed to apply Bacitracin twice a day for four days and to hold application of heating pack and Ben Gay for four days. Interview and clinical record review with the Registered Nurse Supervisor (RN #1) on 6/5/13 at 3:40 PM indicated that she was alerted by Licensed Practical Nurse (LPN) #4 of the presence of the blisters where the hot pack had been placed, however, she was unable to investigate how the blisters occurred because the chemical hot pack was thrown away at the time of the assessment. Interview and review of the clinical record with the Director of Nurses (DON) on 6/5/13 at 12:15 PM indicated that heat was activated when the chemical hot pack was either squeezed and/or crushed. The DON identified that a thin disposable face cloth was used as a protective cloth at the time of the incident. The DON indicated that prior to the incident on 10/12/12 the facility did not have a policy for the use of disposable chemical hot packs. The indicated that after the incident a policy and procedure was developed to address the safe use of disposable chemical hot packs. 2. Resident #164's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #164 had severe cognitive impairments, and required extensive two person assistance for bed mobility, transfers in and out of the bed and chair, dressing, bathing and personal hygiene was non-ambulatory, had impaired functional limitation in range of motion on both sides of the upper and lower extremities and utilized a wheel chair only for mobility. A physician's orders [REDACTED]. The Reportable Event Form dated 11/3/12 identified that on 11/3/12 at 6:10 PM the Nurse Aide (NA) called the charge nurse into Resident #164's room. An assessment of the resident identified a purple and yellow discoloration on the right breast and armpit. The radiology report dated 11/5/12 at 4:49 PM identified that Resident #164 had a partial medial shoulder dislocation. Resident #164 was transferred to the hospital for an evaluation and treatment on 11/5/12 at 6:50 PM and returned to the facility on [DATE] at 9:40 PM. Interview with Occupational Therapist (OT) #1 on 6/5/13 at 1:30 PM identified that Resident #164 routinely flexed his/her arms. Interview with Nurse Aide (NA) #3 on 6/5/13 at 3:40 PM and 3:50 PM identified that prior to transferring the resident back to bed she observed a bruise on the resident's chest while the resident was seated in the wheelchair, she notified the nurse, the nurse examined the resident then NA #3 and another NA transferred the resident back to bed. NA #3 explained that the transfer included the application of a gait belt around Resident #164's waist, the resident's arms were flexed so she moved the resident's arms away from the body, then placed her hands under the resident's arms and lifted Resident #164 back to bed. NA #3 identified that the resident could not bear weight. Interview with the Director of Physical Therapy on 6/5/13 at 4:03 PM identified that any resident who cannot bear weight on his/her legs must be lifted via a mechanical lift. 3. Resident #166's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #166 had severe cognitive impairments, long and short term memory deficits, required total two person assistance with transfers in and out of the bed and chair and personal hygiene and extensive two person assistance for bed mobility and toilet use. A physician's orders [REDACTED]. Both orders were documented on the order sheet by Physical Therapy Assistant (PTA). A physician's orders [REDACTED]. The resident care plan dated 8/9/12 identified a risk for falls. Interventions directed to utilize a Sara lift for transfers and to conduct physical therapy, occupational evaluation and screens as ordered. The nurse's note dated 10/15/12 identified that the Registered Nurse Supervisor was called to evaluate the presence of a large discoloration with swelling on the right hip, thigh and knee. The note identified that the area was warm to touch with the absence of redness and the resident did not complain of pain during range of motion. The APRN directed to obtain an x-ray of the right hip and the x-ray report dated 10/15/12 identified mild osteoarthritis of the right hip with no fracture or dislocation. The nurse's note dated 10/18/12 identified that a large bruise was noted on the right thigh above the knee, the right knee was swollen and warm to touch with the absence of pain. The APRN directed to obtain a posterior, anterior and lateral x-ray of the right leg which indicated an acute femoral supracondylar fracture. Interview with the Rehabilitation Manager and Registered Physical Therapist (RPT) on 6/5/13 at 9:30 AM indicated that the resident was referred to physical therapy (PT) on 6/14 /12 due to a decline in transfer ability due to the resident's inconsistent participation, performance, advancing dementia and need for maximal cues and one step commands, from requiring maximum assist of one to requiring maximum assist of two for stand-pivot transfers. Due to the resident's inconsistent participation, performance, advancing dementia and need for maximal cues and one step commands, a Hoyer (mechanical lift) lift transfer was more appropriate. The RPT indicated that she could not recall why a final evaluation and discharge summary was not done and/or the recommendation to use a Hoyer mechanical lift was not implemented on 6/14/12. 4. Resident #2's [DIAGNOSES REDACTED]. The resident care plan dated 3/26/13 identified the resident had a history of [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2 had short and long term memory problems, moderate cognitive impairments and required supervision and one person assist with transfers and ambulating. A physician's orders [REDACTED]. Interview with the Corporate Registered Nurse (RN #3) on 6/5/13 at 12:45 PM identified that she reviewed Resident #2's smoking assessment and the resident did not require a smoking apron. RN #3 did not know why RN #1 put an apron on the resident. 5. Resident #91's [DIAGNOSES REDACTED]. Review of the clinical record identified that the last smoking assessment had been conducted on 1/28/13, four months ago, and the resident did not require a smoking apron. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #91 had no cognitive impairments and required supervision when ambulating in the hallway. The resident care plan dated 5/14/13 identified the resident had a history of [REDACTED]. Interventions included to educate the resident and family on hazards of keeping cigarettes, assess resident's ability to smoke, lite the cigarette, supervise all smoking and provide a smoking apron if indicated. A physician's orders [REDACTED]. Interview with the Corporate Registered Nurse (RN #3) on 6/5/13 at 12:45 PM identified that she reviewed Resident #91's smoking assessment and the resident did not require a smoking apron. RN #3 stated that smoking assessments are the responsibility of the care plan coordinator and should be done quarterly. RN #3 was unable to indicate why the resident's ability to smoke had not been assessed since 1/28/13. Review of the facility's smoking policy directs that flame retardant aprons should be used to prevent injury related to unsafe smoking. Smoking assessments will be completed on admission, readmission, and quarterly and with any change in condition.

Based on clinical record review, observation and interview for one of two residents (R#2) with falls, the facility failed to check for placement and function of a chair alarm.. The findings include; R#2's [DIAGNOSES REDACTED]. The Nursing assessment dated [DATE] identified R#2 as alert and oriented. The Admission/Interim Care plan dated 8/17/10 identified R#2 as a risk for falls related to cardiovascular accident, decreased safety awareness secondary to dementia with interventions to instruct to ask for assistance prior to attempting to transfer or walk within his/her capacity to understand. Review of nurses' notes dated 8/18/10 at 9:20PM identified that R#2 was observed lying on the floor at 8:10PM, stating he was attempting to ambulate out of the bathroom with the walker and lost balance. A physician order [REDACTED]. Review of nurse's notes dated 8/29/10 at 4:00PM identified R#2 was found sitting on the floor at the foot of the bed with a skin tear over the left elbow, the resident denied complaints of pain and able to move all extremities. At 9PM, bleeding was noted from the left elbow skin tear site and the resident complained of right hip pain. The physician was notified; the resident was sent the emergency room for an evaluation and was diagnosed with [REDACTED]. The Treatment Record dated 8/29/10 for the 3-11pm shift lacked documentation to reflect that the bed/chair alarm was checked for function. Facility documentation dated 8/31/10 identified that NA# 3 assigned to the 7-3 shift was unaware that the resident required a chair alarm and NA#2 who was assigned to the 3-11 shift was not aware that the resident required a chair alarm and therefore did not check the chair alarm. The facility documentation further identified that RN #3 (7-3pm nurse) never checked the alarms and did not delegate this task to the nurse aides. Interview with NA# 2 on 10/28/10 at 2:00PM identified that he/she did not have time to check the alarm due to answering call lights and added that R#2 had a history of [REDACTED].