Every finding on record at Bloomfield Center for Nursing & Rehabilitation

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for community provider appointments, the facility failed to ensure a preoperative order directing to hold a blood thinner for forty-eight (48) hours prior to the scheduled procedure was transcribed correctly resulting in the medication being administered the day prior to and the morning of the procedure, the resident was transported to the appointment and then subsequently the procedure was cancelled due to the error. The findings include:Resident #1's diagnoses included neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems), recurrent urinary tract infections, and atrial fibrillation. A December monthly physician's order directed to administer Eliquis (a blood thinner) oral 5 milligram tablet (mg) by mouth twice daily. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #1 was alert and oriented. The Resident Care Plan dated 10/15/25 identified Resident #1 had an indwelling catheter due to a neurogenic bladder. Interventions included monitoring for signs and symptoms of a Urinary Tract Infection (UTI) and reporting to the provider as needed with changes. The nurse's note dated 12/4/25 at 2:38 PM identified a call was received from the hospital's Interventional Radiology (IR) department and their staff reported the appointment for Resident #1's suprapubic tube (a catheter that's inserted through a small opening in the lower abdomen directly into the bladder to drain urine) placement had been rescheduled for 12/11/25 at 9:00 AM.A physician's order created on 12/4/25 directed to hold the Eliquis for two (2) days, 12/9/25 and 12/10/25, for the suprapubic tube replacement preparation. The nurse's note dated 12/5/25 at 6:36 PM identified the following bloodwork, International Normalized Ratio (INR), Complete Blood Count (CBC), and Comprehensive Metabolic Panel (CMP) were faxed to the hospital in preparation of Resident #1's suprapubic tube change. The report of consultation dated 12/11/25 identified the procedure, replacement of the suprapubic catheter was cancelled. The nurse reported the medication Eliquis was held on 12/9/25 but not on 12/10/25. The note directs the Eliquis needs to be held for forty-eight (48) hours, and the procedure will be rescheduled. Review of the December 2025 Medication Administration Record (MAR) identified although the 9:00 AM and 5:00 PM doses of Eliquis were held on 12/9/25, the 9:00 AM and 5:00 PM on 12/10/25 and the 9:00 AM dose prior to the procedure on 12/11/25 were administered. Interview and review of a written statement dated 12/16/25 with the 3-11PM nursing supervisor, Registered Nurse (RN) #1, on 1/22/26 at 11:21 AM identified on 12/4/25 she received a call from the hospital's Interventional Radiology (IR) staff regarding preoperative instructions for Resident #1's suprapubic tube placement scheduled for 12/11/25. RN #1 explained the instructions included blood work that was required to be obtained and faxed to them, Resident #1 was to have nothing by mouth after 12:00 AM on 12/11/25 except for medications with sips of water and the Eliquis was to be held starting on 12/9/25 at 9:00 AM and restarted at 5:00 PM on 12/11/25 after Resident #1 returned from the procedure. RN #1 identified she verified the orders with the provider and then placed the orders that same day. RN #1 stated after the scheduled procedure she was notified by the Director of Nursing (DON) that the hold order for the Eliquis was placed incorrectly, stating she chose the start date of 12/9/25 at 12:00 AM and then entered the hold date so it would last for two (2) days but did not confirm the end date shown or the time to restart the Eliquis were correct. Interview with the DON on 1/22/26 at 12:32 PM identified although the facility does not have a policy and procedure for the licensed nurses to verify the accuracy of order transcription after they enter verbal orders, per standards of nursing practice, RN #1 should have ensured the orders she entered were complete and accurate and she should have re-checked the start and end dates and times prior to submitting the order. The DON indicated since RN #1 received the preoperative orders verbally and did not document a nurse's note the preoperative orders given, a second check by a licensed nurse on the next shift did not occur. Review of the Transcription of Orders policy dated 01/2024 directed, in part, that orders from an authorized licensed independent practitioner are accepted by a RN or Licensed Practical Nurse (LPN). Orders are considered but not limited to medications, labs, diagnostics and consultations and can be written in the electronic health record or obtained over the phone, verbally and/or from discharge and transfer paperwork from the hospital, physician's office visit or consultant's recommendations. Transcribing is the recording of orders by an RN, LPN or by clerical/non-licensed unit clerk with appropriate training and competency per state regulations. Although requested, a facility policy for physicians' orders was not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for community provider coordination, the facility failed to ensure a complete and accurate clinical record to include communication with the provider regarding preoperative instructions. The findings include:Resident #1's diagnoses included neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems), recurrent urinary tract infections, and atrial fibrillation. A December monthly physician's order directed to administer Eliquis (a blood thinner) oral tablet 5 milligrams (mg) by mouth twice daily. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #1 was alert and oriented. The nurse's note dated 12/4/25 at 2:38 PM identified a call was received from the hospital's Interventional Radiology (IR) department and their staff reported the appointment for Resident #1's suprapubic tube (a catheter that's inserted through a small opening in the lower abdomen directly into the bladder to drain urine) placement had been rescheduled for 12/11/25 at 9:00 AM. A physician's order created on 12/4/25 directed to hold the Eliquis for two (2) days, 12/9/25 and 12/10/25, for the suprapubic tube replacement preparation. Review of the clinical record from 12/4/25 through 12/11/25 failed to reflect documentation of the complete preoperative instructions the 3-11PM nursing supervisor had received on 12/4/25. The only update was the nurse's note dated 12/5/25 at 6:36 PM which identified the following International Normalized Ratio (INR), Complete Blood Count (CBC), and Comprehensive Metabolic Panel (CMP) were faxed to the hospital in preparation of Resident #1's suprapubic foley change. The report of consultation dated 12/11/25 identified the procedure, replacement of the suprapubic catheter was cancelled. The nurse reported the medication Eliquis was held on 12/9/25 but not on 12/10/25. The note directs the Eliquis needs to be held for forty-eight (48) hours, and the procedure will be rescheduled. Review of the December 2025 Medication Administration Record (MAR) identified although the 9:00 AM and 5:00 PM doses of Eliquis were held on 12/9/25, the 9:00 AM and 5:00 PM on 12/10/25 and the 9:00 AM dose prior to the procedure on 12/11/25 were administered. Interview and review of a written statement dated 12/16/25 with the 3-11PM nursing supervisor, Registered Nurse (RN) #1, on 1/22/26 at 11:21 AM identified on 12/4/25 she received a call from the hospital's Interventional Radiology (IR) staff regarding preoperative instructions for Resident #1's suprapubic tube placement scheduled for 12/11/25. RN #1 explained the instructions included blood work that was required to be obtained and faxed to them, Resident #1 was to have nothing by mouth after 12:00 AM on 12/11/25 except for medications with sips of water and the Eliquis was to be held starting on 12/9/25 at 9:00 AM and restarted at 5:00 PM on 12/11/25 after Resident #1 returned from the procedure. RN #1 identified although she verified the orders with the provider and then placed the orders that same day, she did not write a note regarding the preoperative instructions Interview with the Director of Nursing (DON) on 1/22/26 at 12:32 PM identified licensed nurses are responsible for documenting all communication with community providers in the clinical record. Review of the Charting and Documentation policy dated 01/2025 directed, in part, that the charting/documentation is to provide a complete account of the resident's total stay from admission through discharge, provide information about the resident that will be used in developing the plan of care, and as a tool for measuring the quality of care provided to the resident. Licensed staff and interdisciplinary team members shall document all assessments, observations, evaluations and services provided in the resident's medical record in accordance with state law. Documentation shall entail pertinent changes in the resident's condition, reaction to treatment, medications, etc. as well as routine observations. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. Documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or response to care. Document as often as necessary and as the need arises. Document medications, treatments, vital signs and weights as required/requested.

Based on observations, review of the clinical record, facility policy and interviews for 2 of 2 sampled residents, (Resident# 97, Resident #102), reviewed for Activities of Daily Living (ADL's), for Resident #97, the facility failed to develop a comprehensive Resident Care Plan (RCP) for the use of a 24-hour positioning plan and specialized communication needs, and for Resident #102, failed to ensure the RCP reflected a dental problem for a resident with dental issues. The findings include: 1. Resident #97's diagnosis included quadriplegia, diabetes, and feeding difficulties. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 indicating moderate cognitive impairment, spoke Spanish, required an interpreter, had a limitation in range of motion in both upper and lower extremities, and was totally dependent on staff for ADL's. The Resident Care Plan (RCP) in effect from 1/1/2025 through 5/15/2025 failed to identify the 24-hour positioning plan per the physician order or that Resident #97 had communication barriers and required specialized services to communicate. The physician's orders in effect for April and May 2025, directed to transfer Resident #97 out of bed to a power wheelchair with chest and pelvic positioning belts to maintain upright positioning per a 24-hour positioning plan. The Occupational Therapy (OT) progress notes dated 4/3/2025 through 5/15/2025 described Resident #97's out of bed routine was to transfer out of bed to a power wheelchair and to utilize chest and pelvic belts to maintain upright posture per the 24-hour positioning plan. The 24-hour rehabilitation positioning plan directed that on the 7:00 AM to 3:00 PM shift, Resident #97 was to be out of bed to a custom wheelchair (CWC) as tolerated, and on the 3:00 PM to 11:00 PM shift placed back to bed. During an interview on 5/15/2025 at 12:22 PM with Resident #97 he/she was noted to require a translator in order to communicate. Google translator was utilized. The Nurse Aid (NA) care card (directs NA care) dated 5/16/25 failed to identify Resident #97 had a 24-hour positioning plan or that he/she was Spanish speaking and required an interpreter for communication. Interview and review of the RCP with the Director of Nursing Services (DNS) on 5/16/2025 at 1:18 PM failed to identify that Resident #97 had a 24 hour positioning plan or was Spanish speaking and utilized [NAME] (virtual assistive device) for interpretation. Additionally, the DNS indicated that the MDS Coordinator as well as any nursing staff could have updated the RCP to reflect the resident's care requirements. 2. Resident #102's diagnoses included malignant neoplasm of the left breast, moderate protein calorie malnutrition, and dysphagia (difficulty swallowing). The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #102 did not have any dental issues. The quarterly MDS dated [DATE] identified Resident #102 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, was independent after set up help with eating, and required partial/moderate assistance with oral hygiene. The RCP in effect from 1/7/2025 through 5/16/2025 failed to identify any dental issues or problems. A dental hygienist note dated 1/7/2025 identified that Resident #102 had lower right tooth pain at crowned tooth #31 and had no other pathology was noted at the time of the exam. Digital palpation did elicit a mild pain response, but no mobility (of the teeth) was detected. As per the dentist, Resident #102 will be scheduled for further evaluation. A dentist's note dated 1/8/2025 identified that Resident #102 had complained of discomfort of the lower right side of his/her mouth. Resident #102's tooth hurt when biting down. A previous evaluation on 10/24/2024 resulted in a recommendation for a referral to a provider in the community for evaluation for course of treatment. Nursing staff was made aware of the discomfort. Interview and review of the RCP with Director of Nursing (DNS) on 5/16/2025 at 1:20 PM failed to identify why Resident #102 did not have a RCP related to his/her ongoing dental issues since 1/7/2025. Review of the baseline and comprehensive person-centered care plan policy dated 3/2023 directed, in part, the comprehensive person-centered care plan will be developed after the comprehensive assessment, reviewed and revised by a team of qualified persons after each assessment, will be revised episodically as the plan of care changes, and will reflect the resident's current status. The comprehensive person-centered care plan will be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the care plan when there is a new problem identified that needs the discipline to intervene.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 6 sampled residents, (Resident #60), reviewed for abuse, the facility failed to ensure a resident who was exposed to a communicable illness was free to exit their room when wearing appropriate Personal Protective Equipment (PPE). The findings include: Resident #60's diagnoses included quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, was dependent with personal hygiene and rolling left and right, and used a motorized wheelchair. The Resident Care Plan (RCP) dated 4/29/2025 identified Resident #60 required assistance with activities of daily living. Interventions included using a mechanical lift for transfers, using 2 staff for turning and repositioning, and use of a motorized wheelchair for locomotion. A nurse progress note dated 5/5/2025 identified Resident #60 had tested negative for Covid after his/her roommate had tested positive for Covid. A nurse progress notes dated 5/7/2025 identified Resident #60 was on isolation precautions for Covid and had no shortness of breath or respiratory symptoms. A nurse progress notes dated 5/10/2025 identified Resident #60 was on contact/droplet precaution and had no respiratory distress. Review of physician orders failed to direct staff to place Resident #60 on droplet or contact precautions and/or isolation. An observation on 5/12/2025 at 1:30 PM identified a sign outside Resident #60's room indicating contact and droplet precautions. Resident #60 was not visible from the doorway, he/she was observed behind a privacy curtain without a mask, lacked any engaging activities such as television, radio, or personal activity, and lay silently in bed. A nurse progress note dated 5/13/2025 identified Resident #60 was not experiencing any signs or symptoms associated with Covid after an incidental exposure. An observation on 5/13/2025 at 9:34 AM identified Resident #60 was seated in bed behind a closed privacy curtain, not visible from the doorway of the room, sitting silently without a mask, without any type of any engaging activities such as television, radio, or personal activity. Resident #60's roommate was in bed sleeping. An interview with Nurse Aide (NA) #1 on 5/12/2025 at 11:31 AM identified Resident #60 was not allowed to leave his/her room due to his/her roommate testing positive for Covid. Further NA #1 was unable to identify when Resident #60 could leave his/her room. An interview with Resident #60 on 5/13/2025 at 9:33 AM identified he/she missed church this week and was upset he/she could not attend religious services. An interview with the Infection Preventionist (IP) on 5/14/2025 at 9:36 AM identified that residents are not moved if their roommate tests positive for Covid as there is a presumed exposure to Covid. The IP was unable to correctly identify the contagious period for Covid, incubation period for Covid, and Centers for Disease Control (CDC) recommendations for cohorting residents with Covid. The IP stated Resident #60 had not been evaluated for wearing a surgical or N95 mask or checked for mask wearing compliance. Additionally, the IP indicated that room appropriate activities could not be offered to him/her during the isolation period. An interview with the Director of Recreation at 5/14/2025 on 11:28 AM identified that Resident #60 was usually active with recreation activities and had attended bible study, music activities, and plant programs that were offered in the past. She indicated if the resident was currently allowed out of the room, he/she would have been able to participate socially in activity programs for stimulation. Further, the Director of Recreation identified that Resident #60 had not attended or been offered any activities since 5/3/2025. An interview with the Director of Nursing Services (DNS) on 5/14/2025 at 12:21 PM identified that it was unsafe for the roommate of a Covid positive resident to leave the room due to the resident's exposure to Covid. The DNS indicated that it was safe for staff to enter and exit Resident #60's room while wearing a mask, but that it was not safe for Resident #60 to leave the room with a mask. The DNS stated Resident #60 had never been trialed for mask use or for compliance to be out of his/her room with a mask in place. The DNS further noted that Resident #60 was a quadriplegic and could not put on or take off a mask independently. An interview with the Administrator on 5/14/2025 at 12:51 PM identified she was not informed Resident #60 wished to leave his/her room, and that the facility failing to identify that restricting Resident #60 from leaving his/her room when he/she requested could be considered an involuntary seclusion. Review of the facility's operational guide for Covid identified, in part, exposed residents should be monitored for symptoms, receive testing, and wear source control (a mask) for 10 days following exposure.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 sampled residents, (Resident # 96), reviewed for pressure ulcers, the facility failed to update the Resident Care Plan (RCP) with interventions to prevent the development of a pressure ulcer when the resident became more dependent on staff, and for 1 of 3 sampled residents, (Resident #104), reviewed for accidents, the facility failed to update the Residents Care Plan (RCP) after unwitnessed falls. The findings include: 1. Resident #96's diagnoses included severe protein calorie malnutrition, vascular dementia and difficulty walking. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #96 had a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment, required supervision with bed mobility, supervision with transfers, and supervision ambulating. Additionally, Resident #96 was at risk for skin breakdown and had no current pressure areas. Review of the Physical Therapy Discharge summary dated [DATE] through 3/18/25 identified Resident #96 required partial/moderate assistance with bed mobility, partial/moderate assistance with transfers, and partial/moderate assistance to ambulate 10 feet. (A decline in 3 areas was noted to have occurred from the MDS assessment dated [DATE] to the Physical Therapy Discharge summary dated [DATE] in the areas of bed mobility, transfers, and ambulation). The Resident Care Plan (RCP) dated 4/22/25 identified a potential for skin breakdown. Interventions included obtaining labs as ordered, treatments as ordered, and updating the physician and responsible party with changes as needed. The RCP failed to include new iterventions for preventative measures for pressure ulcer development when the resident became more dependent on staff for turning in bed, transfers, and walking. Review of weekly skin assessments from 4/24/25 to 5/1/25 identified that Resident #96 had intact skin. A nurse's note dated 5/6/2025 at 12:58 PM identified a Deep Tissue Injury (DTI) on Resident #96's right hip and a stage 2 (partial thickness skin loss) of the left hip. Resident #96 was seen by the wound nurse practitioner and new orders were put into place. On 5/6/2025 the RCP was updated (subsequent to pressure injury develoment) to include Resident #96's new Deep Tissue Injury (DTI) pressure ulcer to the right hip and stage 2 pressure ulcer on the left hip both related to immobility. Interventions included a dietitian evaluation/intervention as needed, monitor signs and symptoms of wound infection, alternating air mattress placement, and weekly wound evaluations per the protocol. A Nurse Practitioner wound assessment note dated 5/6/2025 identified an initial visit to assess Resident #96's pressure injuries. Significant contributors for increased risk of wound incidence and/or impeding healing included but are not limited to diabetic and vascular complicating factors, generalized muscle weakness, impaired mobility, and inevitable effects of aging. Education was provided regarding pressure relief, general offloading, and frequent repositioning. Interview and review of the clinical record with the DNS on 5/18/2025 at 11:06 AM failed to identify that the RCP had been reviewed and revised with interventions for the prevention of pressure ulcer development following Resident #96's decline identified on the Physical Therapy Discharge summary dated [DATE] in the areas of bed mobility, transfers, and ambulation. The DNS indicated the RCP had not been updated prior to the development of the pressure ulcer, because up to that point, he believed that Resident #96 was mobile and ambulatory. Additionally, the DNS indicated that although the facility conducted weekly at risk meetings with the MDS Coordinator, Rehabilitation, and the Dietician, he was never made aware of Resident #96's decline in bed mobility, transfer status, or ambulation until 5/6/25 when the pressure injuries to the right and left hip were identified. Interview with the MDS Coordinator on 5/18/2025 at 11:16 AM, identified she had met with rehab on 5/18/2025, after a significant change had occurred, and that she had only discussed the decline with rehabilitation, (not updating the RCP), after the DNS had questioned her about the decline of function in the 3 areas of bed mobility, transfers, and ambulation. Review of the NHCA pressure injury prevention management program policy dated 3/2023 directed, in part, to identify potential risk factors and implement preventative measures to prevent skin breakdown. 2. Resident #104 was admitted to the facility in June of 2024 with diagnoses that included hypertension, generalized body weakness, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #104 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment, required moderate assistance for personal hygiene and was independent for bed mobility and transfers. The Resident Care Plan (RCP) dated 10/23/2024, identified Resident #104 was at risk for falls due to poor balance, psychoactive drug use, and unsteady gait. Interventions included use of appropriate footwear (non-skid socks, non-slip soles or shoes/sneakers) when ambulating or mobilizing in a wheelchair, encourage the resident to be out of the room when awake for socialization and/or recreation, use a low bed, and note any changes in gait and report as needed. A Reportable Event form dated 12/21/2025 at 6:52 AM written by Registered Nurse (RN) #4, identified that Resident#104 was found lying in front of his/her bed. Resident #104 suffered a laceration to the mid forehead measuring 2 centimeters (cm) by 0.5 cm. Resident #104's physician and family were notified and an investigation into the incident was initiated. A Reportable Event form dated 12/28/2025 at 5:00 AM written by RN #4, identified that Resident#104 had an unwitnessed fall in his/her room in front of his/her bed. Resident #104 did not sustain any injuries. Resident #104's physician and family were notified and investigation into the incident was initiated. Although Reportable Events describing Resident #104's falls on 12/21/2025 and 12/28/2025 were noted, a review of the RCP failed to identify any new interventions that had been implemented to prevent further falls. Interview with RN #4 on 5/15/25 at 10:35 AM, identified that he was responsible for updating Resident #104's RCP after the falls. RN #4 indicated that the RCP should have been updated, and new post fall interventions initiated to mitigate further falls. RN #4 was unable to explain why he did not update the RCP. Interview and clinical record with the Director of Nursing Services (DNS) on 5/19/2025 at 11:10 AM, identified that Resident #104's RCP should have been updated after the falls. The DNS could not explain why RN#4 failed to update the RCP. Review of facility policy titled, Baseline/Comprehensive Person-Centered Care Plan (CPCCP), identified, in part, the CPC/CP will be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the care plan when there is a new problem that requires disciplines to intervene.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 4 sampled residents, (Resident #97), reviewed for dignity, the facility failed to ensure the resident's body was not exposed while being transferred in the hallway following a shower. The findings include: Resident # 97's diagnosis included quadriplegia, diabetes, and feeding difficulties. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, and was totally dependent on staff for bed mobility, transfers, eating, and bathing. The Resident Care Plan (RCP) dated 4/3/25 identified an Activities of Daily Living (ADL)deficit related to quadriplegia, spinal stenosis, and muscle weakness. Interventions included total dependence on 1 staff for bathing and showering and was totally dependent on 2 staff for repositioning and turning in bed. Observation on 5/12/2025 at 12:27 PM identified Resident # 97 being wheeled down the hallway, in a shower chair, after a shower with his/her buttocks exposed. The resident was noted to be wearing a hospital gown with no further covering. Staff, residents, and the surveyor were noted in the area and able to view Resident #97's buttocks. Observation and interview with the Director of Nursing (DNS) on 5/12/2025 at 12:27 PM identified that he had observed Resident #97 being wheeled down the hall with his/her buttocks exposed. The DNS indicated that the resident should have been covered up completely when being transferred to and from a shower. Subsequent to surveyor inquiry, NA #2 was asked by the DNS to cover Resident #97's buttocks to maintain privacy. Interview with NA #2 on 5/12/2025 at 12:47 PM identified that she was aware that residents needed to be covered completely when being transferred from the shower. Although NA #2 indicated she was aware of the facility policy, she indicated she had been in a hurry when taking Resident #97 from his/her shower. Review of the facility resident's rights policy dated revised 2/2024 directed, in part, to ensure the right to be treated with consideration, respect, and full recognition of your dignity and individuality. The right to privacy in accommodation, in receiving personal and medical care and treatment.

Based on observation, clinical records, staff interviews, and policy review for 1 of 2 sampled resident, (Resident #60), reviewed for infection control, the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) when providing resident care. The findings include: Resident #60 was admitted in April of 2024 with diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure, and quadriplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, was dependent with personal hygiene and rolling left and right and used a motorized wheelchair. The Resident Care Plan (RCP) dated 4/29/2025 identified Resident #60 had COPD. Interventions included monitoring for signs and symptoms of respiratory insufficiency and to monitor/document/report any signs and symptoms of respiratory infection. Nurse progress notes dated 5/7/2025 identified Resident #60 was on isolation precautions for Covid and had no shortness of breath or respiratory symptoms. An observation on 5/12/2025 at 11:31 AM identified signage was posted on Resident #60's door, visible prior to entry, which stated Covid/ precautions with directions that providers and staff must wear gloves, a gown, and an N-95 mask when entering the room. Further observation noted Nurse Aide (NA) #1 was wearing gown, gloves, and surgical mask versus an N-95 mask when providing care for Resident #60 in a room requiring airborne precautions. An interview with NA #1 at that time identified that she was aware she needed to wear an N-95 mask in an airborne precaution room and stated she had forgotten to place the correct mask according to the signage. An interview with the Infection Preventionist on 5/14/2025 at 9:36 AM identified that staff should be using the Personal Protective Equipment (PPE) identified on the sign outside the door for a resident who was on precautions per the facility policy. Review of the facility's Precautions to Prevent Infections policy identified, in part, that clear signage should be posted outside the resident's room indicating the type of precautions and required PPE for use, and staff should be aware of the expectations about hand hygiene, and gown/glove/facemask use.

Based on record review, interviews, and review of facility policy for the only sampled resident, (Resident #60), reviewed for Activities, the facility failed to provide activities that met the needs of a resident with a physical impairment. The findings include: Resident #60's diagnoses included quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, was dependent with personal hygiene and rolling left and right, and used a motorized wheelchair. The Resident Care Plan (RCP) dated 4/29/2025 identified Resident #60 would maintain involvement in cognitive stimulation and social activities. Interventions included inviting him/her to the scheduled activities and provide him/her with an activity calendar. An interview with Resident #60 on 5/13/2025 at 9:34 AM identified he/she was upset that there are no options for recreation activities that he/she could participate in due to his/her hands being paralyzed. An interview on 5/14/2025 at 11:28 AM with the Director of Recreation identified that Resident #60 was not being offered any specialized recreation programs, but she recognized military service on Veteran's Day, placed bingo markers on a bingo card for him/her, and when arts and crafts required the use of hands, she would provide the hands on assistance. The Recreation Director further indicated that although there were other residents who had physical limitations, the facility did not offer specialized recreation activities for residents with physical limitations. Review of the Facility's Therapeutic Recreation Policy identified in part that the therapeutic recreation department will provide resident centered activities based on a resident's age, and physical and cognitive limitations.

Based on observation, review of clinical records, facility policy, and interviews for 1 of 4 sampled residents (Resident #2) reviewed for dignity, the facility failed to ensure a portable oxygen cylinder was stored in a safe manner. The findings include: Resident #2 diagnoses included chronic obstructive, obstructive pulmonary disease, respiratory failure, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment, required supervision with bed mobility, maximal assistance with lower body dressing, and partial moderate assistance to sit on the side of the bed. The Resident Care Plan Conference (RCC) dated 5/15/2025 identified Resident #2 had emphysema related to a history of smoking. Interventions directed staff to monitor for symptoms of dyspnea on exertion, monitor for signs and symptoms of respiratory infection, and administer oxygen as ordered. Observation and interview with Resident #2 on 5/16/2025 at 1:37 PM identified a green portable oxygen cylinder laying sideways on the seat of a manual wheelchair located at the base of the bed. Resident #2 stated the tank was brought in so that he/she could leave the room and socialize with other residents. Interview with Social Worker (SW) #1 on 5/16/2025 at 1:47 PM identified that during a RCP meeting, it was decided to provide Resident #2 with an extra oxygen tank so he/she could move freely throughout the facility and that she knew how to administer oxygen to residents. SW #1 indicated that although not professionally trained, she knew how to turn on the oxygen tank, had provided oxygen to Resident #2 in the past, and had done so to help so that Resident #2 did not have to wait for a nurse. Observation and interview with the Director of Nursing (DNS) on 5/16/2025 at 2:30 PM identified that oxygen should be administered only by a nurse and SW #1 did not have the competency and qualifications to administer oxygen. Review of the Oxygen Therapy Policy directed, in part, that staff identified hazards such as delivering oxygen to residents with COPD because overcorrected oxygen levels may have led to carbon dioxide retention.

Based on review of the clinical record, facility policy and interviews for 2 of 3 sampled residents (Resident #32 and Resident #76) reviewed for pressure ulcers, the facility failed to perform weekly skin checks as ordered, failed to perform weekly pressure ulcer risk assessments, failed to ensure the dietician conducted a nutritional assessment for a resident with a pressure ulcer, and for Resident #76, failed to develop a comprehensive care plan. The findings include: 1. Resident #32 was admitted on [DATE] with diagnoses that included diabetes, chronic kidney disease, dementia and congestive heart failure. The admission baseline Resident Care Plan (RCP) dated 3/26/2025 identified a potential for skin breakdown. Interventions included dietician evaluation/interventions as needed, skin checks with care for changes, report changes to the nurse, turn and reposition every 2 to 3 hours and as tolerated, and weekly skin evaluations. The admission MDS assessment dated [DATE] identified Resident #32 had a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment, and was totally dependent on staff for bed motility, transfers, and wheelchair mobility. Additionally, Resident #32 was always incontinent of bladder, frequently incontinent of bowel, and although he/she did not have a current pressure ulcer, was at risk for pressure ulcer development. Review of the Clinical Record identified a nurses note dated 3/25/25 indicating Resident #32 had a reddened heel, a Hospice Clinical Note and Visit Report sheet identifying a pressure injury to the sacrum on 4/21/2025, and a left big toe in-house acquired deep tissue injury on 4/28/25. Review of the physician orders dated 3/27/2025 directed to apply barrier cream to the buttocks every shift and apply skin prep to the right and left heel every shift, bunny boots and off load when in bed, and physician's orders dated 4/30/2025 directed to cleanse the sacrum with normal saline, apply medical honey and cover with a foam border. a. Physician's orders dated 3/25/2025 directed facility staff to conduct weekly skin assessments on Wednesdays and document findings in Point Click Care (the electronic health record) using the Skin & Wound Total Body Skin Assessment form. Review of the clinical record identified 2 Total Body Skin Assessments dated 4/16/2025 and 5/14/2025 resulting in 5 missing assessments out of 7 opportunities. (4/2, 4/9/, 4/23, 4/30, 5/7/2025) b. A Braden Scale for Predicting Pressure Sore Risk dated 3/26/2025 identified a score of 14 indicating moderate risk of pressure ulcer development. Review of the clinical record failed to identify any further Braden Scale assessments after the initial assessment on admission. c. The Nutritional Evaluation dated 3/28/2025 identified Resident #32 had no skin integrity issues. Review of the clinical record failed to identify the Dietician had evaluated Resident #32 following development of pressure ulcers. 2. Resident #76 was readmitted on [DATE] with diagnoses that included diabetes, chronic kidney disease, and intellectual disability. A nursing readmission assessment dated [DATE] identified that Resident #76 did not have any skin integrity issues. The re-admission MDS assessment dated [DATE] identified Resident #76 with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment and required substantial maximal assistance with bed mobility, transfers, and ambulating 10 feet. Additionally, Resident #76 was always incontinent of bowel, was at risk to develop pressure ulcers, and had a current unhealed pressure ulcer determined to be unstageable. A Skin and Wound Evaluation dated 4/22/2025 identified a pressure ulcer, deep tissue injury that was present on admission. a. A discontinued physician orders dated 4/18/2025 had directed facility staff to conduct weekly skin assessments and document findings in Point Click Care (the electronic health record) using the Skin & Wound Total Body Skin Assessment form. The order was discontinued on 4/18/2025 and never reinstated. Review of the clinical record identified Total Body Skin Assessments dated 5/6/2025 and 5/13/2025 resulting in 2 missing assessments out of 4 opportunities. (during the week of 4/20/2025 and 4/27/2025. b. A Braden Scale for Predicting Pressure Sore Risk dated 4/18/2025 identified a score of 14 indicating moderate risk of pressure ulcer development. Review of the clinical record failed to identify any further Braden Scale assessments after the initial assessment on admission. c. The Nutritional Evaluation dated 4/21/2025 identified Resident #76 had no skin integrity issues. Review of the clinical record failed to identify the dietician had evaluated Resident #76's pressure ulcer present on readmission, since his/her readmission. d. A physician order dated 4/18/2025 directed to cleanse buttocks with soap and water, pat dry, and apply zinc oxide every shift. Although the resident was readmitted to the facility on [DATE] with an unable to stage pressure ulcer, the RCP and Nurse Aide (NA) care card failed to reflect interventions to prevent deterioration or further pressure ulcer development since Resident #76's readmission. Interview with the DNS on 5/19/25 at 2:55 PM identified that Skin & Wound Total Body Skin Assessment forms are to be routinely completed weekly, Braden scale risk evaluations are to be completed weekly for 4 weeks on admission and readmission, the dietician is to conduct a nutritional assessment when a pressure ulcer has developed, and that RCP's are updated with changes in condition. The DNS was unable to explain why Resident #32 and Resident #76, did not have weekly Skin & Wound assessments, Braden scale risk evaluations were not completed weekly for 4 weeks per the facility policy, why the Dietician did not see the residents for nutritional assessments, although she did attend morning report where she could have received the information, or why the RCP's were not updated timely to reflect the changes in condition, Interview with the Dietician on 5/19/2025 at 3:50 PM identified that she did not see the residents for nutritional assessments/updates to the progress notes as she was not aware/informed the residents had pressure injuries. Further, had she been aware, would have evaluated Resident #32 and #76 more extensively for nutritional needs. Review of the Pressure Injury Prevention Protocol directed to identify potential risk factors and implement preventative measures to prevent skin breakdown. Review of the Pressure Injury Nutrition Protocol directed the Dietician to ensure that residents have adequate fluid and nutritional intakes. Review of the Braden Scale policy directed Braden Scale evaluations for all residents upon admission/readmission, then weekly for a total of 4 weeks. Review of the Resident Care Plan Policy directed dated 3/2023 directed, in part, the comprehensive person-centered care plan will be developed after the comprehensive assessment, reviewed and revised by a team of qualified persons after each assessment, will be revised episodically as the plan of care changes, and will reflect the resident's current status.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 4 sampled residents (Resident #2) reviewed for dignity, the facility failed to ensure a portable oxygen cylinder was stored in a safe manner to prevent a potential hazard, for 1 of 3 residents (Resident #60) reviewed for hospitalization, the facility failed to follow physician orders to transfer a resident to the Emergency Department following an accidental occurrence in a dependent resident, and for 1 of 3 residents, (Resident #93) reviewed for accidents, the facility failed to provide a side rail assessment and evaluation prior to using side rails resulting in an injury. The findings include: 1. Resident #2 diagnoses included chronic obstructive, obstructive pulmonary disease, respiratory failure, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment, and required supervision for bed mobility, sitting to lying, sitting to standing, and was independent with mobility once in a wheelchair. Additionally, Resident #2 required oxygen therapy. The Resident Care Plan (RCP) dated 5/15/2025 identified Resident #2 had emphysema related to a history of smoking. Interventions directed staff to monitor for symptoms of dyspnea (shortness of breath) on exertion, monitor for signs and symptoms of respiratory infection, and administer oxygen as ordered. Observation and interview with Resident #2 in his/her room on 5/16/2025 at 1:37 PM identified a green portable oxygen tank cylinder on the seat of a wheelchair unsecured and lying sideways. Observation and interview with the Director of Nursing (DNS) on 5/16/2025 at 2:30 PM identified that the oxygen storage tank in Resident #2's room was improperly stored. The DNS indicated the tank should have been secured in an oxygen tank holder and not laid on the seat of the wheelchair. The DNS indicated that subsequent to surveyor observation, the oxygen tank would be removed and secured. Review of the Oxygen Safety Policy directed, in part, that oxygen cylinders must be stored in a stand or chained area, all cylinders in use must be in a stand, and all connections on tanks must be tight. According to Occupational Safety and Health Administration, (OSHA) compressed gas cylinders must be secured in an upright position regardless of whether they are in use or in storage. Compressed gas cylinders can only be horizontal for short durations when they are being hoisted or carried. 2. Resident #60's diagnoses included quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease. The annual Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was dependent with eating, personal hygiene and rolling left and right, and had bilateral range of motion limitations in the upper extremities. The Resident Care Plan (RCP) in effect from 7/19/2024 to 7/22/2024 identified Resident #60 required assistance with activities of daily living. Interventions included using a mechanical lift for transfers, using 2 staff for turning and repositioning, and use of a motorized wheelchair for locomotion. A nursing note dated 7/21/2024 at 4:26 PM identified that Resident #60 had a Q-tip stuck in his/her right nostril and that the Q-tip was not visible while attempting to visualize. The nursing supervisor was made aware and removed the entire Q-tip which had been embedded in Resident #60's nostril. A change in condition provider note dated 7/22/2024 at 7:51 PM identified the facility's Advanced Practice Registered Nurse had been updated on the Q-tip being stuck in Resident #60's nostril and directed facility staff to send Resident #60 to the Emergency Department (ED)for Q-tip removal. A nursing note dated 7/23/2024 at 5:16 AM identified a call was received from the ED medical doctor to inform the facility a Computed Tomography scan (CT) of Resident #60 did not identify any foreign body within his/her nose and the maxillofacial area was clear of any foreign body. The NA Resident Care Card (directs NA care) dated 5/14/2025 identified Resident #60 was totally dependent on staff for oral care and dressing. An interview with Resident #60 on 5/16/2025 at 10:33 AM identified that staff were using a Q-Tip in his/her nose when the Q-tip became stuck. Resident #60 further identified a nurse removed the Q-tip with a long pair of tweezers and then sent him/her to the hospital. An interview on 5/16/2025 at 10:48 AM with Licensed Practical Nurse (LPN) #3 identified that when an object was placed in Resident #60's hands, he/she could bring it to his/her face, but he/she did not have the ability to independently grasp an object. Further, LPN #3 identified on 7/21/2024 Resident #60 notified her that a Q-tip had been stuck in his/her nostril. LPN #3 stated she notified the nursing supervisor (RN #4), and he removed the Q-tip with a large pair of tweezers. She was unable to explain why Resident #60 was sent to the hospital to have the Q-tip removed per APRN orders if the Q-tip was already removed. An interview and review of clinical records on 5/19/2025 at 8:39 AM with Physical Therapist (PT) #2 and Occupational Therapist (OT) #1 identified around and on the date of 7/21/2024, Resident #60 did not have the ability to independently grasp an object and bring it towards his/her face or bring his/her arm to his/her head to itch their nose or scratch their head due to quadriplegia. PT #2 further stated that during a formal evaluation on Resident #60's upper extremity range of motion in March of 2023, Resident #60 was found to have no active range of motion. An interview with the Medical Director on 5/19/2025 at 11:24 AM identified that sending Resident #60 to the Emergency Department for removal of the Q-tip would have been the correct action to take. Further, he indicated that the facility should not have independently removed the lodged Q-tip as harm could have occurred if there was another object at the end of the Q-tip, there was bleeding, and there was the possibility of infection. The Medical Director stated that if there was an order to send Resident #60 to the hospital, he/she should have immediately been sent to the hospital. An interview with the Director of Nursing Service (DNS) on 5/19/2025 at 12:19 PM identified it was not within the nurse's scope of practice to remove a Q-tip with tweezers when the Q-tip was lodged up Resident #60's nostril and could not be visualized. The DNS could not explain why the nursing supervisor removed the Q-tip himself when there was an order to transport the resident to the hospital for removal. Further, the DNS stated the facility did not fill out an accident or reportable incident form for the incident because Resident #60 was not injured. Attempts to contact the nursing supervisor (RN #4) for interview were unsuccessful. Review of the facility's Accident and Incident policy identified, in part, that it is the responsibility of staff to report incidents and accidents that occur at the facility. Occurrences are to be investigated in a timely manner and preventative measures are to be initiated. 3. Resident #93 was admitted to the facility in April of 2025 with diagnoses that included hypertension, generalized body weakness and dementia. The Nursing admission assessment dated [DATE] identified Resident #93 was alert but confused and required maximum assistance for personal hygiene, toileting hygiene, and transfers. The Resident Care Plan (RCP) dated 4/29/2025, identified Resident #93 with a functional mobility limitation related to dementia and weakness. Interventions included staff assistance with transfers and bed mobility. The RCP failed to indicate side rail use. A Reportable Event form dated 4/30/25 at 6:25 AM written by RN #7, identified that NA #6 reported to RN #7 that she was doing her safety rounds, and witnessed Resident #93's right hand get caught in the side rail which resulted in an injury/skin tear measuring 5.0 centimeters (cm) by 5.0 cm on the back of his/her right hand. RN #7 indicated that the APRN was notified, and treatment was started according to the APRN order. A nurse's note dated 4/30/2025 at 4:35 AM written by RN #7 identified NA #6 had reported to her that she had witnessed Resident #93's right hand get caught in the side rail resulting in a skin tear measuring 5.0 centimeters (cm) by 5.0 cm on the back of his/her right hand. RN #7 indicated that Resident #93 was alert but confused and was not able to explain what had happened. RN #7 assessed Resident #93's right hand, the APRN was notified, and treatment was started according to the APRN order. Attempts to interview NA #6 were unsuccessful. Interview with RN #7 on 5/19/2025 at 10:15 AM, identified that she was notified by NA #6 that Resident #93's right hand had been caught in the side rail, and he/she had sustained a skin tear. RN #7 indicated that she immediately went to assess Resident #93 and identified that 2 half side rails were in use. RN #7 identified that Resident #93 seemed confused and was constantly moving in bed and she was afraid that Resident #93 may roll out of bed and therefore side rails were being used for safety and to assist with mobility. RN #7 could not identify if a side rail assessment had been performed on admission or prior to the side rail use, but stated that a side rail assessment was required per the facility policy, prior to side rail use to ensure side rail safety. Interview and clinical record with the DNS on 5/19/2025 at 11:00 AM, failed to identify a side rail assessment had been completed. The DNS indicated that it was the facility protocol to conduct a side rail assessment prior to side rail use. The DNS could not explain why a side rail assessment had not been completed for Resident #93. Review of facility policy titled, Side Rail Policy, identified, in part, that upon admission, re-admission, significant change, a change in mobility and as needed, the resident will be evaluated for partial side rails to assist with bed mobility. A licensed nurse shall do the initial evaluation which will include observation of the resident's movement in bed and the resident's use of partial side rail to assist with turning and repositioning. The facility shall obtain informed consent from the resident or the resident's representative for the use of side rail and use of side rails will be documented within the resident plan of care.

Based on clinical record review, review of facility policy, and interviews for 1 of 2 residents, (Resident #95), reviewed for nutrition, the facility failed to obtain daily weights for a resident with Congestive Heart Failure (CHF) per the physician's order. The findings include: Resident #95 was admitted to the facility in July of 2024 with diagnoses that included hypertension, Congestive Heart Failure (CHF), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #95 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, and required maximum assistance for toileting, personal hygiene, bed mobility, and transfers. A Resident Care Plan (RCP) in effect for the month of December 2024 identified Resident #95 with a potential for altered cardiac status related to CHF and hypertension. Interventions included monitoring changes in lung sounds on auscultation (i.e. crackles) and evaluating respiratory status for signs of shortness of breath, dyspnea (shortness of breath) on exertion, fatigue, anxiety, cyanosis and monitor weights for weight changes. A physician order dated 12/10/2024 directed to weight Resident #95 every day on the day shift for CHF (monitoring) and notify the physician for a weight gain or loss of 2.5 pounds (Lbs.) in a day (24 hours) or 5 Lbs. in a week. A physician order dated 4/18/2025 directed to administer Torsemide (a diuretic) 20 milligrams (mg) by mouth one time a day for CHF. Further review of Resident #95's clinical record and weights identified that for the month of December; Resident #95 was weighed 8 days out of 22 opportunities; for the month of January 2025 Resident #95 was weighed 7 days out of 31 opportunities; for the month of February 2025, Resident #95 was weighed 2 days out of 28 opportunities; for the month of March 2025, Resident #95 was weighed 6 days out of 30 opportunities, and for the month of April 2025, Resident #95 was weighed 14 days out of 30 opportunities. Further review of the clinical record failed to identify documented weight refusals. Review of APRN #1's progress note dated 4/29/2025 at 9:30 AM identified that Resident #95 had a significant history of CHF and had been off diuretics for quite some time due to weight loss. APRN #1 further identified that Resident #95 had recently experienced episodes of respiratory failure with hypoxia and a chest x-ray revealed pulmonary congestion. APRN #1 indicated that Resident #95 was restarted on torsemide, and his/her breathing and oxygen saturations improved. Interview and clinical record review with RN #2 on 5/14/2025 at 1:35 PM, identified that Nurse Aides (NA's) weigh residents and the nurse enters the weight in Electronic Medical Record (EMR). RN#2 identified that Resident #95's physician's order for daily weights was current and therefore he/she should have been weighed daily as directed and weights documented in the EMR. RN #2 indicated that any weight refusals should also be documented in the clinical record. RN #2 could not explain why Resident #95 was not weighed as directed by the physician. Interview with APRN #1 on 5/14/2025 at 2:30 PM identified that Resident #95's order for daily weights was due to CHF. APRN #1 indicated that Resident #95 should have been weighed daily as directed in the orders. APRN #1 indicated that even though Resident #95 was not being weighed daily as directed, he was assessing him/her often and had not identified significant changes. Interview and clinical record with the DNS on, 5/19/2025 at 11:00 AM, identified Resident #95 should have been weighed as directed by the physician and any refusals documented in the clinical record. The DNS was unable to explain why Resident #95 was not weighed daily as directed by the physician. Although requested, a CHF policy was not provided. Review of facility policy titled, Weights Policy and Procedure, identified in part, that, each resident will be weighed upon admission, readmission, monthly or significant change in condition. Significant weight changes will have verification of weight measurement for accuracy and documentation purpose .If a resident refuses to be weighed or circumstances prevent weighing the resident, the IDT will document reason in the resident's medical record and care plan and attempt to weigh resident another time done.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #66) reviewed for hydration, the facility failed to ensure the correct intravenous solution was administered per the physician's order. The findings include: Resident #66's diagnoses included dementia, acute kidney failure, and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and was independent with eating and bed mobility, required supervision with transfers, and once standing could ambulate 150 feet independently. The Resident Care Plan dated 5/1/2025 identified Resident #66 was at risk for dehydration secondary to infection and poor PO (by mouth) intake. Interventions included peripheral IV fluids, staff were directed to administer IV medications per MD order, and to monitor signs and symptoms of dehydration. APRN #1's provider order dated 5/7/2025 directed staff to administer Sodium Chloride (NS) solution 0.45 %, intravenously, every hour set at 75 milliliters per hour (ml/hr.) for 2 days, due to tachycardia (rapid heart rate). The order was cancelled on 5/7/2025 at 7:05 PM. Review of APRN #1's order dated 5/7/2025 (after receiving laboratory values) directed staff to change the IV administration to Dextrose intravenous solution 5% (dextrose), use 65 ml/hr. intravenously every hour for tachycardia/hypernatremia (high sodium) for 2 days. Review of the Facility Reported Incident (FRI) event dated 5/8/2025 at 10:15 AM, identified LPN #8 had administered D5½ NS to a resident with a high sodium level instead of D5W after the APRN changed the order to D5W. The RN assessed Resident #66 who was noted to be lethargic and tachycardic, and it was then identified the wrong IV fluids had been infused. APRN #1 was notified, assessed Resident #66, and directed him/her to be transferred to the Emergency Department for evaluation. Review of hospital ED record dated 5/8/2025 identified Resident had hypernatremia with altered mental status and tachycardia on admission. Interview with LPN #7 on 5/15/2025 at 6:27 AM identified she worked on the 11:00 PM to 7:00 AM shift that began on 5/7/2025 and took over care from LPN #8 who had worked on the 3:00 PM to 11:00 PM shift on 5/7/2025. She indicated that the incorrect IV solution was hung during the LPN #8's shift and that LPN #8 verbally informed her D5W (the correct solution) was being administered to Resident #66. She stated that per protocol, both nurses were supposed to verify IV solutions together during shift change, but she was late for work that day, and LPN #8 had to leave, so only a verbal report was given. LPN #7 reported that during her initial rounding, she checked the IV site but not the fluid being administered. She also stated she did not take vital signs upon assuming care. At 6:00 AM, during rounds, LPN #7 reported that although Resident #66 vital signs were normal, she identified that Resident #66 was lethargic and not interacting as he/she normally did. LPN #7 reported her findings to the on-coming nurse but never identified that the incorrect IV solution was running into Resident #66 during her shift. Interview with RN #4 on 5/15/2025 at 7:16 AM identified that he was the nursing supervisor on the 3rd shift with LPN #7, on 5/7/2025 into 5/8/2025 when the wrong IV solution was being administered to Resident #66. RN #4 explained that per the facility policy, facility staff should have verified that the IV fluid being administered correctly matched the APRN order. RN #4 stated nurses should have followed the 5 rights of medication administration (right patient, time, route, medication, and dose). RN #4 indicated although he could not recall the medication error, as the supervisor, he should have gone into Resident #66's room and verified the IV solution correctly matched the APRN order. Interview and review of the clinical record with RN #2 on 5/15/2025 at 8:55 AM identified she was the supervising nurse on for 1st shift on 5/7/2025. Although a review of APRN #1's order indicated that Sodium Chloride ½ normal saline was the originally ordered solution, she had provided a bag of D5W ½ NS for LPN #8 instructing him to wait until she heard from the provider to run any IV fluids for Resident #66. RN #2 indicated that the APRN subsequently called and changed the order to D5W, but the facility did not have that solution in stock. RN #2 indicated she felt LPN #8 must have administered what was available, but should have called the APRN, and not substituted D5W ½ NS for D5W without a new APRN order. RN #2 did not indicate who was responsible (LPN #8 or RN #2) to call the provider for a new order, or what action she had taken when the correct solution was not available, stating only that she told LPN #8 to wait until the correct solution was delivered from the pharmacy. Additionally, at approximately 10:00 PM, she indicated, while passing Resident #66's room, prior to leaving the shift, she noted Resident #66 had an IV running but failed to check to see if the correct solution was being administered to Resident #66. Interview and review of the clinical record with LPN #8 on 5/18/2025 at 6:42 PM identified he had verified with RN #2 that he was administering the correct IV solution, showing her the bag of solution originally provided by her (D5 ½ NS). After confirming he had the correct solution with RN #2, at approximately 6:00 PM, he had begun administering D5 ½ NS, the incorrect solution, and not the APRN ordered solution of D5W. He further stated that he had done so after seeing D5 on the bag, believing it was the correct solution ordered for Resident #66. Interview with the Director of Nursing Services (DNS) on 5/19/2025 at 11:08 AM identified LPN #8 administered the wrong IV solution and that the next shift nurse, LPN #7, failed to check that the correct solution had been hung by LPN #8. The DNS stated that policy required IV sites to be monitored every two hours. He could not explain why the incorrect fluid was administered to Resident #66 or why the oncoming nurse failed to recognize the incorrect IV fluid being administered. The DNS stated the expectation was for the nurse to assess Resident #66 and to verify the correct IV fluids were being administered. Interview and clinical record review with APRN #1 on 5/19/2025 at 1:38 PM identified he assessed Resident #66 on 5/7/2025, noted poor intake, elevated sodium, and tachycardia with a normal [NAME] Blood Cell count (high WBC could indicate infection). APRN #1 indicated that Sodium Chloride ½ NS was ordered approximately at 5:00 PM indicating D5W ½ NS had never been ordered. APRN #1 further stated after receiving a high laboratory value of sodium, he changed Resident #66's order to D5W at approximately 8:00 PM. APRN #1 indicated that on 5/8/2025 at 10:15 AM he assessed the resident due to an altered mental status, thought that Resident #66 may have been septic, and subsequently sent Resident #66 to the emergency room for evaluation. Although APRN #1 noted that sodium levels increased from 152 to 158, he did not believe that administering the wrong IV fluids (containing sodium) caused the change in condition for Resident #66 and that he would not be concerned until the sodium level had reached 160. Interview with Pharmacist #1 on 5/19/2025 at 4:00 PM identified that while administering D5W ½ NS to a hypernatremic resident would not be helpful, it would have been difficult to say the error caused Resident #66 to further decline. She noted the sodium increase was unlikely caused solely by the IV fluids, as less than a liter was administered. Pharmacist #1 stated, Resident #66 was febrile and in metabolic overload, which could have contributed to the lethargy. Review of the Hydration policy dated 9/2024 directed, in part, staff follow MD orders for fluid intake, IV fluids, and lab values. Review of the Continuous medication Administration Policy dated 1/2022 directed, in part, the licensed nurse will evaluate the venous access site every 2 hours.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #90) reviewed for hemolytic treatment, the facility failed to follow a fluid restriction for a resident on hemolytic treatment. The findings include: Resident #90 was admitted to the facility in April of 2025 with diagnoses that included end stage renal disease, dependence on renal hemolytic treatment, congestive heart failure (CHF) and anemia. The admission Minimum Data Set assessment dated [DATE] identified Resident #90 had a Brief Interview for Mental Status (BIMS) score 14 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene and bed mobility, was dependent on toileting and transfers and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for April and May 2025 identified Resident #90 was on hemolytic treatment due to end stage renal failure. Interventions included checking and changing the dressing daily at the access site and documenting, entering pre and post weights from the hemolytic center into Resident #90's electronic health record. A physician's order dated 4/7/2025 directed to observe the right chest access port for signs and symptoms of infection: redness, swelling, drainage and pain every shift. Access port for hemolytic treatment is located at the right chest. An APRN's note dated 4/21/2025 at 11:45AM identified that Resident #90 was seen today for evaluation of hemolytic treatment associated hypotension. The note further identified that Resident #90 had been seen today by a nephrologist and a consultation was issued. Per the nephrologist Resident #90 has been having periods of hypotension during his/her hemolytic treatment sessions and a recommendation was made to decrease Resident #90's fluid restriction to 1000cc daily to help address the issue. A review of physician's order dated 4/21/2025 directed hemolytic treatment 3 times per week on Tuesday, Thursday, and Saturday and to maintain a fluid restriction of 1000 cubic centimeters (cc) in 24 hours. Dietary would provide a total of 540 cc giving 180cc (6oz) per meal, nursing would provide 150 cc per shift for medication administration/free water every shift. A review of Resident #90's clinical records from admission in April through 5/14/2025 nurses notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) from 4/21/2025 to 5/14/2025 failed to identify daily documentation and/or a tally of fluid intake consumed by Resident #90 in a 24-hour period since the physician order directing the fluid restriction was obtained. An APRN's note dated 4/25/2025 at 11:00 AM, identified that Resident #90 was seen today for the evaluation of respiratory failure as requested by the nursing supervisor. The note indicated that Resident #90 had been sent out to the emergency room (ER) the previous evening for the evaluation of shortness of breath, pleural effusion, and possible pneumonia. The note identified that Resident #90 was evaluated in the ER and subsequently sent back to the facility. The APRN indicated that Resident #90 was new to hemolytic treatment, had been gaining weight and showing signs of fluid overload, and a fluid restriction of 1000cc daily had been recommended by his/her nephrologist. Interview with NA #5 on 5/14/2025 at 1:00 PM identified that maintaining fluid intake was not part of NA's assignment/responsibility but was part of licensed nurses' responsibility. An interview with RN #2 on 5/14/2025 at 1:10 PM identified that both nursing assistants and nurses were responsible for maintaining Resident #90's fluid intake. RN #2 was unable to explain why the physician ordered fluid intake was not maintained for Resident #90 since he/she had an order for a 1000 cc fluid restriction within every 24 hour time frame since 4/21/2025. Interview and clinical record review with LPN #6 on 5/14/2025 at 1:17 PM identified that the fluid restriction order was not visible in the MAR where nurses would be directed to maintain the fluid restriction and document fluid amounts consumed by Resident #90 on each shift. LPN #6 identified that the order was not placed right, and subsequent to surveyor inquiry, she would activate the order to be visible on the MAR. LPN#6 indicated that the nurse who acknowledged the order was responsible to ensure the order was visible on the MAR. Interview with the DNS on 5/14/2025 at 2:30 PM, identified that although there was a physician's order directing a 1000 cc fluid restriction, the dietician had mapped the amount of fluid to be served with meals and therefore it was not necessary or a requirement that fluid intake amounts be maintained. The DNS indicated that the facility has other ways of assessing residents for fluid overload including a physician's assessment and obtaining labs. The DNS did not explain how the facility was able to track the entire amount of fluid taken in by Resident #90 in a 24 hour period. Interview with the hemolytic treatment nurse (RN#5) on 5/16/2025 identified that a 1000 cc fluid restriction was recommended by resident #90's nephrologist since resident #90 was not tolerating hemolytic treatments due to experiencing hypotensive episodes during treatment hindering excess fluid extraction and effectiveness of the treatment. Interview with Resident #90 on 5/16/2025 at 9:30AM identified that he/she was not aware that he/she was on fluid restriction until 2 days ago. Resident #90 identified that he/she consumes both food/fluids from home and from the facility. Resident #90 indicated that she does not keep track of her fluid intake. Interview on 5/19/20255 at 11:30 AM with the Dietician identified that she placed Resident #90's 1000 cc fluid restriction per 24-hour order after she was instructed by the hemolytic treatment center dietician and per Resident #90's nephrologists' recommendation. The Dietician further identified that Resident #90 had experienced weight gain and was not tolerating hemolytic treatment as expected due hypotensive episodes during hemolytic treatment. The Dietician identified it was a standard practice and expectation that nursing staff would maintain fluid intake records for a resident who was on fluid restriction. The Dietician further identified that she had mapped out the fluid amount to be given with each meal as a guide for staff. The Dietician indicated that she could have forgotten to activate the order to appear on the MAR so that nursing staff would have been alerted to the 1000 cc fluid restriction and to enter the total amounts on the MAR. Review of the Intake and Output Policy identified, in part, that nursing personnel are responsible for documenting fluid intake and/or output totals in the POC section of PCC. The NA is responsible for documenting the totals with meals and fluid taken with meals and those fluid taken in between meals that have been provided by the NA. The nurse is responsible for documenting fluid given to the resident including supplements and those given with medication pass etc. etc. The nurse will assess the total intake to determine if the resident is meeting fluid goals. Although requested, the fluid restriction policy and hemolytic treatment policies were not provided.

Based on clinical record review, review of facility policy, and interviews for 1 of 5 sampled residents (Resident #46) reviewed for medication administration, the facility to ensure medications that had been dispensed and were going to be administered were safely stored. The findings include: Resident #46 was admitted to the facility in July of 2024 with diagnoses that included hypertension, congestive heart failure (CHF), and diabetes. The annual Minimum Data Set (MDS) assessment dated MDS 5/2/2025 identified Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, and was independent for eating, required moderate assistance with personal hygiene, and maximum assistance for toileting transfers. A Resident Care Plan in effect for the month of May of 2025 identified Resident #46 with Potential for altered cardiac status related to CHF and hypertension. Interventions included monitoring changes in lung sounds on auscultation (i.e. crackles), evaluating respiratory status: signs of dyspnea (shortness of breath), dyspnea on exertion, fatigue, anxiety, cyanosis and monitoring weight and/or weight changes. Interview and observation with Resident #46 on 5/13/2025 at 10:02 AM identified he/she had medications (5 pills in a medication cup) at the bedside table. Resident #46 indicated that LPN #7 had left the medications this morning, at the bedside, for self-administration. Interview and observation with LPN #7 on 5/13/2025 at 10:10 AM identified 5 pills in a medication cup on Resident #46's bedside table. LPN #7 identified that she had left Resident #46's room before the administered the medications. LPN #7 indicated that per the facility policy, she should have ensured that Resident #46 took all his/her pills before leaving the room because he/she had not been assessed or approved to self-administer medications. LPN #7 identified the physician ordered pills in the medication cup as 1 pill of trazodone 25 mg, 1 pill of Carvedilol 6.25mg, 1 pill of Ativan 0.5mg, and 2 pills of Torsemide 20 mg. Interview and record review with DNS at on 5/13/2025 3:30 PM failed to identify Resident #46's completed self-administration assessment/evaluation for medication administration. The DNS identified that LPN #7 should not have left Resident #46's medications on bedside table for self-administration. The DNS indicated that he would re-educate staff. Review of facility policy titled, Medication Pass Policy, identified in part, that, medications are administered safely and timely per the physician's orders .always observe the resident until they have swallowed all medications that have been administered. Do not leave medications in medication cup at the bedside or on tableside.

Based on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents, (Resident #96), reviewed for pressure ulcers, the facility failed to identify and complete a significant change Minimum Data Set (MDS) assessment for a resident with a decline in status. The findings include: Resident #96 's diagnoses included severe protein calorie malnutrition, vascular dementia, and difficulty walking. The quarterly Minimum Data Set assessment (MDS) assessment dated [DATE] identified Resident #96 had a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment, and required supervision with bed mobility, supervision with transfers, and supervision ambulating. Additionally, Resident #96 and was at risk for skin breakdown but had no current pressure areas. Review of the Physical Therapy Discharge summary dated [DATE] through 3/18/2025 identified Resident #96 required partial/moderate assistance with bed mobility, required partial moderate assistance with transfers, and required partial moderate assistance to ambulate 10 feet. (A decline in 3 areas for the level of assistance required for bed mobility, transfers, and ambulation was noted from the MDS assessment dated [DATE] through the Physical Therapy Discharge Summary date of 3/18/2025.) The Resident Care Plan (RCP) dated 4/22/2025 identified Resident #96 had an Activities of Daily Living (ADL) self-care performance deficit. Interventions included limited assistance of 1 staff to turn and reposition in bed, limited assistance of 1 staff to transfer between surfaces, and extensive assistance of 1 staff for ambulation. Although the RCP had been updated to reflect the significant change in status, a significant change MDS assessment was not completed. An Advanced Practice Nurse Practitioner (APRN) note dated 5/9/2025 at 12:40 PM identified Resident #96 with a recent decline in function, staying in bed, less interactive, with a new pressure ulcer. Interview and record review with the Director of Nursing (DNS) on 5/18/2025 at 11:06 AM identified he had not been made aware of Resident #96 significant decline in his/her abilities when the decline had occurred in March. Following notification of Resident 96's new pressure ulcer development on 5/6/2025 he was also notified of the residents decline in the areas of bed mobility, transfers, and ambulation. Interview with the Minimum Data Set (MDS) Coordinator on 5/18/2025 at 11:16 AM, identified that she had not identified the significant change in condition until after she had met with rehabilitation on 5/18/2025 following the development of Resident #96's pressure ulcers. The MDS Coordinator identified that the significant change assessment should have been completed within 14 days of the decline, and that it had been an oversite on her part. Review of the Resident Assessment Instrument Manual, Significant Change in Status Assessment (SCSA dated October 2023 directed, in part, the SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline and impacts more than one area of a resident's health. The significant change assessment will be completed within 14 days of the decline.

Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident, (Resident #22), reviewed for Resident Assessment and for 1 of 2 sampled residents, (Resident #102), reviewed for Activities of Daily Living the facility failed to accurately code the Minimum Data Set (MDS) assessment. The findings include: 1.Resident #22 's diagnoses included schizophrenia, encephalopathy and morbid obesity. Review of the clinical record identified Resident #22 had a level II PASRR outcome document on file. Review of the admission MDS assessment dated [DATE] identified that Resident #22 was positive for a PASRR level II assessment. Review of the annual MDS assessment dated [DATE] identified that Resident #22 was coded as no, indicating that there was no level II PASRR (a change from the 6/26/2024 assessment). Interview with the Director of Social Work on 5/15/2025 at 11:09 AM identified that the MDS dated [DATE] should have had the same coding as the MDS dated [DATE]. The Director of Social Work was unable to indicate why the MDS was miscoded, but that a correction could be submitted and she would discuss this with the MDS Coordinator. Review of the Resident Assessment Instrument Manual dated 10/2023 directed, in part, to review the PASRR report provided by the state. If a level II screening was required, code the MDS as yes. 2. Resident #102's diagnoses included malignant neoplasm of left breast, moderate protein calorie malnutrition, and dysphagia (trouble swallowing). The annual Minimum Data Set assessment dated [DATE] identified Resident #102 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment and was independent with eating. The Resident Care Plan in effect on 3/2025 identified Resident #102 had an Activity of Daily Living (ADL) self-care deficit with interventions that included both set up assistance for eating and extensive assistance for eating. The Documentation Survey Reports [Nurse Aid (NA) flow sheets] dated 3/2025, and 4/2025 identified Resident #22 was totally dependent on staff for eating (not independent). Observations on 5/14/2025 at 12:55 PM and 5/16/25 at 12:54 PM identified Resident #102 was being fed lunch by NA #4 and was totally dependent on staff for eating. The Nurse Aide Kardex (NA Care Card) dated 5/16/2025 identified Resident #22 required extensive assistance of 1 staff to eat, required set-up assistance by 1 staff to eat, to provide feeding/dining assistance as needed, and provide adaptive equipment (for self-feeding) including a lip plate, weighted utensils, and a 2 handled cup for all meals. Interview and clinical record review of the MDS assessment, the Resident Care Plan, and NA flow sheet documentation with Director of Nursing Services on 5/16/2025 at 1:18 PM identified there was conflicting documentation for self-feeding, set up assistance prior to self-feeding, self-feeding with adaptive equipment, and feeding with staff assistance. The DNS was unable to explain why the MDS assessment was coded incorrectly, adding he would place a therapy request in for Resident #102 to be evaluated to determine how much assistance Resident #22 required to eat. Review of the Resident Assessment Instrument Manual dated 10/2023 directed, in part, to code the MDS with the intent to assess the ability of a resident to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.

Based on observations, facility policy, and interview during a tour of the facility, the facility failed to maintain a clean and sanitary environment and an environment free of pests. The findings include: Observations on 5/14/2025 at 10:55 AM through 5/14/2025 at 11:25 AM identified the following: 1. On the A Wing, dirty trays were noted on the counter and fruit flies were noted in Resident #102's room. 2. On the C Wing the carpets were noted to be brown and stained yellow, and brown, and red in front of the nurse's station. Interview and observation with the Housekeeping Supervisor on 5/14/2025 at 11:24 AM identified although the pest control provider had been in the building to treat fruit flies in another resident's room, there were still fruit flies in Resident 102's room. The Housekeeping Supervisor indicated that although spot and steam cleaning of the carpet had been completed last week, carpet stains were still present. The Housekeeping Supervisor was unable to provide any documentation that carpet cleaning had been performed the previous week. Further, the Housekeeping Supervisor indicated that the facility had received a quote for replacement of the carpet. The Housekeeping Supervisor indicated that the quote would be provided to the surveyor. Although requested, a facility quote for carpet replacement was not provided. Review of the carpet spot cleaning policy directed, in part, check carpet for spots daily. Remove soil and moisture from spotted area, for dry spot vacuum to remove loose soil, for wet spot blot with clean white absorbent cloth, liberally spray carpet spot remover to area being cleaned. Review of carpet wet extracting and interim cleaning policies directed, in part, carpet wet extraction is done semiannually April and December, and to follow procedures for interim cleaning, and a cleaning schedule Sunday through Saturday for select areas and perform machine weekly maintenance.

Based on review of the clinical record, facility policy, and interviews for 2 of 7 sampled residents (Resident #45 and Resident #60) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the accuracy of a Level 1 PASRR and failed to subsequently submit for a Level 2 PASRR evaluation with an inaccuracy or a change in diagnosis. The findings include: 1. Resident #45 was admitted to the facility in 5/2018 with diagnoses that included anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, experienced feeling down, depressed or hopeless half or more than half the days in a 2 week time period and failed to be coded to indicate that a level II PASRR evaluation had been completed. The Resident Care Plan (RCP) dated 3/24/2025 identified Resident #45 required monitoring for psychotropic medications, used antidepressant medication, had a problem with his/her mood, and had both anxiety and a history of suicidal ideation. Interventions included administering medications as ordered, intervene as necessary, approach/speak in a calm manner, and provide behavioral health consults as needed. The RCP failed to include any information related to PASRR. Review of the clinical record PASRR information identified a level 1 PASRR completed on 8/17/2020 by the facility and listed the diagnosis of major depressive disorder, and post-traumatic stress disorder (PTSD). The Level 1 PASRR indicated that the resident had no history of suicidal talk and failed to identify Resident #45's history of suicidal ideation and history of two prior psychiatric hospitalizations. The PASRR level I outcome identified no referral to a level 2 PASRR was needed because the level 1 PASRR was negative. Further, the PASRR level I indicated, in part, a new screen must be submitted should a change occur. Subsequent to the Level 1 PASRR submission on 8/17/2020, Resident #45 was diagnosed with anxiety, with a documented onset date of 4/5/2024. The facility failed to submit a new PASRR with a change of condition for the diagnosis of anxiety and for evaluation of the need for a Level 2 PASRR. 2. Resident #60 was admitted to the facility on [DATE] with a diagnosis of anxiety, dependent personality disorder, major depressive disorder, and bipolar disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, and experienced feeling down, depressed or hopeless half or more than half the days in a 2 week time period, and had diagnoses that included dependent personality disorder, anxiety, major depressive disorder, and bipolar disorder. The MDS did not indicate a level II PASRR assessment was competed. The Resident Care Plan (RCP) dated 4/29/2025 identified Resident #60 required monitoring for psychotropic medications, and had a mood problem related to bipolar disorder, major depressive disorder, anxiety, dependent personality disorder, and insomnia. Interventions included administering medications as ordered, provide behavioral health consults as needed, and monitor/record/report mood patterns of depression, anxiety, and sad mood to the physician. The RCP failed to include any information related to PASRR. A Level 1 PASRR completed on 10/12/2017 by the facility listed the diagnosis of anxiety and did not include the diagnoses of dependent personality disorder, major depressive disorder, and bipolar disorder. The outcome for the Level 1 PASRR indicated that Resident #60 was coming to the facility from out of state, had a diagnosis of schizoaffective disorder, and no referral for a level 2 PASRR was needed as the level 1 was negative due to insufficient evidence of a major mental illness. The PASRR outcome further directed in part, should there be a discrepancy in the reported information, a status change should be submitted to the PASRR vendor for further evaluation. The facility failed to review Resident #60's Level 1 PASRR for accuracy, failed to include all of Resident #60's mental illness diagnoses, and failed to submit a status change for further evaluation with the appropriate mental health diagnoses to the PASRR vendor for a determination if a level II was required. Subsequent to the Level 1 PASRR submission on 10/12/2017, Resident #60 was diagnosed with unspecified dementia with an onset date of 4/5/2024. The facility failed to submit a PASRR re-evaluation for Resident #45 with a change of condition for the diagnosis of dementia. Interview and review of the clinical record with the Social Worker (SW) #1 on 5/15/2025 at 10:21 AM identified that for residents not admitted directly from the hospital, the facility completed the level 1 PASRR form themselves and it was checked for accuracy. SW #1 identified neither Resident #45's nor Resident #60's Level 1 PASRRs were coded correctly and was unable to explain why a new PASRR was not submitted for evaluation for a level II for reasons of either inaccurate information or a change in mental health diagnoses. She indicated she was not employed by the facility as the time that either of the resident's PASRR information was completed by the facility and that she would bring the inaccuracies to the team for further discussion. Interview and review of the clinical record on 5/15/2025 at 10:40 AM with the Administrator identified that PASRRs for residents were completed when a resident was admitted to the facility or if the resident had a change in level of condition. Further, she noted that neither Resident #45's nor Resident #60's level 1 PASRR contained accurate and complete medical diagnoses information, and she was going to direct SW #1 to submit an updated PASRR form to the PASRR vendor for further evaluation. Review of the RAI manual dated October 2023. directed, in part, to complete the PASRR question with an admission assessment, annual assessment, significant change in status assessment, significant correction to prior comprehensive assessment. Review the Level I PASRR form to determine whether a Level II PASRR was required. Review the PASRR report provided by the State if Level II screening was required and code according to the evaluation. Although requested, the facility did not have a policy for PASRR.

Based on clinical record reviews, reviews of facility documentation, facility policies, and interviews for three (3) sampled residents (Residents #1, #2, and #3) who were reviewed for misappropriation of funds, the facility failed to ensure funds from the residents' accounts were not withdrawn and misappropriated without the resident's knowledge or approval. The findings include: 1. Resident #1's diagnoses included schizophrenia and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation. The social worker note dated 4/4/25 at 1:00 PM identified Resident #1 reported that he/she went to the front desk on 4/4/25 to withdraw funds and was informed the balance was twenty-six (26) dollars. Resident #1 reported that he/she withdrew twenty dollars ($20) and his/her balance at that time should have been one hundred and sixty-six dollars and fifteen cents (166.15) and after the withdrawal it should have been one hundred and forty-six dollars and fifteen cents (144.15). The note identified Resident #1 reported that all other withdrawals he/she made were in the amount of fifty (50) dollars. The note identified the social worker reported the incident to the Administrator. The Facility Reported Incident form dated 4/4/25 identified Resident #1 went to take money out of his/her funds account and was upset when Resident #1 was informed there wasn't as much as he/she thought should be in the account. Resident #1 stated he/she takes fifty (50) dollars out at a time. Upon review of Resident #1's records there were four (4) withdrawals that were for amounts other than fifty (50) dollars. The summary report dated 4/9/24 identified an investigation found Resident #1 consistently withdrew money in the amount of fifty (50) dollar increments for each transactions and Resident #1 did not authorize any transactions or request any withdrawals for other amounts. The summary report indicated a review of the transaction log revealed four (4) withdrawals that deviated from the amounts Resident #1 would normally withdraw and Resident #1 denied making those withdrawals and indicated the signatures on those receipts were not Resident #1's. The summary report identified a receptionist whose signatures were present on those receipts and a comparison of the signatures revealed inconsistencies with Resident #1's signature. The summary report indicated that a former employee who had been terminated in January 2025, Receptionist #1, was observed on video at the front desk when Receptionist #1 had called out sick on a day when one (1) of the questionable transactions occurred. The report identified the questionable transactions were as follows: on 11/19/24 a withdrawal in the amount of forty-five (45) dollars was made, on 11/27/24 a withdrawal in the amount of thirty (30) dollars was made, on 12/16/24 a withdrawal in the amount of twenty-five (25) dollars was made, and on 12/19/24 a withdrawal in the amount of forty (40) dollars was made for a total of one hundred and forty (140) dollars. 2. Resident #2's diagnoses included schizophrenia, metabolic encephalopathy, and dementia. The quarterly Minimum Data Set, dated [DATE] identified Resident #2 had poor memory recall deficits. Review of the Facility Reported Incident form dated 4/11/25 identified as part of an ongoing audit of residents' personal funds, facility management identified several questionable transactions in Resident #2's account. The report indicated there were questionable transaction receipts that were handwritten facility receipts for food deliveries but there were no receipts from the restaurant to verify those transactions. The dates are as follows: on 1/31/24 a receipt was present for food in the amount of thirty (30) dollars, on 3/27/24 a receipt for food in the amount of twenty-five (25) dollars, on 6/13/24 a receipt for food in the amount of thirty (30) dollars, on 6/27/24 a receipt for food in the amount of twenty-six (26) dollars, and on 7/11/24 a receipt for food in the amount of thirty (30) dollars for a total amount of one hundred and forty-one (141) dollars. 3. Resident #3's diagnoses included depression, anxiety, and dementia. The quarterly Minimum Data Set, dated [DATE] identified Resident #3 had some memory recall deficits. Review of the facility Reportable Event Report summary dated 4/11/25 identified as part of an ongoing audit of residents' personal funds, it was revealed that there were inconsistencies in money withdrawals when compared to prior transaction records. The report indicated on 11/15/24 a withdrawal in the amount of thirty (30) dollars was made with a notation on the receipt that stated, for food, but there was no corresponding receipt from the food vendor. An interview with Receptionist #2 on 5/5/25 at 1:29 PM identified when a resident requests to withdraw funds from their account, the receptionist writes a receipt with the resident's information, has the resident sign the receipt and if the resident cannot sign the receipt, then a second signature is obtained from the management staff and then she signs the receipt as the person who distributes the funds. Receptionist #2 identified that she was not involved in the transactions in question for Resident's #1, #2 and #3. Interview with the Administrator on 5/5/25 at 1:36 PM identified the business manager reported to her that Resident #1 had a concern regarding a discrepancy in his/her balance of one hundred and forty (140) dollars. The Administrator identified the receipts for Resident #1 were pulled, Resident #1 stated that he/she only takes out fifty (50) dollars at a time and when reviewed, it was found that there were several transactions that were not for that amount. The Administrator identified an investigation was immediately initiated which included a review of the personal funds of all residents. The Administrator indicated the normal process for record keeping when a resident makes a withdrawal was the receptionist writes a receipt, the resident and the receptionist sign that receipt and it goes to the business office. The Administrator identified if the funds are for food or goods, and the receipt was to be kept with the copy of the handwritten receipt that goes to the business office. The Administrator identified she determined that a former employee, Receptionist #1, was responsible for the misappropriation of funds, initially for Resident #1 and then once an audit of all personal fund records was done, for Residents #2 and #3 as well. The Administrator identified facility policy on abuse directs misappropriation of any type is not tolerated and Receptionist #1 did not follow this policy. Review of the facility policy titled Abuse Policy and Procedures, revised date 12/23, directed, in part, it was the policy of the facility that each resident has the right to be free from misappropriation of resident property and exploitation. The policy further defined misappropriation as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, facility documentation, facility policy, and interviews for one (1) resident reviewed for suicidal ideation, (Resident #2), the facility failed to secure hazardous substances that resulted in a suicide attempt and subsequent death of Resident #2 resulting in a finding of Immediate Jeopardy, past non-compliance. The finding includes: Resident #2 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, depression, Alzheimer's dementia, and suicidal ideations (SI). A Psychological evaluation dated [DATE] identified Resident #2 had a recent history of a suicide attempt. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had severely impaired cognition, required one (1) staff assist for walking in the corridor, and had little interest or pleasure in doing things nearly every day and felt or appeared down, depressed, or hopeless half of the days of a two (2) week period. A care plan dated [DATE] identified Resident #2 had a psychosocial well-being problem related to Suicidal Ideation (SI) statements, with interventions that included depression screening and to monitor/document Resident #2's feelings. A nurse's note dated [DATE] at 9:25 AM identified Resident #2 reported to a Nurse Aide (NA) that he/she wanted to go to sleep and never wake up. Resident #2 stated that there was no plan, but he/she was not far from having a plan, one-to-one supervision was implemented and the psychiatry APRN was made aware. A Psychiatric evaluation dated [DATE] written by Advanced Practice Registered Nurse (APRN) #1 identified Resident #2 was making statements that he/she wanted to end his/her life. Resident #2 identified if he/she was given poison, he/she would take it, and if the remote was a gun, he/she would shoot him/herself in the head. Given Resident #2's history of suicide ideation, an Emergency Department (ED) evaluation was indicated for risk of self-harm. Hospital documentation dated [DATE] identified Resident #2 was sent to the ED for suicidal ideations and Resident #2 did not merit inpatient geriatric psychiatric admission as the resident was not a danger to self or others and recommended that he/she be returned to the facility. A Nurse's note dated [DATE] at 4:39 PM identified Resident #2 stated he/she did not want to live anymore, h/she did not have a plan, but would eventually, the resident was placed on one-to-one supervision until evaluated by psychiatric services. A Psychiatric evaluation written by APRN #1 dated [DATE] identified Resident #2 had a long history of making statements of wanting to kill him/herself. APRN #1 requested Resident #2 go to the hospital for evaluation of SI, however, by the time paramedics arrived, Resident #2 was in overall good mood and could not recall the statements he/she had made. It was appropriate for the facility to safely monitor Resident #2 and assess for persistence of suicidal thoughts rather than send Resident #2 out to the hospital each time he/she mentioned he/she wanted to die. A physician's order was written that directed if Resident #2 expressed SI with a plan, place Resident #2 on one-to-one supervision until evaluated by psychiatry. If Resident #2 expressed SI without a plan, nursing was to reassess in 30 minutes, and if Resident #2 continued to express SI with or without a plan, Resident #2 was to be placed on one-to-one supervision until seen by psychiatry. A nurse's note dated [DATE] at 1:56 AM written by Registered Nurse (RN) #1 identified that at approximately 1:00 AM Resident #2 ingested about 50 milliliters (ml) of Clorox bleach and had vomited large amount of abdominal contents. NA #1 who was assigned to Resident #2 reported Resident #2 was restless, she toileted and tucked him/her into bed, and when she thought Resident #2 had settled, she went to the charge nurse to request a medication to address Resident #2's restlessness. When she returned to the NA station, she observed Resident #2 had taken her personal Clorox cleaning solution and drank what was left in the bottle. An assessment was completed, the APRN was notified, 911 was called, and emergency medical services arrived at 1:15 AM. Review of hospital documentation dated [DATE] identified Resident #2 was admitted status post suicide a attempt with intentional ingestion of bleach, resulting in acute hypoxic respiratory failure and airway edema. Resident #2 had a worsening status, Resident #2's POA made the decision to transition to Comfort Measures Only (CMO). Interview with NA# 1 identified she worked ,d+[DATE]-[DATE] during the 11:00 PM to 7:00 AM shift and was assigned to Resident #2. She identified that she placed her personal belongings which included a bottle of Clorox cleaning solution with bleach and placed next to the computer at the unsecured NA workstation. Resident #2 was restless and had to be re-directed back to h/her room several times at the beginning of the shift. NA#1 stated that she had re-directed Resident #2 one final time back to his/her room, placed the resident into bed and then went to LPN #1 to see if Resident #2 had any as needed medications for restlessness. NA #1 stated that she returned to the unit at 12:55 AM and observed Resident #2 behind the NA station holding the Clorox bottle that was now empty, The resident stated I'm sorry, I hope I don't get you into any trouble . NA #1 stated that the bottle had previously contained approximately 50 milliliters of the bleach solution. Interview with LPN #1 on [DATE] at 3:08 PM identified she was the nurse who worked [DATE] during the 11:00 PM to 7:00 AM shift and identified around 12:55 PM NA #1 came to her and identified that Resident #2 needed a medication for restlessness, shortly thereafter NA# 3 came to her and stated that Resident #2 was vomiting. Upon entering Resident #2's room the resident was vomiting a clear yellow liquid that smelled of bleach, and NA #1 identified that Resident #2 had drank his/her cleaning solution, the supervisor was notified, and the resident was sent to the hospital. Interview with Assistant Director on Nurses (ADNS) (the interim Director of Nurses) on [DATE] at 10:45 AM identified that NA#1 should not have brought a hazardous substance into the building and left it unsecured. Interview with the Facility Administrator on [DATE] at 3:00 PM identified that the facility had been notified that Resident #2 had expired at the hospital on [DATE]. Immediately following the incident on [DATE], the facility educated staff to not bring in any form of chemicals, such a bleach, in the building at any time, and personal belongings are to be left in a locker located in the break room. Audits were initiated by the nursing supervisor every shift with direction to immediately secure personal belongings if observed. The action plan was verified as implemented during an onsite visit on [DATE], resulting in Immediate jeopardy, past non-compliance

Based on clinical record review, review of facility documentation and interview for 1 of 2 sampled residents (Resident #38) reviewed for hospitalization , the facility failed to ensure that the resident's care was comprehensive related to insulin administration and/or had interventions in place to maintain the resident's highest practicable wellbeing prior to an outpatient surgical procedure, and/or for 1 of 4 sampled residents observed for medication administration (Resident #38), the facility failed to administer medications as directed by the physician, and/or monitor blood pressures according to facility policy. The findings include: a. Resident #38's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] identified intact cognition, required extensive assistance with activities of daily living with the exceptions of eating and locomotion which the resident was identified as being independent, and received injections daily. The care plan dated 4/26/17 identified insulin dependent diabetes with interventions which included to monitor for signs and symptoms of [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. (This insulin is comprised of short and long acting insulin combined and according to the manufacturer's instructions the insulin should be administered either 15 minutes prior to a meal or within 15 minutes of starting a meal). A physician order [REDACTED].#38 was scheduled for a surgical procedure on 7/19/17 at 11:00AM with instructions to hold the [MEDICATION NAME] (anticoagulant), for 2 days prior to the appointment. A facility appointment form identified the resident was scheduled for an appointment on 7/19/17 for a biliary stent change and was given instructions for NPO (nothing by mouth) after midnight on 7/19/17. Review of the blood glucose flowsheet for 7/19/17 identified a blood sugar of 102 mg/dl (milligrams per deciliter) at 6:30 AM, (normal blood sugar is 70-100). A review of the Medication Administration Record [REDACTED]. The Medication Incident Report identified the [MEDICATION NAME]was administered at approximately 9:00 AM. Review of the MAR for 7/19/17 identified the [MEDICATION NAME] 70/30 insulin was signed off as administered, and then circled, however, there was no explanation identified on the back of the MAR indicated [REDACTED]. Further review of the Medication Incident Report identified while out of the facility for an outpatient surgical procedure, Resident #38 became lethargic, sweaty, and a blood sugar reading 19 mg/dl. Resident #38 was admitted to the hospital following the change in condition and was not able to have the scheduled surgical procedure. The hospital discharge summary dated 7/20/17 identified Resident #38 presented to the emergency room from an outpatient office due to an unresponsive episode. It further identified the resident was NPO (nothing by mouth) for the procedure but still received her/his normal dose of insulin. The resident was admitted to the hospital for 3 days from 7/19/17 to 7/21/17. The resident was then discharged and returned to the facility with [DIAGNOSES REDACTED]. A review of facility documentation identified Resident #38 reported he/she had been administered insulin on the morning of 7/19/17 at 9:00 AM. Further review of facility documentation identified LPN #5 initially identified to the Nursing Supervisor she administered the insulin but subsequent to the resident being admitted to the hospital, LPN# 5 denied administering the insulin. Interview with the DNS on 10/5/17 at 11:30 AM identified she did not have a policy for resident's on an NPO status and/or a protocol which addressed the coordination of resident care in preparation for outpatient surgical procedures. The DNS further identified it is the Nursing Supervisor's responsibility for the coordination of the residents' care. A review of the clinical record with the DNS at the time failed to identify instructions related to the administration of medications and insulin on the day of her/his scheduled outpatient procedure and/or that the physician was notified of the blood sugar reading was 102 mg/dl. The DNS further identified that her expectation would have been for the insulin to be held due to the resident's NPO status. According to the [MEDICATION NAME] Mix 70/30 manufacturer's instructions [MEDICATION NAME] Mix 70/30 starts acting fast. If you have type 1diabetes, inject within 15 minutes before you eat a meal. If you have type 2 diabetes, inject within 15 minutes before or after starting your meal. Your insulin dose may need to change because of illness, or change in diet or level of physical activity. b. Resident #38's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified intact cognition. The August 2017 care plan identified alteration in cardio-vascular status with interventions which directed to administer medications per MD order and monitor vital signs as per MD order. The physician's orders [REDACTED]. Observations on October 2, 2017 LPN #2 administered [MEDICATION NAME] 10mg at 9:00am. Review of the October 2017 MAR indicated [REDACTED]. The September 2017 MAR indicated [REDACTED]. Interview with LPN #2 on 10/3/17 at 9:30AM identified she administered the [MEDICATION NAME] two times on October 1 and 2, 2017 as documented by initials in the MAR. Interview with LPN #3 on 10/3/17 at 10:00AM identified the medication time for the daily dose of [MEDICATION NAME] was changed following the request of Resident# 38 to receive [MEDICATION NAME] in the afternoon. LPN # 3 identified the time of the [MEDICATION NAME] was changed on the MAR, however the 9:00AM times were not blacked out, just a line partly drawn through the 9:00AM and a 2:00PM was hand marked in the column for the administration time. LPN # 3 further identified that this was not following the policy for changing a medication time for a resident. LPN #3 identified the medication should have been marked off and rewritten on the MAR. Interview with the DNS on 10/4/17 at 7:30AM identified it is the responsibility of the licensed nurse to completely yellow out the medication and rewrite the entire medication order with the new time of administration per physician order. Furthermore the DNS identified medications are administered according to a standard schedule and special schedules for administering medications are specified by a physician. c. Review of the clinical record identified the most recent recorded blood pressure was documented on 9/1/17. The DNS identified the policy for monitoring residents on antihypertensive medications followed the pharmacy recommendations of weekly monitoring of blood pressures and it was the responsibility of the licensed staff to monitor blood pressures according to the facility policy/ pharmacy recommendations. Review of the facility blood pressure and pulse monitoring policy identified all residents receiving medications which are to affect blood pressure shall have blood pressures taken and recorded a minimum of once weekly for the duration of therapy. The above is a violation of the Regulations of Connecticut State Agencies Section 19-13-D8t (m) (2)(c).

Based on clinical record reviews, review of facility documentation and interviews and/or for two of three sampled residents (Resident #5 and #6) who required assistance with personal care, the facility failed to provide appropriate supervision to ensure the resident was properly positioned in the bed to prevent a fall out of the bed and/or failed to ensure the appropriate number of staff provided assistance and/or supportive braces were utilized during a transfer and/or that bathing equipment was inspected for proper function and/or for one of three sampled residents (Resident #4) who was at risk for elopement, the facility failed to ensure a wander guard device was functioning. The findings include: 1. Resident #5's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had some memory deficits, intact cognition, required total two person assistance with bed mobility, turning side to side, total one person assistance with personal hygiene and dressing, a weight of 256 pounds and no history of falls in the past ninety days. The resident care plan dated 11/13/16 identified the resident was at risk for an alteration in skin integrity. Interventions directed a pressure relieving mattress. The nurse aide care card directed a one person assistance with bed mobility. The nurse's note dated 12/18/16 at 1:00 PM identified as the resident was being positioned during care by the nurse aide, the resident's legs slid off of the mattress and the resident's weight carried him/her off of the mattress and onto his/her knees, with staff assist the resident was lowered onto his/her back on the floor. The nursing assessment identified Resident #5 complained of pain to the right knee, the Advanced Practice Registered Nurse (APRN) was notified and an x-ray of the right knee was ordered. The x-ray report dated 12/18/16 identified Resident #5 had sustained an impacted mildly displaced fracture through the right distal femoral metadiaphysis. A nurse's note dated 12/18/16 at 9:00 PM identified that the x-ray results showed a mildly displaced fracture of the right femoral metadiaphysis, the APRN was notified and the resident was sent to the emergency department. The Reportable Event dated 12/18/16 at 12:25 PM identified that the resident rolled out of bed during care onto his/her knees and complained of right knee pain. The investigation identified Resident #5's legs slid off the bed in the midst of turning over and because of the resident's weight the nurse aide was not able to pull the resident's legs back up on the bed. The report indicated the resident held onto the side rail and in slow motion slid off the bed to the ground. The report identified the bed was not in a low position but was up for care. Subsequent to the incident the care plan was revised and directed two person assistance with personal care. The hospital Inter-Agency Referral Report (W-10) dated 1/2/17 identified the resident was hospitalized from [DATE] through 1/2/17 with a [DIAGNOSES REDACTED]. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #2 on 4/24/17 at 2:30 PM identified that Resident #5 was an assist of one person with bed mobility, as per the care card. NA #2 stated the resident was helpful with turning and repositioning, was able to hold onto the side-rail and she did not have difficulty turning and repositioning with one assist in the past. NA #2 identified on 12/18/16 the resident was positioned too close to the edge of the bed and when she attempted to turn the resident to the other side of the bed and the resident's legs slide off of the bed, bring the resident to his/her knees on the floor. Interview with the former Director of Nursing on 4/20/17 at 12:00 PM identified that after the fall, the facility re-enacted the incident and determined Resident #5 had been positioned too close to the side of the bed causing the resident's legs to slide off of the bed when NA #2 turned the resident. Review of the in-service documentation dated 12/22/16 identified NA #2 was in-serviced on proper positioning of a resident in bed, and when to call for assistance. 2. Resident #6's [DIAGNOSES REDACTED]. The Resident Care Plan dated 10/9/15 identified that the resident was at risk for falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 had no memory or cognitive deficits, required extensive one person assistance with dressing, personal hygiene and transfers excluding to and/or from the bath and toilet, the resident's balance during surface transitions and walking was not steady and only able to stabilize with staff assistance, functional limitation in the range of motion that interfered with daily functions and placed the resident at risk was noted impairment of bilateral upper and lower extremities, and utilized a wheelchair and/or walker for mobility. The signed, monthly physician's order for December 2015 directed to transfer with a minimum of two (2) person assistance, ambulate assist of one (1) utilizing a rolling walker, bilateral Ankle Foot Orthosis (AFO) on feet to support flaccid drop foot, gait belt and with a wheelchair follow. The nurse's note dated 12/25/15 at 12:00 PM identified the 7AM-3PM Nursing Supervisor was called by the B-wing charge nurse to assess Resident #6 secondary to a fall. Upon arrival Resident #6 was observed lying on the floor in the B-wing shower room with the nurse aide standing along the resident. An assessment identified a bruise, ecchymotic area about 5 centimeters (cm) by 3 cm to the lower right lateral back, the resident complained of pain to the right elbow and right ribs. Resident #6 was Hoyer lifted off the floor with the assist of two (2) and returned to his/her room. Subsequent to physician notification, the Advanced Practice Registered nurse (APRN) directed that an x-ray of the right elbow and right ribs be obtained immediately to rule out fractures. The x-ray report dated 12/25/15 identified an impacted right humeral neck fracture and old fractures of the second and third ribs, no acute fracture at this time and the presence of osteopenia. The report identified the report was faxed to the facility on [DATE] at 3:35 PM. The nurse's note dated 12/25/15 at 7:30 PM identified the APRN was updated of the x-ray report that showed a positive right humeral fracture and the resident was transferred to the Emergency Department (ED) at 8:35 PM. The Reportable Event Form dated 12/25/15 at 11:15 AM identified that the resident was observed laying on the floor of the B-wing shower room. The investigation identified Resident #6 was being transferred from the shower chair to the wheelchair and during the transfer the resident slid from the shower chair onto the floor. In her written statement, the nurse aide identified the shower chair was locked, the statement failed to reflect documentation that the wheelchair wheels were locked. The emergency department note dated 12/25/15 at 9:08 PM identified the resident had stated the nurse aide did not put the lock on the break for the wheelchair and he/she slipped. A physician's order dated 12/2/615 directed sling right arm at all times, monitor circulation, motion and sensation every shift and follow up appointment with orthopedic physician in one week. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, identified that she had transferred Resident #6 by herself on 12/25/15 from the shower chair to the wheelchair. NA #1 stated she locked the shower chair brakes and attempted to transfer the resident from the shower chair to the wheelchair, when the resident fell backwards, the shower chair moved and the resident fell to the floor. NA #1 identified she thought the resident was an assist of one with transfers, and was unaware the resident required two (2) person assistance for transfers. NA #1 stated although she had applied the brakes to the shower chair, she was told the next day by the former Director of Nursing (DON) the shower chair was taken out of service because the brakes were not functioning properly. Interview with the Director of Maintenance on 4/25/17 at 10:30 AM identified that every month the wheelchairs are checked for function, including brake function. The Director of Maintenance stated when the wheelchairs are checked so are the shower chairs are checked, and although they document the function of the wheelchairs, there was no documentation regarding the function of the shower chairs. The Director of Maintenance identified that from this point forward the shower chairs will be tagged, tracked and function will be documented. 3. Resident #4's [DIAGNOSES REDACTED]. The Nursing Admission Evaluation dated 3/30/17 identified resident #4 had short term memory problems, was unable to recall after five (5) minutes, was oriented to person only, decision making was poor and required supervision, and the Elopement Risk Evaluation section identified the resident was at risk for elopement and a wander guard bracelet was applied to the ankle. A physician's admission order dated 3/30/17 directed to apply a wander guard to the left ankle, check placement every shift and functioning every 11PM-7AM shift. The admission care plan dated 3/30/17 identified the resident was at risk for elopement related to the resident verbalized statements about leaving. Interventions directed a wander guard device, to attend recreation activities, and redirect as needed. The nurse's note dated 4/4/17, 3-11PM shift, identified Resident #4 was anxious and agitated all shift, had continued to try to leave with a bag packed and coat on and several attempts were made to re-direct. The admission Minimum Data Set assessment dated [DATE] identified Resident #4 had severe cognitive impairment, required extensive one person assistance with ambulating, utilized a wheelchair and/or walker for mobility, the resident's balance during surface transitions and walking was not steady and was only able to stabilize with staff assistance and the resident had one fall in the past thirty (30) days. A physician's order dated 4/7/17 directed the resident may be seen by psychiatry to evaluate for depression. A physician's order dated 4/12/17 directed may send resident to the Emergency Department for an evaluation secondary to agitation and combativeness if the family was unable to calm the resident. Review of the nurse's notes from 4/4/17 through 4/14/17 identified that Resident #4 had episodes of increased agitation, non-compliance with taking medication, a fall on 4/9/17, on 4/12/17 the resident attempted to leave through the front lobby, set off the wander guard alarm and was so agitated family was called to visit with the resident to try to calm Resident #4 down. The nurse's note dated 4/14/17 at 5:00 PM identified Resident #4 was observed walking on the sidewalk away from the facility towards the corner bus stop. Upon return to the facility, an assessment identified the resident was dressed appropriately and no distress and/or injuries were noted and when asked why he/she was outside the resident stated that he/she was trying to go home. Subsequent to the elopement one to one supervision was initiated for three (3) days. The Reportable Event Form dated 4/14/17 at 4:10 PM identified an unauthorized leave of absence, the resident was found walking on the sidewalk near an intersection down the road. The documentation noted that while a charge nurse, Licensed Practical Nurse (LPN) #8, was walking down the hallway, Resident #4's chair alarm was sounding and she was unable to locate the resident in the facility. The report identified that LPN #8 went outside and saw the resident standing at the end of the street, assisted the resident back into the building and noted the wander guard alarm did not sound when the resident entered the building. Review of the April 2017 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) failed to reflect documentation that the wander guard bracelet was checked every shift for placement and on the 11PM-7AM shift for function until 4/18/17, four (4) days after the elopement. The records also failed to reflect documentation as to the date the device would expire, therefore the wander guard may not have been functioning effectively on 4/14/17. Interview with the Director of Nursing (DON) on 4/19/17 at 1:20 PM identified that although the resident had a wander guard on the left ankle, upon returning to the building, the alarm did not sound. The DON stated that the device was to be checked every shift for placement and on 11PM-7AM for function. The DON stated prior to the incident there was no documentation and/or tracking regarding when the alarm would expire. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #8 on 4/27/17 at 11:00 AM identified that after she received report she was going down the hall to meet Resident #4, and heard the chair alarm going off but did not see the resident. LPN #8 stated she checked the bathroom and a room across the hall but was not able to locate the resident. LPN #8 identified she went to the front desk looked outside and saw a resident down the street. LPN #8 stated when she brought the resident back inside the wander guard alarm did not sound. Review of the facility policy and procedure regarding Elopements identified residents at risk for elopement will have a wander guard alarm device applied. The policy identified the device will be checked every shift and functioning once daily. Additionally, the policy noted that the expiration of all devices including extra devices in stock will be checked weekly with corresponding documentation. Subsequent to the 4/14/17 elopement, documentation was added on the wander guard checklist to indicate when the device would expire and Resident #4's wander guard was replaced.

Based on review of clinical records, review of facility documentation, review of facility polices, observations, and interviews for two of five residents reviewed for pressure ulcers (Residents # 26 and #100), the facility failed to ensure that recommendations by interdisciplinary team members (occupational therapy) were followed to minimize the risk for pressure ulcer development and/or failed to ensure prescribed treatments were consistently implemented per physician orders [REDACTED]. The findings include: 1a. Resident #100 (R #100) had [DIAGNOSES REDACTED]. Review of R #100's weight log dated 6/4/15 identified that the resident weighed 350 pounds on admission. The quarterly MDS dated [DATE] identified that R #100 had a BIMs score of fifteen out of fifteen, indicative of intact cognition, and required extensive assistance of one person for bed mobility and transfer. Review of the clinical record identified a quarterly assessment packet dated 6/25/15. Although the Braden scale assessment for this quarter was undated, the remaining assessments were completed on 6/25/15. At that time, the resident ' s Braden score was documented as seventeen (17), and though indicative of low risk for skin breakdown, the assessment identified issues related to the resident's potential for skin issues related to friction and shear, very limited mobility related to changing his/her position, and that the resident was chair fast. The clinical record lacked documentation to reflect that a plan of care was developed for the potential for altered skin impairment was initiated. Although the 6/26/15 MDS identified that the resident required extensive assistance for bed mobility, review of the care plan dated 7/11/15 identified that the resident was able to self-turn and reposition in bed. Review of R #100's weight log dated 8/11/15 identified that the resident weighed 368.4 pounds, a gain of 18.4 pounds since admission. An assessment of R#100's wheelchair seating by Occupational Therapy (OT) dated 8/19/15 identified that R #100 was snug in his/her wheelchair. The documentation identified that the resident was at maximum width for comfort and safe wheelchair positioning without developing pressure sores. The documentation identified that the resident would be re-screened in one month and to notify the rehabilitation department if any weight gain or loss. The OT screen further recommended that staff monitor the resident's skin integrity. The clinical record lacked documentation to reflect that a plan of care for the potential for altered skin impairment was initiated at this time. b. Review of R #100's weight log dated 9/7/15 identified that the resident weighed 397 pounds after a reweigh, a gain of 28.6 pounds since August of 2015. The clinical record lacked documentation to reflect that OT was notified of the weight gain as recommended for appropriate fit of the resident's wheelchair. Review of the clinical record identified that OT rescreened R #100 on 9/16/15. The OT documentation identified that R #100 was noted to have gained weight since June 2015 and was still wedged into his/her wheelchair with increased risk of pressure sore development. The documentation further identified that the resident would need skilled occupational therapy to address positioning and obtain an appropriately sized wheelchair. Interview with OT #2 on 10/8/15 at 12:50 PM identified that during R #100's original OT screen in August of 2015, she/he noted that the resident was snug in his/her wheelchair and recommended that if the resident had any weight gain (5 to 10 pounds), he/she should be fitted for a new wheelchair to prevent skin breakdown. OT #2 stated that the 9/16/15 assessment was completed secondary to a random observation by OT personnel of R #100 on the unit which identified that R #100 was wedged too tightly into his/her wheelchair. OT #2 stated that the screen was completed due to the increased risk of pressure ulcer development and the need for a better fitting wheelchair. The clinical record lacked documentation to reflect that a plan of care for the potential for altered skin impairment was initiated at this time. OT #2 stated that the rehabilitation department had a communication log for nursing to request assessments by OT. OT #2 stated that nursing should communicate any changes with residents through the log and/or verbally to the rehabilitation department. Review of the communication log with OT #1 and OT #2 lacked documentation to reflect that nursing staff communicated R #100's weight gain to OT personnel. Interview with RN #2 on 10/8/15 at 1:25 PM identified that nursing had an order for [REDACTED].#2 further stated there may have been a communication problem regarding Resident #100's positioning in the wheelchair. c. Review of the nursing weekly skin integrity documentation dated 9/1, 9/8, and 9/15/15 for R #100 did not reflect any skin integrity issues. A nursing note dated 9/20/15 identified that a nursing assistant identified an open area on R #100's left posterior thigh. On 9/20/15, the APRN ordered staff to cleanse the area around the left posterior thigh with normal saline followed by [MEDICATION NAME] and a dry clean dressing to cover. The 9/20/15 nursing note lacked documentation to reflect a description of the wound, measurements, and/or staging of the wound. A care plan was initiated on 9/20/15 to address the resident's pressure ulcer with interventions that included a specialty air mattress and a specific turning and repositioning schedule. Further review of R #100's clinical record identified a late entry nursing note dated 9/22/15 which stated that during morning care on 9/20/15, R #100 was found to have developed an open wound. The documented assessment in the entry identified that R #100 had a 1.0 centimeter (cm) by 1.0 cm by 0.2 cm open area on the upper left posterior thigh. The nursing note further indicated that a Wound Consult was to be obtained on 9/21/15. The 9/22/15 late entry nursing note lacked documentation to reflect staging of the open area. Interview with RN #2 on 10/8/15 at 1:25 PM identified that R #100's pressure ulcer should have been staged when the wound was initially discovered and measured on 9/20/15. RN #2 stated that all nursing staff had been educated regarding documentation of wounds which should include the exact location, staging, and measurements of the wound. RN #2 further stated that many of the nurses wait until he/she (RN #2) is working to complete documentation of the wound and to determine if the wound is an actual pressure ulcer. Review of R #100's clinical record including the weekly pressure ulcer flow sheet, identified that R #100's wound was not staged until 9/21/15 and was identified at that time to be a Stage III pressure ulcer. Review of the Wound Care Specialist evaluation dated 9/21/15 which stated that the resident was evaluated and presented with a Stage III pressure ulcer of the left posterior thigh of at least fifteen days duration. Measurements by the Wound Care Specialist were documented as 1.0 cm by 1.5 cm by 0.4cm with 30% yellow necrosis and 70% granulation tissue with moderate serous exudate. Physician orders [REDACTED]. d. Interview with Resident #100 on 10/8/15 at 9:30 AM stated that he/she had a new mattress in his/her bed and a new wheelchair with a cushion because of the development of his/her pressure ulcer. R #100 stated that his/her previous wheelchair was too tight for him/her and that his/her current one fit much better. R #100 further stated that while in bed, he/she can reposition him/herself. Review of the clinical record dated 9/24/15 identified an assessment of resident's turning and repositioning needs. Although the 9/24/15 assessment identified that R #100 could reposition him/herself, observation of the resident at the time of the interview identified the resident was able to move and reposition only the top part of his/her body while in bed but had difficulty moving his/her lower body off of the bed for pressure reduction. Review of the facility's policy and procedures on pressure ulcer prevention directed in part that prevention and treatment of [REDACTED]. The policy further directed revisions of the care plan would be completed as indicated by the interdisciplinary team discussion and recommendations. In addition, the policy for documentation of wounds directed in part to have the nurse who identifies the ulcer, notify the appropriate disciplines and document the description of the wound on the weekly skin flow sheet which included the staging system (tissue layer involvement). 2. Resident #26 (R #26) had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R #26 had a BIMs score of fifteen out of fifteen, indicative of intact cognition, and required extensive assistance with bed mobility and transfer. The care plan dated 10/2/15 identified that R #26 had an alteration in skin integrity as evidenced by a left foot wound, with interventions that included to monitor a wound vac for function and placement every shift. The care plan directed that if the wound vac was not functioning for more than two hours, remove foam and replace with a wet to dry dressing. Physician orders [REDACTED]. Observation on 10/9/15 at 7:45 AM identified that R #26's wound vac was on the resident's wheel chair and not on the left foot per physician's orders [REDACTED].#26 at the time of the observation indicated that he/she had an outside physician's visit the previous day, that the wound vac was removed at that time, and was never reapplied. Interview with Registered Nurse (RN) #6 on 10/9/15 at 8:42 AM identified that R #26 returned from the physician visit sometime time before 4:00 PM on 10/8/15. RN #6 stated that an order to continue wound vac was entered into the clinical record though noted by LPN #6. RN #6 stated that it was the responsibility of the LPN to initiate the treatment after noting the order. RN #6 also indicated that he/she was not aware that the wound vac had not been reapplied to R#26's wound. Interview with LPN #5, who worked the 11-7 shift from 10/8 to 10/9/15, indicated that he/she was aware that R #26's wound vac had not been reapplied to resident's left foot wound but that he/she had encouraged the resident to elevate his/her leg during night. LPN #5 stated that he/she did not inform the 11-7 supervisor that the wound vac had not been reapplied. Interview with LPN #6 on 10/9/15 at 3:50PM identified that although he/she noted the order for the application of the wound vac, he/ she did reapply the device per physician order. LPN #6 stated that the resident had a dry dressing on which was placed at the physician office and therefore he/she thought that would suffice. LPN #6 stated that a previous order was in place that directed placement of a dry dressing if the wound vac was not functioning. However, the wound vac was functioning properly. Subsequent to surveyor inquiry, the wound vac was reapplied to R #26's left foot wound at 9:00 AM on 10/9/15, approximately seventeen hours after the resident returned from the outside physician's visit. Review of the facility's wound care policy directed in part that the licensed nurse was responsible for administering treatment per physician orders, was responsible for replacing the dressing if it is soiled, loose, or missing, and was required to ensure that all resident dressings were in place during the shift worked. In addition, the policy directed that the licensed nurse would document on treatment administration record.

Based on clinical record review, observations, review of facility policy and procedures and interviews for one of three sampled residents (Resident #7) reviewed for accidents, the facility failed to ensure that the resident was free of an accident. The findings included: Resident #7's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, had problems with memory and that the resident was totally dependent on staff for bed mobility and transfers .The RCP dated 4/14/13 and the physician's orders [REDACTED]. The Accident and Incident (A&I) report dated 5/9/13 identified that during transfer from the bed to the wheelchair via a Hoyer mechanical lift (with NA#1 and NA#2 assisting), a strap on the Hoyer lift sling slipped off the mechanical lift, due to the resident having a "tremor " resulting in the resident hitting his/her head on the base of the mechanical lift. The acute care hospital discharge documentation dated 5/9/13 indicated that Resident #7 presented with two deep lacerations to the head. A frontal laceration measured 2 inches and the occipital laceration was 1 inch. The lacerations required sutures and/or staples to approximate the wounds. A facility progress note dated 6/21/13 indicated that Resident #7 suffered a fall on 5/9/13 from a mechanical lift and was transferred to Acute Care Hospital #1 for an evaluation, work-up was negative, and the resident returned with staples to the scalp laceration and sutures on the forehead laceration. In addition, Resident #7 had a follow-up head Computed Tomography (CT) scan completed 6/11/13. The radiology report for the CT scan concluded no acute abnormality seen and age related severe cerebral atrophy as before (compared to 5/9/13). Neurology was also consulted and an Electroencephalogram (EEG) completed, with no evidence of seizures. Interview with NA#1 on 12/16/13 at 2:08 PM, indicated that during transfer of Resident #7 on 5/9/13 from the bed to the wheelchair, he/she had positioned the sling underneath the resident and hooked the straps to the Hoyer mechanical lift. NA#1 asked NA#2 for assistance with the transfer. NA#1 indicated that when the transfer began, the resident was lifted off the bed and was moved over towards his/her wheelchair. At that point, NA#1 indicated that he/she was concentrating on guiding Resident #7's legs and not the resident's upper body. NA#1 indicated that when he/she noticed that Resident #7 was falling out of the sling, NA#1 grabbed Resident #7 and pulled the resident towards him/her, however, was unable to prevent the resident from falling out of the sling and striking his/her head. NA#1 indicated that although Resident #7 did have jerking motions to his/her extremities, this was the resident's baseline and the jerking motions were no more severe than another day when transferring the resident. Interview with the DNS on 12/16/13 at 5:00 PM identified that Resident #7 did not have a history of a neurological and/or seizure disorder prior to the fall on 5/9/13. In addition, testing conducted post fall was negative for neurological and/or seizure disorder. Interview with Person #3 (representative from the mechanical lift company) on 12/16/13 at 4:00 PM indicated that the Hoyer mechanical lift is designed to withstand a patient having tremors, jerking limbs, and/or seizures. And though the presence of tremors/jerking/seizures for a resident being actively transferred may cause the sling to sway back and forth, it would not cause a properly positioned sling strap to become unhooked from the mechanical lift. In addition, if the sling were to begin to sway, a staff member should be positioned between the resident's legs to control the swaying motion and provide safety to the resident.

Based on clinical record review, interview and observation for one (R#1) of twelve residents reviewed for risk of elopement, the facility failed to implement measures to prevent an elopement, which lead to a finding of immediate jeopardy. The findings include: R#1's [DIAGNOSES REDACTED]. Review of the Interagency Report dated [DATE] identified R#1 had been admitted to acute care on [DATE] after being observed wandering around his/her apartment complex looking for his/her deceased spouse. R#1 was found to have a urinary tract infection and was discharged to the long term care facility on [DATE]. The Nursing Admission assessment dated [DATE] identified R#1 as alert, memory intact, oriented to person, place and time, but failed to have a completed elopement assessment according to facility policy. Review of the physician orders [REDACTED]. Review of the nurse's notes dated [DATE] at 6:00 PM identified R#1 as alert, oriented and forgetful. Review of the Interim Care Plan dated [DATE] identified the resident as a fall/safety risk with cognition impairment related to the [DIAGNOSES REDACTED]. Review of every fifteen minute check documentation dated [DATE] identified the resident was placed on every 15 minute checks as of 5:30 PM, but failed to identify completion of the 15 minute checks from 8:30 PM to 10:45 PM. The 15 minute checks were restarted at 11:00 PM but the facility documentation failed to identify that the resident was observed after 3:45AM. Review of physician order [REDACTED]. Review of the nurse's notes dated [DATE] at 4:40 AM identified Nurse Aide (NA) # 1 observed that R#1 was not in his/her room, and the 11:00 PM-7:00 AM Nursing Supervisor (RN #2) initiated a missing person search at that time. The nurse's note further identified that at 4:45AM, the front door was observed to be ajar and the police were alerted that a resident was missing. A subsequent nurse's noted dated [DATE] at 6:20 AM identified the resident was located, was alert and conversant, but did not identify any further related circumstances. Interview with NA#3 on [DATE] at 2:30 PM, who was assigned to provide care to R# 1 on the 3:00 PM-11:00 PM shift, identified that R#1 wandered room to room and NA#3 reported this to the 3:00 PM -11:00 Nursing Supervisor (RN # 1). NA#3 prepared R#1 for bed at approximately 8:00 PM, but R#1 was out of bed by 8:45 PM, dressed, and sitting with the Nursing Supervisor (RN #1) at the desk with his/her coat on. Interview with the 3:00 PM-11: PM Unit Nurse (LPN #2) on [DATE] at 2:00 PM identified that on [DATE], during the 3:00 PM-11:00 PM shift, R#1 was walking around the nursing unit and/or sitting at the nurses' desk with a jacket over his/her johnny with the 3:00 PM-11:00 PM Nursing Supervisor (RN #1). Interview with the 11:00 PM-7:00 AM Nursing Supervisor (RN #2) on [DATE] at 10:00 AM identified that the 3:00 PM-11:00 PM Nursing Supervisor (RN #1), reported to him/ her that R#1 needed a wander guard, but there was no wanderguard available. The interview further identified that Nursing Supervisor (RN # 2) spoke to NA #1 and directed him/her to complete the fifteen minute checks per the facility policy. According to the interview with Nursing Supervisor (RN # 2), during the 11:00 PM- 7:00 AM shift, R#1 was walking around, but was re-directed back to his/her room. At 4:40 AM, Nurse Aide #1 reported that R#1 was not in his/her room and a search was initiated. At 4:44 AM the 11:00 PM-7:00AM Nursing Supervisor (RN#2) noticed that the front door was slightly ajar and called the police at 4:45 AM to report a missing person. The Police arrived between 4:55AM and 5:00 AM. The canine team arrived at 5:45AM and R#1 was found across the street in the water. Interview with the 3:00 PM-11:00 PM Nursing Supervisor (RN # 1), on [DATE] at 11:00 AM identified that he/she admitted Resident #1 on [DATE] at 6:00 PM, but did not complete the elopement risk assessment. The interview further identified that R #1 was alert, forgetful, had a history of [REDACTED]. The 3:00 PM -11:00 PM Nursing Supervisor (RN # 1) also identified that he/she encouraged R#1 to sit with him/her at the desk while he/she completed paperwork, because the resident was wandering around the unit. He/she further stated that R#1 would have been much safer with a wander guard, but one was not available. According to the interview with the 3:00 PM -11:00 PM Nursing Supervisor (RN #1), he/she reported to the 11:00 PM-7:00 AM Nursing Supervisor (RN #2), that R#1 required close supervision and if R #1 became disruptive, "get a wander guard" for the resident. Interview with the 11:00 PM -7:00 AM nurse aide, NA #1, on [DATE] at 1:45 PM identified that R#1 stated that he/she wanted to go home and that the resident did not have a wanderguard on. NA #1 further stated that the nurse working the 11:00 PM-7:00 AM shift on the A Unit, where R# 1 was a resident, also knew that R#1 wanted to go home. NA #1 identified during the interview that he/she completed the every fifteen minute checks until 3:45 AM, which was the last time he/she saw the resident and then proceeded to go behind a closed door with NA #2 to provide personal care to another resident. Upon completion of the other resident's personal care and upon exiting the other resident's room, shortly after 4:00 AM, NA #1 went to R# 1's room and did not see the resident. NA#1 identified that he/she did not feel that the resident had left the facility because an alarm had not sounded. Nurse Aide #1 and Nurse Aide #2 continued to work their way down the hallway checking residents before reporting the missing resident to LPN #1. NA #1 could not recall what time the nurse was alerted that the resident was missing. Interview with LPN #1 on [DATE] at 2:00 PM identified that R#1 was alert and verbal and spent most of his/her time with the ,[DATE] Supervisor at the desk until approximately 1:00 AM. LPN#1 stated that R#1 stated that he/she wanted to leave and return to his/her spouse. LPN#1 further stated that he/she was told by the ,[DATE] Supervisor that there were no wander guards available. LPN #1 proceeded to check places where the wander guards are frequently located but could not find one. At 4:30 AM, LPN#1 was approached by the nurse aide and was told that R#1 could not be located. The ,[DATE] supervisor had already been notified and a building search was immediately begun. Interview with the Director of Nursing on [DATE] at 10:00 AM identified that it is an expectation that on admission an elopement assessment be completed and if a resident is determined to be a risk, interventions put into place. He/she further stated that wander guards were available in the facility. Review of the elopement policy directed that the residents will be accounted for at all times and residents will be assessed for risk of elopement and a care plan developed. Interview and review of the facility security tape on [DATE] at 1:30 PM with the Administrator identified that R#1 was in the building [DATE] at 4:48 AM and was observed with his/her coat on, with pocketbook in hand, walking in the direction of the front door. He/she further stated that there were at least three wander guards available. Two were in the Supervisor's office but not in the correct file cabinet, and one with Maintenance. Interview with the Director of Nursing and the Corporate Nurse on [DATE] at 3:30 PM identified that there is not a facility policy for every 15 minute checks but it had been a standard of practice to complete them for seventy two hours after admission. They further stated that the charge nurse is responsible for checking wander guard placement every shift and the ,[DATE] Supervisor is expected to check function at hour of sleep. Review of acute care hospital progress notes dated [DATE] identified that R#1 arrived at the hospital at 7:10 AM after being found partially submerged in water, after disappearing from the long term care facility. R #1 was admitted to critical care with hypothermia with a temperature of 89 degrees, superficial forehead scratches, and scattered abrasions to the lower extremities.